Understanding Stress and Treating Stress Related Health Problems

Paul Reller, L.Ac.

Many patients come to me in my clinical practice over the years with health problems that are poorly understood and not clearly diagnosed, and most of the time their medical doctor tells them that the problem is just due to stress or aging. Where that leaves us is a sort of limbo where we are faced with problems that we don't understand and can do very little about because of this highly generalized explanation. In truth, this explanation is not very helpful unless we come to grips with a scientific explanation of stress and aging that allows us to tackle and correct specific health imbalances. Once we understand the meaning of stress, much of which has a lot to do with the physiological process of aging as well, then we can tackle specific aspects of the problem. The key to treating health problems related to stress is to first individualize and understand your problem, then to restore either the acute or chronic stress related systems. With chronic stress and aging, the key is the restoration of a healthy homeostasis, and careful attention to systemic health, hormonal balance, metabolic balance, and inflammatory mechanisms is necessary in the assessment.

In general, most of us think of stress in terms of a chronic emotional problem, and use such terms as ‘stressed out’ to describe it. In truth, like many words, the term stress has many meanings, and when your physician uses the term stress, he or she is probably using one of the other meanings than the one that comes into your mind, which is a mentally or emotionally disruptive influence, or distress. Mental and emotional stress, though, is associated with an array of physiological factors, and understanding these physiological factors helps us to achieve a more objective perspective of our mental and emotional stress when it applies to specific health problems. Often, the first step in resolving health issues related to mental and emotional stress is to objectify it. When these health problems remain too subjective, there is often an aura of uncertainty that keeps us from taking concrete steps to resolve them. There needs to be better communication and patient education in this realm, because this area of health concerns, perhaps more than any other, depends on an interactive approach by both the patient and physician. Emotional and mental problem resolutions do not resolve completely by just taking a pill. On the other hand, there are stress factors in the body that have little to do with mental and emotional stress, and when the term stress is used without a specific context, the patient may jump to the conclusion that their physician is referring to mental and emotional problems, or that a vague psychological or emotional syndrome must be causing their physical or metabolic stress syndrome. These types of assumptions are often unhelpful in therapy, and once again, the importance of achieving a more concrete and objective defining of the health problems related to stress is very important to a successful outcome.

Physiologically, stress may refer to a mechanical or a metabolic strain. Stress on a joint may be mechanical, where an imbalance of muscular forces, and possibly poor body mechanics, places strain on the joint that causes mechanical deterioration. In most instances, though, the term stress, as applied to chronic health problems, is referring to metabolic stress, which overstrains the system in a variety of ways, especially with immune, hormonal, and nervous system dysfunctions. The key to this type of stress is understanding specifically what type of strain is occurring, and what type of disorder is created that specifically relates to the health problem in question. Once again, a generalized use of the word ‘stress’ is not helpful. Many times, new patients come to the Licensed Acupuncturist because they were told, or they read, that acupuncture can reduce stress. In fact, many medical doctors over the years have put down the practice of Complementary Medicine and the scope of acupuncture, or Traditional Chinese Medicine, by implying that all it does is reduce stress and perhaps temporarily relieve pain. This is very misleading, and while acupuncture may help relieve the effects of distress, or emotional and mental stress, the real need of the patient, in most instances, is relieving specific metabolic stresses and the specific problems that they create.

Metabolic stress is also defined in a number of ways in medical dictionaries. Steadman's medical dictionary defines stress as: “reactions of the body to forces of a deteriorating nature, infections, and various abnormal states that tend to disturb its normal physiological equilibrium (homeostasis).” The same dictionary defines mental and emotional stress as: “a physical or psychological stimulus such as very high heat, public criticism, or another noxious agent or experience which, when impinging upon an individual, produces psychological strain or disequilibrium.” While a standard medical practice may not be able to do anything about the noxious agents or experiences that are causing the imbalance, a physician that spends the time and treats the problem holistically can both take care of the homeostatic disequilibrium, or health imbalance, and help make the patient more aware and achieve a strength in their health, that helps the patient do their job and change these noxious agents or experiences, or if that is not possible, deal with them better. This takes a cooperative and proactive approach to stress-related health problems on the part of the patient, as well as a physician that can take the time and work with the patient to correct specific health imbalances, strengthen the system, and engage the patient in this targeted proactive approach. The medical doctor in today's system does not have the time to spend, and in fact, is too expensive to engage properly in this type of therapy. The Complementary Medicine physician is ideally suited, and especially the Licensed Acupuncturist and herbalist, who brings a variety of effective tools and is relatively inexpensive, and often brings a wealth of scientific understanding to solve the individual puzzles of stress and holistic health imbalance.

