When the Body Says No: The Cost of Hidden Stress (28 page)

Included in the study were thirty-six female adults or adolescents, none of whom had rheumatic disease. Among the subjects, fourteen had the RF antibody. Compared with the women
without
the antibody, the RF-positive group scored significantly higher on psychological scales reflecting the inhibition of anger and concern about the social acceptability of behaviours. They also scored higher on a scale that indicated traits such as “compliance, shyness, conscientiousness, religiosity and moralism.”

The presence of the antibody in these subjects suggests that emotional repression had already initiated immune reactivity against the self, although not to the point of clinical disease. One might expect that should additional stressful events occur in the lives of these women, they could further incite the immune mutiny, activate inflammation and trigger frank disease. “Emotional disturbances in conjunction with rheumatoid factor may lead to rheumatoid disease,” the researchers concluded.
⁹
It is also possible to develop rheumatoid arthritis
without
the anti-self antibody RF. As we would expect, in those cases the degree of stress may even have to be greater—precisely as found in another study.
¹⁰

A 1987 review of the literature concluded that “the weight of evidence from a variety of studies strongly suggests a role for psychologic stress in inducing, exacerbating, and effecting the ultimate outcome in rheumatoid arthritis.”
¹¹

Just how specific the effect of stress can be in provoking autoimmune disease is illustrated by the experience of Rachel, a young Jewish woman. Her first episode of rheumatoid arthritis occurred in response to an event that was a re-enactment of childhood emotional trauma.

Rachel had grown up in conflict with her older brother, whom she always perceived to be the favoured sibling. The parents separated, and she felt especially rejected by her father. “I was always the second-class citizen,” she says. “It was my brother that he wanted. I still remember walking halfway down the block by myself behind them, my father
with his arm around my brother. I remember always having to go into the back seat. I was told by my mother quite a few years ago that I went to Chicago to visit my dad with my brother only because she said, ‘You take both kids or you don’t take either.’ I was never wanted there.”

As a child Rachel says she was another “good little girl who never caused any problems,” a coping style she continued into adulthood. Two years ago on Rosh Hashanah, the Jewish New Year celebration, she was at her mother’s home, preparing dinner for the family. She was in a hurry, since she was to leave in time to avoid meeting her brother, who had decided to join the family at the last moment. “He didn’t want to come with me there, so we’d made an agreement that I would go early to my mother’s house and help her cook. At 4:00 p.m. I would leave so he and my sister-in-law and niece could spend the rest of Rosh Hashanah with my mother.”

“Am I getting this right?” I interjected. “What you’re saying is that you would go there and cook and do all the work and then you’d leave so others can have a nice ceremony and a meal together? Why did you accept that arrangement?”

“Because it was Rosh Hashanah and I feel family should be together.”

“What happened?”

“When I was at my mother’s house, my body went into pain that you wouldn’t believe. I was taken to the hospital. The arthritis was in one of my legs, and I couldn’t use it at all. I don’t usually scream in pain. The whole emergency room heard me, I’m sure. The very next day, I was back at the hospital because it was throughout my whole body. I could not move. Even being wheeled in a wheelchair, I was screaming my head off.”

Not only are the onset and flare-ups of rheumatic diseases related to stress but so is their severity. In a study initiated in 1967, fifty young adults newly diagnosed with rheumatoid arthritis were followed over a period of five years. Psychosocial stress factors preceding the onset of the disease were assessed at the beginning. All the patients were examined twice yearly and had annual X-rays of the wrists and hands, the commonest locations of disease activity. At study’s end, the subjects were classified according to the degree of tissue damage: in category 1, no
swelling on physical examination or X-ray evidence of bone destruction, called erosions; in category 2, soft tissue swelling but no bone erosions; in category 3, bone erosions in the wrists and hands. The results were published in
The American Journal of Medicine
. The researchers observed that the patients who would eventually place in category 3 were, on entering the study, “judged by the interviewers to have a significantly higher frequency of psychosocial stress factors associated with the onset of disease” than those who finished in the other categories.
¹²

Most of the interviews I conducted in preparing this book took place in people’s homes. Gila, a fifty-one-year-old woman with rheumatoid arthritis, insisted on meeting at the neighbourhood McDonald’s outlet. She could serve as the prototype of the “self-sacrificing, conforming, self-conscious, shy, inhibited, perfectionistic” rheumatoid patient described in the psychological literature.

