The Effects of Stress, Depression, and Hostility on Cardiovascular Health:

Stress:

Prolonged or excessive mental stress puts you at risk for cardiovascular disease. Stress can take a deadly toll.
The research over the past two decades at Duke University and other leading institutions show clearly that mental stress affects the cardiovascular system negatively. More specifically, some stress-related emotions, such as anger, hostility and anxiety are particularly dangerous to the heart. Studies show anger promotes arterial occlusion, heart attacks, and arrhythmias. Hostility is also linked to cardiovascular hyperactivity and high blood pressure. Intense emotion, in general, increases the heart rate and therefore increases the need for blood and oxygen, which can cause angina. In fact, current research has shown mental stress during average, daily life can be a potent trigger of ischemia, a condition in which there is an inadequate supply of blood to the heart. (James A. Blumenthal Ph. D., professor of Medical Psychology at Duke, University). There are dramatic changes in blood pressure in response to mental stress that can reduce blood supply. Emotional stress also causes the body to produce hormones that in turn cause a chemical condition in the arteries that attracts cholesterol more easily.

Managing your stress effectively can help prevent damage to the cardiovascular system.  
In a recent study at Duke University, researchers found there was a 74% reduction in the risk of cardiac events among patients receiving stress management training. (Reported in the Center for the Advancement of Health’s, Facts for Life, March 2000)
There are a variety of behavioral skills that can be learned and used to manage stress. A discussion of these skills follows, but it is important to add that these behaviors are best learned when used in social settings. Changing behavior requires practice, patience, and is best acquired with emotional support from someone else or in a group.

Depression:

Depression is a risk factor for cardiovascular disease. Researchers at the University of California reviewed 11 large-scale studies covering 36,000 individuals to assess the link between heart disease and depression. They found that those who had clinical depression or depressed mood were between one and one half to four more times more likely to develop heart disease in the years to come. (American Journal of Preventive Medicine, July 2002)

Depression is also a factor for people who have experienced heart surgery. 40 to 65% experience depression shortly after heart surgery and 25% continue to be experience severe depression. As we know, depression can influence the immune system and the rate of healing. This data points to the importance of identifying and treating depression. The symptoms of depression are as follows: sleep problems, eating problems, negativity, irritability, feeling worthless, excessive guilt feelings, excessive crying, lack of pleasure and an ongoing feeling of lethargy or boredom. See a doctor if these symptoms persist. It is important to note that anxiety and depression are often linked. You should report all symptoms when seeking medication or behavioral therapy. Today there are excellent medications available to treat depression.

Many family physicians are familiar with anti-depressants or will refer you to a psychiatrist or psycho-pharmacologist who specializes in psychotropic or antidepressant medication.

A list of medications available is at the conclusion of this lesson under Some Common Questions. In the following section, Techniques to Manage Stress and Depression, you will find a complete list of behavioral management strategies.

Hostility:

Hostility, which is often a component of depression or the Type A personality, puts you at greater risk for heart disease. Patricia P. Chang, a researcher at Johns Hopkins University, reported that young men who react to stress with anger are three times the normal risk of developing premature heart disease. This is according to a study of 1,337 physicians who were tracked for 36 years. (April 22, 2002,Archives of Internal medicine.) The report concluded, “the incidence of cardiovascular disease was significantly higher for those with the highest level of anger compared with those with lower levels of anger”. Chang says evidence points to the stress related release of extra hormones that prepare the body for shock by constricting the blood vessels and forcing the heart to work harder.

Fortunately, even people born with “hot tempers” can learn how to manage anger by developing an awareness of their behavior and then learning a procedure for dealing with the hostile feelings. In brief, the process begins with awareness and is followed by:
1) Learning to sense the onset of resentment confusion, or agitation.
2) Clarifying the origins of the anger.
3) Understanding the difference between “acting out”, and talking it out.
4) Learning to be assertive rather than aggressive.
5) Communicating calmly and clearly without accusations, and developing empathy.
6) Developing skills for cooperation and serenity.