If the problem is one of metabolic stress, the first thing that must be done is to identify and define this stress, and make sure that the patient and the physician are on the same page when trying to clear this harmful metabolic stress. Since metabolic stress is defined medically as a deteriorating force, the medical problems resulting are usually chronic and degenerative. The specific stressor should be addressed and resolved, and the effects of the metabolic stress also treated intelligently. Sometimes, the stressor is no longer present in metablic stress disorders, yet the disease of degenerative condition is still present. A careful assessment of these stresses and consequences is absolutely necessary. Once the patient understands the problems and specifics, they can be resolved with the help of a physician.

Mechanical stress can also be a big problem, not only causing mechanical degeneration and inflammatory problems with your tissues, but also creating impingment syndromes that result in neuropathies and dystrophies, as well as autonomic nervous dysfunctions that impact on the whole health. The extensive study of myofascial pain syndromes has confirmed that most patients with chronic myofascial pain syndromes also develop some autonomic symptoms. These commonly include nervousness, insomnia, apprehension, increased allergy symptoms, dry skin and constipation, and gastrointestinal disorders. The Licensed Acupuncturist that is skilled in various physiotherapies, termed Tui Na in Traditional Chinese Medicine, as well as acupucture and herbal/nutrient therapy, is able to both resolve the mechanical stress and treat the consequences.

A new perspective of stress in modern medicine: Psychoneuroimmunology

For twenty years, the subject of psychoemotional stress has been heavily researched in modern medicine, especially in the realm of psychoneuroimmunology, a holistic perspective of health that explores the relationship between psychological factors, neurophysiological mechanisms, immune responses, and the hormonal, or endocrine functions. The subject of the placebo responses, cognitive effects on treatment, stress biomarkers, and the health consequences of beliefs, knowledge and expectancies on treatment outcomes has been a realm of medical research that has been exceedingly interesting to the University researchers, but generally put down by the clinical medical doctors and pharmaceutical researchers. This are of medicine has, in recent years, become a subject of interest to clinical nursing specialists, and is finally gaining some momentum in standard medicine. The term Mind-Body approach is now becoming common in standard practice, although a few years ago this would have been ridiculed by most M.D.s. Nevertheless, despite the bias against holistic medicine in standard practice, the sound research of decades makes this subject hard to reject. Of course, this same holistic connection between the Psyche, the Nervous System, and the whole physiology of the human organism, was a central facet of Traditional Chinese Medicine, and was well documented in texts dated to at least 400 BC. The challenge for humanity today is to advance their modern understanding of stress and apply it holistically and objectively to medical treatment and improved health.

Objective Signs of Metabolic Stress and their meaning

Laboratory analysis may now give the patient and physician some interesting biomarkers of stress. The two chief biomarkers relate to adrenal and metabolic strain from physiological and/or emotional/mental stress. These two biomarkers are diurnal cortisol and alpha-amylase, which are both measurable with inexpensive salivary samples. Understanding these two key biomarkers of stress helps us understand the complete picture of what we need to accomplish to better cope with stress and resolve pathologies related to chronic stress.

Alpha-amylase is an enzyme that is created to yield increased glucose and maltose from the breakdown of large carbohydrates such as starch and glycogen (the chief form of carbohydrate energy storage in our bodies). Glycogen is the form of starch that is stored in animal tissues, commonly called ‘animal starch’ to distinguish it from plant starches in our food. We store most of our energy fuel as fats (triglycerides mainly), but our bodies do keep a significant amount of animal starch, or glycogen, in all of our cells, and this fuel is utilized mainly when a sudden increase in energy is needed in the organ cells or muscles. Such a sudden need of cellular energy is usually generated by stress, or strain above what our bodies can normally handle. The glycogen storage in our bodies that is accessible to our organs is primarily stored in the liver cells. Red blood cells and muscle cells store various amounts of glycogen to handle mechanical, or musculoskeletal, strain. Our brains store glycogen and starch that can be converted within the brain when needed, to glucose energy, by a localized process called glycogenesis. Our daily habits, and training, both physical training and mental, determine the amount of stored glycogen in our cells. When there is a daily strain from stress that we are not trained to handle, or are physically and mentally incapable of handling, there is too much alpha-amylase secreted that is not utilized, and will show up on the saliva tests.

