DAMAGE CONTROL
| STRESS AND ITS IMPACT ON THE HEALTH AND WELL-BEING OF WOMEN —Esther Sternberg,
MD, Research Professor, American University, Washington DC; Director, Integrative Neural Immune
Program; Chief and Senior Investigator, Section on Neuroendocrine Immunology and Behavior, National
Institute of Mental Health/National Institutes of Health, Rockville, MD
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| Introduction: science returning to ancient teachings that emotions and health are one; stress can promote
sickness, and changing stressful responses can restore health; study of molecules, hormones, and nerve
pathways shows many ways in which brain and immune system communicate; way in which central nervous
system (CNS) regulates immune system and changes immune system function, and connections in
immune system important in maintaining health
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| Brain’s stress response: nerves, molecules, and hormones involved; hypothalamic-pituitary-adrenal (HPA)
axis—corticotropin-releasing hormone (CRH; stress hormone) released from hypothalamus and stimulates
pituitary gland to release adrenocorticotropic hormone (ACTH) which in turn causes adrenal glands
to release glucocorticoids (steroids); immune system regulated by sympathetic nervous system (SNS),
peripheral nervous system, and vagus nerve; immune molecules—immune system sends signals to CNS
via cytokines (immune molecules present during inflammation) that change how immune system functions;
inflammation, immune signaling, and immune molecules play important role in nerve cell death,
survival, and repair; cytokines—act like hormones; made at site (immune system) distal to organ affected
(brain); affect brain function and activate stress response and sickness behavior (behavior brought on by
brain, but triggered by immune molecules); immune disease results when neuroendocrine stress response
out of balance
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| Stress: Hans Selye first physician and scientist to recognize theory of stress; defined it as body’s nonspecific
response to any demand; different kinds of stress (eg, psychologic, physical, physiologic) can occur
at same time; once brain receives incoming signals through perceptual centers, they feed into final
common pathway of stress response
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 | Components of stress response: hormonal stress response—produced by CRH; CRH stimulates pituitary
gland to secrete ACTH and adrenal glands to secrete glucocorticoids; neuronal stress response—adrenergic
nervous system activated; adrenaline released from adrenal glands and adrenaline-like chemicals
(norepinephrine) released from adrenergic nerve endings; hormonal and neuronal stress response coordinate
into fight-or-flight response; stress response essential—provides energy to perform and focus attention
(especially needed in dangerous situations); some stress good for person; optimal level essential
for person to perform; animal studies show correlation between nerve firings; low nerve firing in part of
brain (locus caeruleus) regulating sympathetic part of stress response if animal inattentive and drowsy;
repeated firings of nerve cells cause stress center of brain to “freeze up”
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| Handling stress: whether person feels stressed or stimulated depends on ratio of demand to control experienced;
controlling stress response achieved by fooling brain into thinking it is in high-demand, high-
control situation, as opposed to low-control situation; complete control of any situation not practical;
stress response reduced if person can learn to feel in control or actually take control of certain aspects of
situation; training and practice important; biofeedback, stress reduction programs, meditation, yoga,
prayer, exercise, social support, Mediterranean lifestyle, and psychotherapy useful stress management
tools; allow person to disconnect emotional response from initiating event; no single modality works for
all people or for individual throughout life
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| Stress and sickness: stressors have different effects, depending upon dose, pattern, duration, and person’s
sex; allostatic load—cumulative effect of all stressful events on body; unlikely that single stressful event
or multiple stressful events with time to recuperate cause sickness; activation of brain’s hormonal stress response
(CRH, ACTH, and glucocorticoids) way to shut off immune response; glucocorticoids among most
potent anti-inflammatory drugs produced in body; stress causes sickness through activation of brain hormones
and nerve pathways that ultimately affect receptors on immune cells that change how immune cells
function; disease results when neuroendocrine stress response out of balance; illnesses associated with
blunted hormonal stress response include rheumatoid arthritis, systemic lupus erythematosus, Sjögren’s
syndrome, dermatitis, asthma, fibromyalgia, and chronic fatigue syndrome; interruption of HPA axis can
also occur at tissue level through impaired sensitivity to effects of glucocorticoids (known as glucocorticoid
resistance); hypothalamic-pituitary-gonadal axis plays important role in regulating autoimmune inflammatory
disease and immune system
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| Female sex hormones: estrogens proinflammatory; low concentration of estrogens stimulates cellular
component of immune response and high concentration stimulates anti-inflammatory cytokines; communication
occurs between stress hormone axis and sex hormone axis and they regulate one another; no single
hormone plays role in regulating how person responds to stress or how stress response affects
immune response
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| Autoimmune inflammatory disease: greater incidence in women than men (2:1 to 10:1); no question female
sex hormones play important role in manifestation of illnesses; multigenic and polygenic; many illnesses
have small genetic component; whether person develops disease depends on genetic load; genetic
contribution of traits accounts for ≈35%, environmental factors for ≈65%; complementary and alternative
modalities directed at changing environmental milieu that predisposes or protects person from inherited
diseases
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| Conclusion: genetic and developmental factors and environmental exposures determine set point of host
response in hormonal stress response; all contribute to regulating immune system; understanding how
hormonal stress response affects health can assist health care provider in preventing and treating disease
and assist patient in using complementary and alternative modalities together with modern advances of
medical science; stress normal part of life; people should seek care if stress impairs functioning; person
should not be expected to handle stress alone or allowed to accept situation as their biology (may need
medication or guidance from health care provider)
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| HOW TO SPOT DOMESTIC ABUSE BEFORE IT SPIRALS OUT OF CONTROL —Jeanne King, PhD,