Techniques to manage emotional stress and depression:

Diaphragmatic Breathing
The deep breath is the single most effective tool for stress management. Take a few deep, cleansing breaths several times a day or whenever you are experiencing too high a level of stress. It is important to use diaphragmatic breathing, not short shallow breaths. Place your hands on your abdomen over your diaphragm and breathe in without raising your shoulders. As you do so, you should feel your abdomen moving out and experience your diaphragm filling up like a balloon. Then let out your breath through pursed lips and think of squeezing out all the air in the balloon. Breathe out slightly longer than you breathe in. It can help to count slowly to 3 on each “in” breath and 4 on each “out” breath. This action gives a primitive signal to the brain and body to relax. It also provides you with more oxygen for your brain and muscles. Taking the “deep breath” automatically provides you with more oxygen for your brain and muscles and improves your circulation, consequently you think better and move more easily.

Self Care
Good self-care in the areas of diet, sleep, exercise, and behavior is at the core of stress management. When under stress people often drop healthy habits and use negative or quick fixes like eating too much, sleeping too little, smoking, (a major risk factor) excessive alcohol consumption or TV watching. Avoid drug abuse, smoking, overeating, excessive TV watching, angry over-reactions, social withdrawal, and procrastination. Incorporate the following healthy habits instead: eat well and often enough, restrict caffeine and alcohol intake, exercise regularly and moderately, sleep enough, avoid drug abuse, limit TV watching, be proactive, and become socially involved with positive people and/or family. Learn to set limits. Never say “sure” when you really mean “NO”.

Self-care also involves knowing when to pace your self, establishing short and long term goals, and planning ahead. It requires self-awareness in terms of activities and hobbies that are pleasurable to you. In other words, you need to find out what brings you joy, pleasure and relaxation and then just make time for these activities. Freud said we need to balance work, love, and play to find satisfaction in life. This is all part of taking good care of your self. It is just as important as seeing your doctor when you have an illness.

Cognitive Behavioral Strategies
Researchers at Duke University came up with five effective behavioral techniques to reduce emotional stress and lower the risk of cardiac events. Stop catastrophizing (exaggerating the harmful effect of something that happens to you). Stop personalizing (seeing yourself as the cause of a negative event). Stop all or nothing thinking (reducing complex situations to absolutes). Stop over generalizing (interpreting one unpleasant situation as part of an endless pattern). Stop mental filtering (focusing on the bad while filtering out the positive).

Another cognitive strategy requires that you look closely at your thoughts to see whether the situation that you think is stressful merits as much stress as you are feeling. Ask yourself, “What is the worst that can happen?” or “Is there anything else I can do to influence the situation or have I done everything possible?”
Remember. Your thoughts can be controlled and your reactions can be controlled to reduce your stress.

Positive Thinking
Positive thinking benefits your brain, your mood, your health, and those around you. Some examples of positive thinking are:
“I can deal with situation.”
“I am going to get through this.”
“This is not the worst that can happen.”
“I have faired well in this kind of situation in the past and I can do it again.”
“I am going to plan for success.”
“I am proud of myself for the following reason: (fill in as many as you can)”

Use your mind to turn negative thinking into positive thinking to reduce stress and distress. Let your thinking help you to induce confidence and calmness.

Change negative self talk to positive self talk.
“What’s the use--it’s too late to change anything.” 
CHANGE TO: “NOTHING VENTURED, NOTHING GAINED. THERE IS NOTHING TO LOSE BY TAKING ACTION.”

“I can’t take the time to de-stress”
CHANGE TO: “I CAN TAKE CONTROL OF MY LIFE: RELAX, ENJOY, SLOW DOWN, AND SMELL THE ROSES.”

“What’s the use? It’ll never get better.” 
CHANGE TO: “THIS TOO SHALL PASS.”  