Cortisol is a steroid hormone produced by the adrenal gland, or top of the kidneys, and is well known to be released in the body in acute response to stress, but is also useful in the body to increase blood sugar, stimulate gluconeogenesis in the brain, suppress immune inflammatory responses that are in excess, and aid in fat, protein and carbohydrate metabolism. Because of the wide array of immediate effects of cortisol, there are a number of pharmaceutical analogs used extensively in medicine. The levels of cortisol in the body are tightly regulated, with the hypothalamus-pituitary-adrenal axis controlling the levels, which normally follow a diurnal pattern, with less cortisol during sleep and more during the active portion of the day. When cortisol levels do not change quickly enough to provide a good response to stress, we generally say that the patient has a adrenal deficiency syndrome. Slow cortisol response that is chronic will create a feeling of daytime fatique and insomnia, and have quite a depressing affect on the thyroid function. To adequately assess cortisol levels, first a waking cortisol level is measured, usually with active metabolites in the saliva. If this is off, a diurnal cortisol panel is taken, with 4 samples space throughout the day and night. Other related adrenal hormones, steroid hormones, thyroid hormones, and cortisol binding globulin, are usually measured as well to produce a thorough analysis and diagnosis. The production of cortisol in the adrenal gland involves a series of precursors, cholesterol, pregnenelone, and progesterone, and deficiencies of these may decrease adrenal cortisol responses, as well as a problem with hydroxylase enzymes, or the aldosterone metabolism and feedback. Using a pharmaceutical cortisol analoque may also damage the natural cortisol response in the body, and hypothyroid conditions will, of course, affect the metabolic rate of cortisol production.

Many studied factors are well known to stimulate increased cortisol responses, including stimulants like caffeine, sleep deprivation, intense exercise, high mental stress, anxiety, anorexia, and long commuting. Oral contraceptives increase cortisol levels even in young women that excercise regularly. Patients with excess body fat may generate excess cortisol in these fatty tissues. Postmenopausal estrogen deficiency is highly linked to increased cortisol, or unhealthy changes in diurnal cortisol response. Many therapeutic measures have been studied and are shown to decrease excess cortisol levels, including acupuncture, massage therapy, stress reduction therapies, omega-3 fatty acids, magnesium, etc. The best long-term benefit, though, will come from a balancing of the endocrine system, with a holistic and comprehensive restoration of physiologically normal steroid hormone levels, thyroid and hypothalamic function, and adrenal function. A knowledgeable Licensed Acupuncturist can prescribe inexpensive lab tests and analysis, and use a complete protocol to restore this homeostasis in a step-by-step process.

IgA (immunoglobulin A) and lysozyme have also been identified as biomarkers of stress. These metabolites are measurable in simple inexpensive salivary metabolite tests as well. While these biomarkers are not as clearly associated with stress disorders, they also provide additional information that the physicians of the future can assess and help guide therapy. Not all patients with high stress will test positive, and some patients may have other reasons in their health history for the high levels seen on tests. These facts do not rule out the usefulness of such biomarkers. Instead, a complete profile should be performed with individualized assessment. In standard medicine, there is much resistance to this strategy, as standard medical doctors have been convinced that they must use tests that are universally applicable in order to utilize drug therapies that are universally applicable. The difference in basic approach is becoming very clear to the patient population in recent years, and patients who respect the logic of the individualized comprehensive assessment and holistic integrated approaches in medicine are increasingly choosing to utilize Complementary and Integrative Medicine.

