Mar 18, 2008

HEALTH MATTERS: Hidden stress can cause physical symptoms

By LJ Anderson / Daily News Columnist

Over one-half of all patients walk away from a doctor's visit without receiving a definitive reason for their symptoms. This diagnostic dead-end causes frustration for both the patient and the provider. The evaluation may be incomplete, though, if the patient was not asked about stress factors in his or her life. Hidden stress factors can cause real symptoms - not detectable on diagnostic tests - but only elicited through careful questioning by a health care provider trained and willing to look for further clues.

David D. Clarke, MD, is a board-certified internist and gastroenterologist with a private practice in Portland, Ore., a clinical assistant professor of medicine at Oregon Health Sciences University, and the author of "They Can't Find Anything Wrong!" (www.stressillness.com).



Q: How did your thinking about stress illness evolve as you treated patients?

A: I knew almost nothing when I started in 1983 because medical education typically neglects this area. But Dr. Harriet Kaplan, a psychiatrist who is also certified in medicine at UCLA, gave me the framework and taught me what to look for. I learned the rest from in-depth interviews with over 7,000 patients whose diagnostic tests were normal. It was five to six years of learning before I could reliably zero in on the hidden stress responsible for a patient's illness.


Q: What are the causes of most stress illness that you have treated, and how does it manifest itself?

A: Most stress illness is caused by issues in five areas: prolonged effects of stress in childhood, stress in present-day life, and three mental health conditions that many people (and their doctors) don't recognize, depression, post-traumatic stress and anxiety disorder.
The physical symptoms of stress illness may be anywhere from head to toe: pain, muscle aches, joint stiffness, difficulty breathing, nausea, vomiting, bowel problems, dizziness and many more. People with stress illness often have more than one symptom simultaneously.



Q: How would a patient recognize that he or she had a stress illness, and then be treated?

A: You start with a medical evaluation to look for other diseases. If that shows no cause, then you should consider the possibility that stress is causing the illness. If we can find and treat the stress, and the illness gets better, we have good evidence that we are on the right track.

How do you find a hidden stress? Start by writing a list of everything in your life that causes stress, fear, worry, anxiety or anger. Keep the list with you and add to it as new ideas come to mind. Many people notice significant relief of symptoms if they can change just a few items on the list for the better. One of my patients, for example, noticed that he had stomach pain while driving to work but not while driving home from work. Making some changes in his workplace relieved the problem. Next, if you are the kind of person who takes care of everyone else but neglects your own needs, then insist on taking several hours each week solely for your own joy. Third, learn relaxation technique: get relaxed, breathe deeply then consciously relax each muscle group in your body, one by one, starting with the feet and working up to the head. Fourth, ask yourself if it would be acceptable to watch an innocent child grow up exactly as you did. If not, consider that prolonged effects of childhood stress are capable of causing illness. If you feel ready, try writing a letter (not to be mailed) to the person or persons who caused the stress that expresses your deepest feelings. Fifth, many people with symptoms of depression do not feel particularly depressed. Instead, they sleep poorly, have no energy, have lost enthusiasm for activity they previously enjoyed, may have lost their appetite, and cry more easily. This can be treated with counseling and/or medication with good results for most. Sixth, have you had a terrifying or traumatic experience that intrudes into your thoughts or causes nightmares? One of my patients went to a therapist for the first time 12 years after a brutal assault. The therapist was gentle but my patient still vomited during the encounter and developed severe pains the next day. Fortunately, her post-traumatic stress disorder responded well to treatment, which it usually does. Finally, do you experience worry, tension or anxiety out of proportion to any reason for those feelings? If so, you may have an anxiety disorder. One of my patients had attacks of diarrhea a few times per week. But they never occurred while she was at home where she felt safe. Treatment for anxiety stopped the attacks.


Q: How much physical pain do you estimate is, at its root, stress illness?

A: A study by Kurt Kroenke et al. many years ago showed that 50 to 60 percent of people who go to the doctor have no medical explanation for their symptoms one year later. Most of these patients have stress illness, in my experience. This means that hundreds of millions of medical office visits in the United States are for a condition that cannot be diagnosed with tests. Compounding the problem is the fact that most doctors don't know what to look for when diagnostic testing is normal. The good news is that with relatively simple questions, the hidden stresses can be uncovered and effective treatment initiated. Most of these patients will feel a lot better fairly quickly.



LJ Anderson writes on health matters every Tuesday. She can be reached at lj.anderson@yahoo.com.