“I keep making mistakes. What’s the matter with me?” 
CHANGE TO: “I WILL NOT FOCUS ON THE MISTAKE. I WILL KEEP GOING UNTIL I AM BACK ON TRACK IN ORDER TO MAINTAIN MY SELF CONFIDENCE.” 

“I am in such bad shape, it’s no use.” 
CHANGE TO: “I CAN GRADUALLY IMPROVE PHYSICALLY AND MENTALLY.”

Progressive Relaxation
The Progressive Relaxation Exercise is easy to do, quite pleasant, and requires 10 minutes, but its effects are powerful. Ideally, you should do the relaxation exercise every day for thirty days. Practicing this technique for the 30 days trains your body to relax on command. It takes repetition to learn how to release tension. When we are under stress our muscles automatically tense, our blood pressure rises, we breathe rapidly as our pulse quickens, hormones are released and our blood clots more easily. These effects of stress can ultimately impact the arteries. The body retains these undesirable effects of stress for several hours or more. It is important to help the body release tension and return to a normal state of function.

To practice progressive relaxation, lie down in a quiet place, on your back, and get comfortable with your knees up and arms relaxed. You can do this sitting up with your feet flat on the floor and your arms resting on a table surface, but it is more effective when lying down. Begin by taking several deep breaths and noting any areas of tension in your body. Then begin with your feet and focus on relaxing your feet and releasing any tension. If you cannot discern your tension level, flex your feet and create tension and then relax them until you can tell the difference. Continue through the seven areas in the body that hold tension: legs (shins and thighs), lower back, abdomen, shoulders, neck, face and head and focus on relaxing each area. This should take at least ten minutes. There are tapes and CDs available that guide you verbally through the process, but it can be just as effective if you do it alone with the aid of some lovely, calming music. When you finish the process, imagine yourself in a tranquil spot feeling at peace. This exercise can also be used to prepare for a restful sleep.

Visualization and Meditation
Visualization and meditation help you to calm yourself, lower your blood pressure and provide the body with an opportunity for relaxation and rejuvenation.

Meditation helps you to calm your mind, to develop a feeling of peace and inner happiness. Meditation helps you to stay in the “present” and to learn how to control anxiety, agitation, and to feel more relaxed. It increases awareness which is the beginning of any constructive change or healing.

To practice meditation you can:
1) Focus on your breathing.
2) Focus on counting as you breathe.
3) Focus on a sound.
4) Use prayer or devotion.
5) Focus on a repeated word or phrase.
6) Practice “mindfulness”, stay in the present with focused awareness.
For further study: Learn to Meditate, A Practical Guide to Self Discovery and Fulfillment, David Fontana, Ph. D.

Visualization can help you to relax or to plan to do something successfully. Athletes visualize themselves performing their athletic skill precisely in order to prepare for a competitive event. You can visualize yourself (while in a relaxed state) in a certain situation and use the visualization to imagine yourself in control and performing at your best. This is a form of self-hypnosis. You can also relax by using “progressive relaxation” with music and then imagining yourself in a tranquil, peaceful place feeling calm and in control.

Clear Communication
Clear communication reduces emotional stress because it not only helps you get what you need, but reduces the frustration and anger associated with misunderstandings. Look at the COMMUNICATION CHECKLIST below to assess your communication skills and record the ones you feel you need to work on.
     - I try to convey what I want and need clearly.  
     - I try to convey my positive intentions when I begin to communicate with someone.
     - I try to be AWARE of the other’s needs and current situation when communicating.
     - I listen as an “active participant”.
     - I think of communication as cooperative participation.
     - I avoid warped messages that don’t convey what I really mean.
     - I try to speak on one issue at a time.
     - I stay with the conversation and don’t think ahead or worry about the past.
     - I can ask for feedback when I need it.
     - I give feedback that is generated from a positive stance, not from one-upmanship.
     - I can agree to disagree because disagreement is unavoidable.
     - I realize conflict is inevitable and that it can produce positive change.
     - I make an effort to air my differences in a calm manner.
     - I try to recognize when criticism is helpful and react as if I am being “coached”, not as if I’ve been rejected.
     - I resist self -blame and over reaction when I am criticized.
     - I try to resist immediate “denial” when criticism is offered.
     - I try to maintain my composure and speak calmly, in the face of criticism.
     - I am interested in what the other person wants when I am negotiating.
     - I present my ideas using “specifics”.
     - I try to collaborate and to create mutual advantages for my self and the “other” when I interact verbally.
     - I respect the “other’ and expect respect.
     - I establish an atmosphere of cooperation, trust, and honesty with others. 
     