Other biomarkers now utilized in the analysis of stress related pathologies include reserved B lymphcytes, the C3 subunit of the complement system, various cytokines of the complement system, and the imbalance of helper T-cell responses. Of course, each individual patient may present a different array of these various biomarkers, and the baseline values of each individual may be somewhat different. This lack of universality of stress biomarkers has led to an easy skepticism over the years, as standard biomedical research is looking for factors that can be applied universally to make a universally applied pharmaceutical realstic. The truth is that various biomarkers of disease must be analyzed on an individual basis, and the sum total of a variety of objective values in laboratory analysis must be applied to the signs and symptom patterns of the individual patient. With this approach, a clear set of treatment protocols may be individually tailored to each patient, vastly improving the potential treatment outcomes. A number of modern laboratories are now offering such an approach.

To objectively assess that imbalances associated with chronic metabolic stress, simple saliva and veinous bloodstick testing is now readily available and highly accurate. Years of research and testing have resulted in the laboratory experts refining these tests and proving accuracy. Laboratories such as ZRT (Zava Research Technology) in Portland, Oregon, now provide much information to both patients and physicians to insure trust in these laboratroy assessments, the science involved, and the professional assessments that are individualized to the patient. These tools now enable the Complementary Medicine physician to utilize modern objective laboratory values and biomarkers to enhance and individualize the treatment of stress related disease and disorder. These tests also help the patient and physician understand what can be done to prevent an unwanted acceleration of the aging process, and to prevent diseases related to aging.

Acupuncture and Stress Reduction: Scientific proof

Numerous studies in recent years are proving how acupuncture reduces stress, both physiological (metabolic) and psychological. It has been well known that acupuncture is a good treatment for stress reduction for many years, but proving this in studies proved complicated. A number of human studies cited below show how acupuncture, even in simple and uniform choice of needle sites without stimulation, provided changes in the key biomarkers of stress, cortisol and IgA. The effects of an array of integrated treatments in Traditional Chinese Medicine, or the Acupuncture scope, may address a variety of underlying causes of stress dysfunction, though, that greatly exceeds these effects seen from needle therapy. When the stress is analyzed from a holistic and individualized perspective, the puzzle of what is causing the metabolic, physical or psychoemotional stress can be solved, and treatment tailored to both resolving symptoms and treating the causes of the disorder.

While the approach in modern pharmaceutical medicine is to block production of these stress related chemical factors when there is a clear association with disease, this is often a very problematic approach. If the patient is found to have high morning cortisol, or high alpha-amylase in saliva, simply blocking the production of cortisol and alpha-amylase will not really restore health. Acupuncture may modulate these chemicals in the body by restoring homeostatic mechanisms to better health, something that the current pharmaceutical approaches have not really tried to accomplish. This doesn't mean that there is no place for pharmaceuticals in the treatment of stress related pathologies, just that it not a question of either or, but a question of how best to design a treatment protocol that integrated various approaches to achieve the ultimate patient outcome. Traditional Chinese Medicine is the benchmark for holistic medical care, and has utilized this approach for centuries, with modern research now guiding its use as well. Many patients today are realizing the sound efficacy of Traditional Chinese Medicine and this holistic restorative approach, and coming to realize that the bias against this type of approach and therapy has not been one of patient concern, but of economic self-interest in the medical community.

Herbal and Nutrient Medicine in Stress Reduction: Scientific proof

A significant part of the practice of the Acupuncture profession, or Traditional Chinese Medicine, involves integrating acupuncture needle stimulation with herbal formulas and nutrient medicine. Much research has come to light in the last few years concerning the amazing efficacy of utilizing specific herbal and nutrient chemicals in treating specific stress related disorders. This type of research is now proceeding with a greatly accelerated advance in the number, size and complexity of studies. While the whole array of this research is too big to present here, some samples will help you to realize the incredible benefits of herbal and nutient medicine when applied with knowledge and skill.

Most of the population still does not understand the science of nutritional medicine. The general notion is still stuck in the past, with an idea that nutritional deficiencies occur with poor diet and a general supplementation with a multivitamin will probably fix all of these problems. While this is part of the story, it is a small part, and may be relegated to research from about 70 years ago. Modern research reveals that specific nutrient chemicals may play an important role in specific physiological mechanisms, and are becoming an important part of integrated approaches even in standard medicine today. Of course, the adoption of a legal mandate for coverage of Complementary Medicine by governmental health organizations and private insurance companies in Europe greatly accelerated the adoption of these protocols in European standard practice, and such mandates are needed in the United States as well, for the public good.