Psychologist, Author, Speaker, and Consulting Expert on Family Violence Intervention, Denver, CO
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| Myths about domestic abuse: occurs primarily in lower socioeconomic population; abuser can change;
victim responsible to help abuser change
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| Risks inherent in leaving battering relationships: on way out of abusive relationship, victim likely to be
revictimized by perpetrator’s use of legal system to continue to batter and regain control of family; battered
women more vulnerable to physical attack, attack on personal privacy, civil liberties, and parental
rights after leaving abuser; 75% of all homicides by intimate male partners occur after victim leaves
abuser; domestic abuse fundamentally about control; violence manifestation of domestic abuse
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| Pregnant women: account for 25% of victims of domestic abuse; 40% of all assaults on women by domestic
partner occur during first pregnancy; estimated that pregnant women have twice risk for battery
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| Family court: often facilitates continuation of battering dynamic; if perpetrator controls family finances
(most often case), litigation can be controlled through, eg, legal stalking, financial starve-out tactics,
threats of obtaining custody of children; perpetrators often use threat of obtaining custody of children to
obtain what they want
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| Role of health care provider: do not assume family court provides victim with protection from perpetrator
of domestic abuse; support victim and make appropriate referral to domestic violence agency or advocate;
protocol in office for handling victims of domestic violence and familiarity with protocol in
hospital recommended; never assume one health care provider will do job of another
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| Encourage victim to take control: belief that victim responsible for and can control violence is myth; victim
enables violence, but does not control it; help victim utilize internal resources in conjunction with social
resources to protect self when leaving abusive relationship; encourage victim to take responsibility
for own life and relinquish responsibility for perpetrator’s actions; victim lives in perpetual state of fear,
often manifesting in health problems, ie, irritable bowel syndrome, chronic pelvic pain, insomnia, headaches,
anxiety, depression; best point of intervention is early prevention
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| Signs and signals: 1 of 3 people experience domestic abuse at some point in life; red flags—bruises; partner
accompanies patient to every visit and does not leave room; partner answers questions for patient; patient
appears depressed; complaint of pelvic pain; children accompanying patient appear fearful
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| Victim: feels oppressed, controlled, manipulated, and caged; feeling as though walking on eggshells
common; male victims—often described as “henpecked”; same dynamic of excessive jealousy, possessiveness,
hypersensitivity, unrealistic expectations, and mood shifts (“Dr. Jekyll/Mr. Hyde” personality)
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| Abuser: externalizes blame; blames victim for her (or his) problems, circumstances, feelings, and thoughts;
lives on side of righteousness; blames victim for altercations perpetrated on victim (major red flag);
dynamics and symptoms same whether abuse physical, emotional, psychologic, or sexual; control and
possessiveness primary characteristics; victim consents to being controlled, whether consciously or
unconsciously; abuser nonempathic to victim’s feelings; behaves as though world revolves around him
(or her), expecting victim to cater to needs; child abuse—70% of intimate partner abusers abuse their
children; intimate partner violence important predictor for child abuse; battering—can be physical,
emotional, or psychologic; used to establish and maintain dynamic of unequal power within relationship;
although important symptom, only one facet in larger picture
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| Isolation: victim often isolated from all sources of support, eg, social, emotional, financial; creates relationship
of dominance, dependency, and exclusivity; isolation social mechanism that maintains domestic
violence, and denial psychologic mechanism that maintains it; speaker opines health care providers serve
as important frontline resource for domestic violence intervention
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Educational Objectives
| The goal of this program is to educate the listener about the connections between emotions and health and
the role of health care providers in identifying and supporting victims of domestic violence. After hearing
and assimilating this program, the clinician will be better able to:
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| 1. Summarize how nerves, molecules, and hormones connect the brain and immune system.
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| 2. List the 2 components of the stress response.
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| 3. Discuss how the brain signals the immune system and how stress contributes to chronic disease.
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| 4. Explain how a victim of domestic violence can continue to be victimized after leaving the perpetrator
of abuse.
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| 5. Recognize the dynamics underlying domestic violence and the role of health care providers in assisting
victims of domestic violence.
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Suggested Reading
Elliott L et al: Barriers to screening for domestic violence. J Gen Intern Med 27(2):112, 2002; Eskandari F
et al: Neural-immune interactions in health and disease. Ann N Y Acad Sci, 966:20, 2002; Marks JS et al:
Does a failure to count mean that it fails to count? Addressing intimate partner violence. Am J Prev Med
30(6):530, 2006; Marques-Deak A et al: Brain-immune interactions and disease susceptibility. Mol Psychiatry
10(3):239, 2005; Sternberg EM: Neuroendocrine regulation of autoimmune/inflammatory disease. J
Endocrinol 169(3):423, 2001.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any
significant financial relationship with the manufacturer or provider of any commercial product or service
discussed. For this issue, the faculty reported nothing to disclose.
Dr. Sternberg was recorded at Pain Management in Women Over the Lifecycle sponsored by the University of
California, San Diego, School of Medicine and held April 27-29, 2006, in San Diego, CA. Dr. King was
recorded at the 24th Annual OB/GYN Update sponsored by HealthPartners Institute for Medical Education,
held April 20-21, 2006, in Minneapolis, MN. The Audio-Digest Foundation thanks the speakers and the
sponsors for their cooperation in the production of this program.
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