Socializing
Social isolation is known to be a risk factor for cardiovascular disease. Dr. Dean Ornish from the University of California was the first to research the importance of social connections, heart disease, and health. His book, Love and Survival was a groundbreaking work on the importance of giving and receiving love. It boosts your immune system and combats illness. Socializing in any way with family, friends, or as a member of a church, club, or interactive class is beneficial. Having a commitment to a cause, a philosophy or something greater than your self seems to promote good health. It is now well known that those people who have pets, love their pets and are committed to caring for them are healthier.

Time Management
These psychological symptoms of “time pathologies” are bad for your heart: impatience, restlessness, a “racing mind’, feeling time pressured or overwhelmed much of the time. These thought patterns can be modified through awareness, vigilance, and practice.

Step 1. Learn to recognize the symptoms. Develop awareness of your pathological, pressured sense of time.
Step 2. Think: “Slow down. What’s the hurry? Use patience. Stay calm.”
Step 3. Practice relaxation exercises to learn how to calm your self.

For daily time management, remember to plan ahead, prioritize, write to do lists, cross off things you have accomplished and add the unaccomplished items to your next day’s list.

Exercise
Exercise is a well-recognized stress reducer. Daily exercise such as walking or running can keep anxiety under control. In fact, some people feel it can be as effective as anti-anxiety or antidepressant medications. This is because exercise helps your body create its’ own chemicals, endorphins, that immediately induce a feeling of well being. Many recovering alcoholics follow a strict exercise routine in order to "feel good" without engaging in substance abuse. Inducing endorphin production can become a positive addiction.

Writing
The Journal of the American Medical Association reported that writing about stress can not only reduce symptoms of stress; it can reduce symptoms of common diseases such as asthma and rheumatoid arthritis that are often exacerbated by stress. A study showed that 47% of patients who wrote about their most stressful experiences for 20 minutes per day for 30 days showed “clinically relevant improvement” in their medical conditions. Dr. Spiegel of Stanford University reported that writing about negative emotions helps patients acknowledge, bear and put into perspective the distress they experienced.

Humor
The value of humor cannot be underestimated. A laugh a day can keep the doctor away. There is an old story that appeared in the New England Journal of Medicine about a millionaire who contracted a fatal disease and beat it using a humor cure. He built himself a movie theater and watched funny films five hours a day. One year later he showed no sign of the rare blood disease that should have killed him. Laughter creates good chemicals in the body that work against the negative effects of stress. National Public Radio ran a story about “laughing clubs” that have been forming in various areas of the country. In these times of high stress, communication overload and endless multi-tasking, we all need a good laugh.

Seek psychotherapy
Psychotherapy can be an effective tool to learn personalized stress management techniques and to help people to overcome resistance to positive lifestyle change. Counseling and psychotherapy can be useful for overcoming addictions, social phobias, and anger management or relationship problems. It is a necessity for those who experience excessive depression and anxiety. In combination with medication, therapy for depression can be life saving. For those who have milder depressive or anxiety disorders, psychotherapy alone is often very helpful as it is tailored to a person’s unique needs. Seek psychotherapy from qualified, licensed professionals only. There are a growing number of “cardiac psychologists” who specialize in cardiac issues and behavioral change.