One good example of nutrient medicine in stress related pathologies is a 2006 randomized and double-blinded clinical trial of glutamine, an amino acid, in the treatment of post-surgical patients at intensive care units (quite a stress) at 16 hospitals in France, conducted by Rouen University Hospital. The study found that supplementation with glutamine in IV nutritional fluid (parenteral) greatly improved clnical outcomes. The randomized groups (but with similar types and severity of injuries) had drastically different outcomes of complications of infection, pneumonia, survival time, hyperglycemia, and insulin-requiring patient status. Most of these measured outcomes showed improvement of 20-80% with the inclusion of glutamine (see link to the study below). Such a study shows how this amino acid could be applied in standard clinical practice as well.

Oxidative stress is the key word that comes up in most studies of metabolic stress and disease mechanisms. Oxidative stress can be defined as the imbalance of oxidative tissue clearing need versus the ability of the body to clear the oxidative free radicals that accumulate in this process. When the body is faced with tissue degeneration, inflammatory injury, cancerous growths, etc. there is a need to clear the old tissues and replace them with new health growth. Breaking down these unhealthy tissues and cells, and cellular components, is accomplished mainly via the oxidative metabolism, where oxygen compounds react with these tissues, cells and cellular components in a way that breaks them down to smaller components and allows the body to circulate them away. Hydrogen peroxide is an example of a common oxidative molecule that we are all familiar with. Unfortunately, if the body's capacity for clearing the debris and utilizing these oxygen radicals is less than optimal, this process can lead to damaging oxidative stress. Antioxidants are a broad class of herbal and nutrient chemicals that help our bodies achieve this clearing of oxidative free radical accumulation, and reduce this type of metabolic physiological stress.

Information Resources

1. Many researchers have hypothesized in the past that stress related disorders were the subject of socioeconomic problems instead of physiological problems endemic to the population. This study, in 2005, at Princeton University and the University of Michigan, found that key biomarkers of chronic stress, especially basal cortisol levels, had no significant correlation with socioeconomic status: http:/www.ncbi.nlm.nih.gov/pmc/articles/PMC2566242/
2. A 1999 study of stress biomarkers found that IgA and Lysozyme enzymes were higher in a significant percentage of subjects testing high on stress scales: http://journals.lww.com/joem/Abstract/1999/10000/Are_Salivary_Immunoglobulin_A_and_Lysozyme.13.aspx/
3. Genetic assessment has also been introduced into the arena of biomarkers of stress, with telomere shortening being an accurate biomarker of stress as well as aging in the body: http://ouroboros.wordpress.com/2006/08/23/telomere-length-as-a-biomarker-of-stress-and-aging/
4. Scientific study explains how a type of Siberian ginseng aids decreases fatique as well as caffeine with enhancement of normal health biological processes: http://www.sciencedirect.com
5. Scientific study at the University of Tsukuba, Japan, in 2010, found that acupuncture attenuated decrease in salivary IgA, a biomarker of stress, that was induced by heavy exercise: http://www.ncbi.nlm.nih.gov/pubmed/20351374
6. Scientific study at the University of Tokyo, Japan, in 2003, found that acupuncture inhibited an increase in salivary cortisol, a biomarker of stress, that was induced by heavy exercise: http://www.ncbi.nlm.nih.gov/pubmed/12900681
7. Scientific study in 2010 at the Institute of Biomedical Research at the Pontifical Catholic University of Rio Grande do Sul, in Brazil, concluded that acupuncture was efficient in attenuating psychological stress in elderly patients, as well as improving immune function: http://www.ncbi.nlm.nih.gov/pubmed/20709154
8. Scientific study has also measured the effects of acupuncture stimulation on the brain and increased athletic endurance, as this study in 2002 from the Research Institute of Sports Science in Seoul, South Korea demonstrates: http://www.sciencedirect.com/8
9. A 2006 randomized double-blinded study in France, at 16 hospital intensive care surgical units, conducted by Rouen University Hospital, found that glutamine reduced post-surgical complications dramatically in these stressful conditions: http://www.ncbi.nlm.nih.gov/pubmed/16505644

The information on this website is not intended to be used as a specific medical advice or cure. Please consult with the practitioner or an appropriate physician, such as a licensed acupuncturist, naturopath, or medical doctor, to discuss the proper application of the information contained on this website.