Gila was diagnosed in 1976, during an episode of polymyositis, or generalized muscle inflammation. By the time she sought medical attention, she had lost much of her muscle bulk in her shoulders and hips. Her muscles of respiration were so weakened that she was breathing in a shallow way. She couldn’t lift her arms or legs or swallow anything dry. When the specialist saw her, she was hospitalized immediately for a course of intravenous corticosteroid medication. “He said I was a walking corpse. I should not even have been walking around. On my lung-function tests, when I was blowing into the machine, the needle would not move. Not even the slightest movement. But I compensated. You know … I didn’t realize. When I was walking, I didn’t notice that I was swinging, instead of lifting, my leg.”

“Why, do you suppose, you didn’t notice?”

“I was busy, I guess. I was tired. Because I had two kids, small kids, and I was running around.”

“I’m curious why you wanted to meet me at McDonald’s.”

“At home I’m always self-conscious about how my house looks. It has to be clean and tidy. If somebody comes to my house and notices that there is dust here or there, then …”

“You’re not talking about tidiness, you’re talking about perfection. You can’t get away from dust, can you? Dust is part of life. And if you can’t accept that, everything has to be perfect. Are you that way with everything?”

“Yeah. Before I had the rheumatoid arthritis actually, I was even more … My aunts called me a superwoman. My husband used to go out of town. He had to work in a sawmill for his apprenticeship. I was by myself here with two kids. I worked, and I worked overtime because we just bought a house. Sometimes I worked seven days a week, ten hours a day.”

“What did you do?”

“I used to work for the post office. I enjoyed the work, though.”

“You liked working ten hours a day, seven days a week?”

“Going to work is almost like going on holiday. I enjoyed the people there. I was friends with the supervisor; nobody gave me a hard time. Although everybody seems to be bored about post-office work around me, I just can’t understand why they are bored and complaining. I’m having a good time. So I think that was one of the reasons, too, that I had rheumatoid at first. I think I was abusing myself. I didn’t have enough rest. Not enough sleep.”

In addition to her job and her housework, Gila also felt she needed to maintain an immaculate garden and backyard. Her home was located between the houses of two retired couples who kept their yards to perfection, and she was concerned that if she neglected her garden their house values would go down. “Yes, impeccable. They would mow every week. So I have to do my lawn every week to keep up.” She also was keen for her children to be exposed to opportunities she herself had missed. On weekends she drove them to piano lessons, singing lessons, ballet lessons, folk dancing, sports events.

Gila did all this without any assistance from her husband and, all the while, worked at the post office on the afternoon shift, from 4:30 p.m. until 1:00 a.m. She slept about four hours a night for years. “When I had my rheumatoid arthritis, my physiotherapist told me, ‘When you have the pain, you have to stop. You have to rest, because that means your body is telling you that you need to stop.’ And so I do that. But the thing is, my housework is not done the way it used to be. Before, I would vacuum every other day, or even twice a day. Now, my husband is the one doing the vacuuming because I can’t do it any more. And I’m not happy with the way he vacuums. So sometimes I do it after him, although I don’t let him know that. I’m just doing the finishing. My house is not clean or neat and tidy the way it used to be.”

Gila was brought up in the Philippines, amid circumstances the reader by now will have guessed. She was the eldest of eight children and the caregiver to all. Her parents criticized her mercilessly. When anything went wrong, she was spanked.

“I had asthma. And every time I got a spanking, the asthma came. And every time I got the asthma, my mom would say, ‘Oh, that’s God’s punishment because you were bad. Because you didn’t do your job, because you answered back.’ So then I tried to do everything. I was not purposefully being bad. I was doing my best, and I was still being punished when I forgot. And sometimes I just couldn’t do it the way she wanted it. She is also a perfectionist.”

