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The stress vortex

On World Heart Day we explore stress, that important concept that underlies cardiac disorders and appears to predict coronary crisis.

The word stress, used loosely today in society, has many connotations and can imply a range of circumstances from ordinary workplace or familial dissonance to serious mental disturbance. Crucially, what starts off as a minimal disturbance in one sphere of activity can have significant ramifications that affect many life spheres, if left unattended.

Life and society in the 21st century are profoundly stress generating. While a range of reasons may be held responsible, central to all manner of stress genesis is “the yawning gap between expectation and reality”. Modern lives have spiralled unthinkingly into a vortex, driven by predominantly Western economic models: of unremitting desire, relentless aspiration, pursuit of material gain, needless and thoughtless consumption, transient and elusive fulfilment, and unfettered hedonism. Stress is a natural accompaniment, a constant companion, as new desires replace the old, and the gap between expectation and reality remains constant, if not ever-widening.

Can we escape this vortex? Reduce, even remove, the negative factors that perpetuate stress in our lives? Transform ourselves into that epitome of self-management that others look up to?

Six friendly men of stress:

Rudyard Kipling, the India-born British author famously said (to paraphrase him), “I have six friendly men, they taught me all I know; their names are, who, what, why, when, where and how”. Let’s begin our journey by exploring the six friendly men of stress (see box).

Sources of stress

The Psychological Conflict Hypothesis: The concept of a psychological conflict comes from Freudian thought and is believed to underlie emotional stress. Freud proposed that we have both an unconscious and a conscious mind and that there were inherent conflicts between the primitive urges (Id), the unconscious (ego, current awareness) and the feedback from the moral agency (super-ego). While Freud emphasised sexual urges, psychological conflicts are generally believed to have their genesis in the dissonance that can arise between our inner urges and socially permissible actions; a dissonance that may defy resolution.

The Self Actualisation Hypothesis: Proposed by Maslow, it assumes that each individual has to ascend different steps of the self-actualisation pyramid. At the very bottom of the pyramid are the person’s survival needs; after which appear, progressively, security needs, social needs and ego needs in that order (see box). When all these needs are addressed to a significant extent, the person achieves a state of self actualisation, of fulfilment and being content with one’s lot. Stress is a constant companion at various points on the self-actualisation pyramid and disappears when self actualisation is achieved. However, Maslow’s rather utopian view of the lasting self-actualised state of being may not hold true in the fast-paced modern world, where events often outpace individual development in most unexpected ways.

The Locus of Control Hypothesis: An important psychological construct used to explain the development of depression, an important consequence of stress is the locus of control hypothesis. It has been observed that rats placed in connected cages soon learn to avoid the cage that habitually gives them an adverse stimulus such as an electric shock. However, when the rat receives shocks in an unpredictable manner, it becomes listless, withdrawn and inactive, a state of “learned helplessness”. This has led to the understanding that internal locus of control (where the person feels in control of his circumstances) is protective from emotional stress; while an external locus of control (being controlled by one’s circumstances), makes one vulnerable to it. In the years of post-war industrialisation this phenomenon was recognised in “assembly line workers” who had little control over the nature or pace of their work and were expected to perform a repetitive task for hours on end. Interestingly, our much vaunted IT revolution has ushered in a new generation of “assembly line workers” who operate on international time and in response to international demands, often with little control over their workspace destiny.

The Coping Hypothesis: One point which eludes us when we are in a stressful situation is that there are, usually, only two ways out. Take for instance the example of a very short-tempered boss who reacts without provocation. One can either attempt to modify the situation (i.e. bring about a change in the boss so that he loses his temper less); or one can modify one’s own expectations (i.e. accept that boss with his short temper and learn to work around it). No prizes for guessing which is the easier pathway here. It is often said for this reason “when you cannot modify the situation, modify your expectations”.

Coping strategies are of two kinds: i. Problem-focused coping where the attempt is to short-circuit negative emotions by modifying, avoiding or changing the threatening situation and; ii. Emotion-focused coping where the attempt to moderate or eliminate unpleasant emotions by rethinking in a positive way. Some strategies employed include relaxation, denial and wishful thinking.

In many circumstances, both approaches are combined in the effort to overcome stress.

Managing Stress:

A number of strategies can help in stress management. Some of these are outlined herein (see box).

Preventing Stress

The prevention of stress is achieved through good self management. The key to self management lies in being mindful: of oneself and the world around. Inexorably linked with this mindfulness is developing a better understanding of oneself and one’s fellowmen. Caught as one is in the vortex of modern existence, mindfulness can often be elusive, as the roller coaster of life takes us from one event to the next.

The famous Tibetan Buddhist teacher and philosopher Sogyal Rimpoche differentiates the active laziness of the West whereby unimportant tasks become responsibilities, part of a rigid schedule, and begin to dictate one’s existence (appointments, schedules, waiting times); from the passive laziness of the East, hanging out in front of the roadside stall with film music blaring, watching the world go by.