Know your optimal stress level
Dr. Hans Selye, the father of stress theory, recommended that we acknowledge our individual stress style. He said some of us are naturally the “racehorse” type who is rather high strung and prefers a high level of action and stress. Without enough stress and speed, the “racehorse” types are bored and become stressed from lack of stimulation. The other extreme, is the “turtle “type which has the “slow and steady wins the race” approach to life and dislikes chaos, change, and speed. The “turtle” type gets very stressed when things are too fast. The “racehorse” type gets stressed when things are too slow. It helps if you know your type and manage your stress and life accordingly.  This corresponds to the current concept of “Type A or Type B” personalities.

Common questions:

Q. In addition to the techniques described above to fight stress and depression, do medications help as well?
A. Yes. There is a multitude of medications available.
Sedatives and tranquilizers control anxiety: barbiturates (Phenobarbital), diazepam (Valium), buspirones (Buspar), chlorpromazines (Thorazine, Compazine).

Mood stabilizers: divalproex sodium (Depakote) or topiramate (Topomax), also used in epilepsy, may be used for individuals who have mood swings.

Hypnotics induce sleep: Seconal, Ambien, Dalmane, Halcion, Placydil, Restoril, Sonata.

Antidepressants: MAO inhibitors (Nardyl, Parnate). SSRI, or selective serotonin reuptake inhibitors (Celexa, Paxil, Prozac, Zoloft, Lexapro),  Mixed (Desyrel, Effexor). Tricyclics (Elavil, Tofranil, Norpramin, Sinequan, Pamelor).

There are ‘home remedies” based on herbal products and mixtures that are not recommendable because of unknown side effects and conflict with other medications. The FDA has not approved most of them. All the medications that we mentioned should be used under strict medical supervision. They have side effects and many of them are habit forming leading to serious addiction.

Q. Are some cases of anxiety or depression induced by medications?
A. Yes. Beta-blockers (Inderal, Toprol) may produce depression. Sedatives and tranquilizers may also lead to depression. Appetite suppressors have been known to induce palpitations and anxiety.

Q. Does the use of antidepressants present any danger to cardiac patients?
A. Yes. Some do. For instance, the tricyclic and MAO inhibitor drugs may induce palpitations and even severe cardiac arrhythmias.

Q. At what point should I seek medical or psychological help?
A. If you experience a depressed mood for more days than not for a period of two weeks or more with any 2 of the following symptoms:
1) Poor appetite or overeating
2) Insomnia or hypersomnia
3) Low energy or fatigue
4) Low self-esteem
5) Poor concentration or difficulty making decisions
6) Feelings of hopelessness

Q. Can severe emotional stress lead to a heart attack or stroke?
A. Yes. When you are severely distressed emotionally your body enters a state in which there is a high production of adrenalin, which affects the entire cardiovascular system. The adrenalin rush induces rapid heartbeat, arrhythmias, elevated blood pressure and a possible increased shear effect in the arteries which is very serious if a plaque is present. Even if there is only minimal blockage in the arteries extreme stress can produce a total blockage.

Q. Is "road rage" a form of hostility that can be harmful to us?
A. Yes. It can be harmful to you, your passenger and others on the road.  It is also harmful to your body because it induces the automatic stress response of increased blood pressure; rapid heart beat, shortness of breath, and increases in adrenalin. The effects of the stress reaction remain in your body for several hours after you experience the rage.

Q. In what way do emotional disorders influence other cardiovascular risk factors?
A. If, for example, a person is clinically depressed they may engage in compulsive over eating, which may lead to obesity, which may lead to diabetes all of which put a person at risk for cardiovascular disease. Another example: a depressed, anxious, or bi-polar person might smoke or "self medicate' with alcohol or other addictive substances putting themselves at risk for cardiovascular disease.

Q. How can I motivate myself to stay positive?
A. This is difficult for some people and even for those that are naturally optimistic because the mind tends to retain negatives longer than positives. However, with determination to take responsibility and make the choice to focus on the positive, it is possible. Of course, emotional support definitely helps. Remember, you can choose to focus on the negative and see the down side of the world or you choose to change your irrational or excessively negative thoughts to positive thoughts and see the bright side of life.

 Reviewed July 19Th, 2007