Gila’s husband beat her in the early years of their marriage. Later the abuse lapsed into emotional indifference, but he continues to be morbidly jealous and controlling.

Although some physiotherapists brought up stress issues in their work with Gila, none of the physicians who have treated her for rheumatoid arthritis ever inquired about her personal or emotional life. The wisdom of Sir William Osler has been lost in that vast Bermuda Triangle of modern medical practice.

After she developed her illness, Gila realized she needed to do some psychological work. She understood that her disease, unwelcome as it was, was perhaps trying to teach her something. The medical system was unable to help. At her own request, Gila was referred to a psychiatrist. “He told me that I should not be so upset, that I should treat my husband like he was my oldest son. I didn’t go back. I didn’t want a third son. I wanted a husband.”

In women with rheumatoid arthritis, the immune system has shown increased disturbance during periods of stress, but those who enjoyed better marriage relationships were spared exacerbations of disease activity like inflammation and pain.
¹³
Another study found that increases in relationship stresses were associated with increases in joint inflammation.
¹⁴

Results like these are not surprising. Recall that stress is a response to a perception of threat. Laboratory studies have demonstrated that many organs and tissues of the body become more vulnerable to inflammation and harm during or after periods perceived as threatening.
¹⁵
Stimuli interpreted as potentially dangerous can instantaneously induce dilation of blood vessels, swelling, bleeding, increased susceptibility to
tissue damage and a lowered pain threshold. Such changes can be initiated rapidly in subjects simply by interview techniques that augment the perception of threat.

There are several potential pathways by which overwhelming psychological pressures could become manifested as inflammation in joints, connective tissues and body organs. One of the teachings of the influential second-century Roman physican Galen was that any part of the body can affect any other part through neural connections. The rapid body changes in response to stress are, no doubt, effected through the instantaneous activity of the nervous system. Discharges originating in the brain can stimulate faraway nerve endings to release powerful pro-inflammatory molecules capable of inducing joint damage through hyperactivity of the immune cells. Some nerve-derived chemicals are also potent irritating agents for inducing pain. In autoimmune diseases, elevated levels of some of these substances are found in the fluid of inflamed joints as well as in the circulation. Such a dramatically quick mechanism was likely responsible for the acute onset of Rachel’s arthritic symptoms as she was labouring over the Rosh Hashanah supper she was not to attend. The severity of symptoms during that first attack indicated the severity of her repressed emotional reaction to the situation with her brother.

The
chronic
features of autoimmune disease involve the entire PNI super-system, particularly the brain-hormone-immune connections. The hypothesis that stress-induced PNI imbalances are physiologically responsible for the onset and flare-ups of autoimmune conditions rests on abundant research evidence.

Elaboration of the many potential mechanisms by which stress acts through the PNI system to cause autoimmune illness would involve too much scientific detail for our purposes. Suffice it to say that the body’s stress apparatus, and particularly the production of the key stress hormone, cortisol, becomes unbalanced through chronic overstimulation. Recall that normal cortisol secretion by the adrenals regulates the immune system and dampens the inflammatory reactions triggered by the products of immune cells. In rheumatoid arthritis, there are lower than normal cortisol responses to stress: we can see why, then, there would be disordered immune activity and excess inflammation. On the one hand, the immune system escapes from normal control and attacks
the body to cause inflammation, and on the other, the required anti-inflammatory responses are weakened and ineffective.

It is surely no coincidence that the one medication consistently used in all the autoimmune conditions is the adrenal corticosteroid, cortisol—or, more accurately, its synthetic analogues. Cortisol is the hormone most central to the stress response and the one that studies show to be most disregulated after chronic stress. Autoimmune connective tissue diseases, from SLE and rheumatoid arthritis to scleroderma and ankylosing spondylitis, reflect an exhaustion and disruption of the organism’s normal stress-control mechanisms.