Neither, he contends, is ideal; instead, he highlights the importance of spirituality and contemplation and the need for us to devote some time in each day to examining the deeper meaning of life. In his view “Our task is to strike a balance, to find a middle way, to learn not to overstretch ourselves with extraneous activities and preoccupations, but to simplify our lives more and more. The key to finding a happy balance in modern lives is simplicity.”

It must be noted that stress clearly has its benefits. Imagine if you did not feel stressed out in advance of an interview or exam; your preparation and performance are both likely to be sub-optimal. Some stress is therefore necessary in order for human beings to “survive”. Too much stress, on the other hand, can be unproductive, even wasteful; resulting in much negative energy being expended. What we must try and achieve, therefore, is a fine balance between ambition and motivation on one hand and equanimity of mind on the other. And, while we strive to control our own destinies, by being in control of our lives and circumstances, our destiny may have other plans, that we cannot fathom; plans that we must learn to accept and live with. Perhaps, therein lies the key to effective stress management.

Dr. E.S. Krishnamoorthy is a Senior Consultant in Clinical Neurology & Neuropsychiatry based in Chennai. Interact with the author on www.neurokrish.com

Some heart facts

Stress impacts on the heart: it can cause myocardial infarction (heart attacks) and sudden death. It can affect the regulation of your heart beat by the central nervous system.

The INTERHEART study investigated the relationship between chronic stressors and Myocardial Infarction in about 25,000 people from 52 countries. After adjusting for other risk factors, those who reported “permanent stress” at work or at home had double the risk for developing a heart attack (MI).

The broken heart syndrome , sudden ballooning of the heart apex (left ventricle) follows acute stress. Often there is no evidence of obstructive blood vessel disease. Episodes of intense emotional or physiological stress are reported prior to presentation and maybe the triggering factor. Even when intense bouts of emotion don’t kill, they may cause long-lasting heart damage.

The Whitehall II study found over a two-fold increased risk for new coronary heart disease in men who experienced a mismatch between effort and reward at work. High-risk subjects were those who were competitive, hostile, and overcommitted at work, in the face of poor promotion prospects and blocked careers.

Cardiac syndrome X affects women more; there is angina-like chest pain and a positive response to the treadmill test with normal heart circulation. Cardiac syndrome X patients report more depression, anxiety and somatic (physical) concerns; they also have better prognosis.

Depression is a primary risk factor for Ischemic Heart Disease and an independent secondary risk factor for Heart Attacks. Depression also has a direct impact on cardiac risk factors such as diabetes, hypertension and obesity. Depression after myocardial infarction more than doubles the risk of death and of another heart attack. People who suffer chronic anxiety are more likely than others to suffer heart attack. Emotional trauma such as the death of a spouse, mental or physical abuse, or post-traumatic stress disorder (PTSD) increases risk of heart attack.

People with Type D personalities (characterised by pessimistic emotions and inability to share emotions with others) and Type A personalities (characterised by anxiety directed outward as aggressive, irritable, or hostile behaviours) are more likely than others to suffer heart attacks.

Freud said that happiness comes when one has pleasure in love and work. Research shows that marital stress in women and both marital and work stress in men greatly increase the risk of death due to a cardiac event. A famous doctor has observed “where can he go if he is unhappy at work and at home?” The implied, if somewhat flamboyant, answer was always “to an early grave.”

Be happy and keep your heart healthy!

DR. ENNAPADAM S.KRISHNAMOORTHY

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Featured Founders Blog

Buddhi Clinic: Leading the Way in Integrated Care for the Brain and Mind

In today’s fast-paced world, a large section of the population is denied the opportunity to manage chronic diseases through a wellness, holistic and healing-oriented approach.

Dr. Ennapadam S Krishnamoorthy

The burden of chronic disorders is largely attributed to the perils of modern medicine that prioritises cure through prescription drugs instead of focusing on the entire continuum of human healthcare engagement: rejuvenation, restoration and rehabilitation. The end result: an unhealthy ageing population.This is where India’s ancient and holistic Ayurvedic system as a viable form of alternative medicine comes in. It is about time medical practitioners harnessed the full potential of Ayurveda as it’s based on a strong foundation of scientific research, much like modern medicine’s tenets. 

In recent years, a growing body of research points to integrated medical treatments—a combination of complementary (alternative) and modern (allopathic) medicine—gaining popularity. While modern medicine’s thrust is on cure, integrative medicine focuses on disease prevention, comfort and care.

However, despite the marked shift in patients’ preference for alternative forms of healing, I observed a deficit of innovation in therapies that are based on integrative medicine. This is where Buddhi Clinic’s genesis and my entrepreneurial journey can be traced. 

I realised there was no other healthcare outfit in the world that provides a unique 360° evaluation of body, brain and mind through an integrated approach. At Buddhi, we take a holistic approach to diagnose a medical condition that combines the scientific rigour of modern medicine’s diagnosis and drug treatments with the therapeutic benefits of ancient healing traditions. 

In essence, my long-term vision for our healthcare startup that was founded as a project in 2009 and company in 2013, is to make complementary and alternative medicine (CAM) gain acceptance as mainstream therapies. From my experience, I realised this would be possible only by seamlessly integrating them with modern medicine. 

Let me tell you how this is done at Buddhi Clinic.

A Game-Changer in Brain and Mind Integrated Therapy

We are the pioneers and innovators of integrated care for the brain and mind. What sets Buddhi Clinic apart from the rest is that we don’t follow a cookie-cutter approach to diagnosis and treatment. Our raison d’être lies in being able to provide unique personalised treatment strategies for patients that is managed by interdisciplinary process-driven programmes. 

Since several neurological and mental health disorders and disability are longstanding issues, patients need continuous and comprehensive care. Thus, we strive to offer a better quality of daily life to our patients by curating a range of therapeutic solutions based on considerable clinical and empirical research, and our team’s extensive experience.

Buddhi Clinic’s focus is on neurology and mental health rehabilitation and therapy. We have also created a range of interventions for pain, mental health, lifestyle and disablement conditions. 

While our diagnostic approach and internal treatments are allopathic, we also rely on traditional healing therapies to restore the equilibrium of your brain and mind interface. Buddhi Clinic’s seamlessly integrated approach offers 14 non-pharmacological treatment modalities that are an amalgamation of modern science and ancient wisdom.

We offer treatment programmes for each condition customised for children, adults and the elderly. These include: Ayurveda, Acupuncture, Acupressure, Naturopathy- water, mud, aroma and magnet treatments; Reflexology and Yoga; and Rehabilitation therapies – speech, neurodevelopmental, physiotherapy and a range of specialized psychological therapies. We have also curated treatment combinations for Psychology – CBT, CRT, Behavioural, JPMR, ERP, EMDR; and Neuromodulation or brain stimulation (a full house of treatments). 

Empowering the Patient Based on the McDonalds Model”

One of the guiding principles behind founding Buddhi is respecting and understanding patient preferences and engaging patients in shared decision-making. Towards this end, we perceive our startup to be the McDonald’s of “Brain and Mind Care and Rehabilitation”. 

Similar to how a customer can curate his meal in a McDonald’s outlet, Buddhi Clinic, too, offers patients the choice to curate integrated treatment programmes tailored to their specific needs. This is called the “choice model” and is better suited for mild impairment and chronic or progressive health conditions. In such situations, we give patients the choice and flexibility to select a combination of modern and ancient interventions rather than rely on a single medical treatment, procedure and therapy. It is our belief that for best treatment outcomes, the patient should be in control of his own decisions regarding his healthcare options.

That said, our team also draws up a “prescription model” when the patient suffers from a chronic condition and requires continuous restoration and rehabilitation.

Crucially, at Buddhi Clinic, we adopt a holistic approach to healing our patients and focus on their overall wellness and recovery that goes beyond cure. We think different—not just about illness or disablement but also about ability and enablement. 

Research and Innovation Led Approach

Nothing fulfils me more than making sustained efforts to give our patients a better quality of life. Our patient-focused approach includes continuously monitoring their progress and offering them quality pre-treatment, mid-treatment and end-of-treatment assessments. 

Over the years, we have delivered quality healthcare to over 10,000 patients who have received an excess of 1,00,000 interventions. Our success stories that cover conditions such as autism, epilepsy, depression, Parkinson’s disease and dementia, among others, are documented as detailed case studies in ‘Buddhi Books’. The books are aimed at fostering the spirit of research and continuous learning to enable children, adults and elders achieve a better quality of daily life.

Buddhi Clinic also endeavors to offer innovative products and services to enhance the integrated approach to long-term brain and mind care. For instance, we use Transcranial Magnetic Stimulation (TMS) to treat neurological and psychiatric disorders. Transcranial Direct Current Stimulation (tDCS) and transcutaneous auricular Vagus Nerve Stimulation (taVNS) are also the Neuromodulation innovations we bring in. While the former two, rTMS and tDCS stimulate specific brain pathways for specific conditions and outcomes, the latter tAVNS stimulates the auricular (ear lobe) branch of the vagus nerve (ABVN), an easily accessible target that innervates the human autonomic nervous system. Like this, there are other innovations in the pipeline that we hope will lead to paradigm disruption in this space.

Building a Service-Oriented Approach

In order to create a healing environment based on holistic principles, we aim to continue to provide personalised and meaningful patient experiences at competitive rates. Since today’s patients have greater discernment, patient satisfaction is paramount to us. Our service-oriented approach helps us deliver, on an average, 10-20% more therapy to each paying client, apart from serving the disadvantaged at low cost or free of cost.

In the coming years, it is our goal to collaborate with doctors and diverse talents in the healthcare sector to serve populations beyond Chennai and India. Our objective is to demonstrate our capability as pioneers and leaders in integrated care with a brain and mind focus. 

One of my key learnings as a healthcare entrepreneur has been that it’s not enough to achieve a robust bottom line growth. It is equally important to sustain it by creating impact at scale through a committed patient-focused approach.