I Will Never Tell You To Relax

When I was in medical school some 30 years ago, I was taught never to tell a patient to relax. Nothing seems to make someone less relaxed than being told to do so. The alternative advice was to tell them to clench their toes and then slowly let go and feel the sense of relaxation sweep up your legs into the rest of your body. Showing them how to relax proves much more effective than telling them. That actually seems to work and I've tried it on myself numerous times.

I share this anecdote because it is a good prelude to today's topic. How do you tell someone about the dangers of stress without stressing them out?  That would seem to defeat the purpose of alerting them. I'll come back to this paradox later.

It's been an acceptable axiom for some time now that stress wreaks physiological damage on our bodies, even perhaps on the chromosomal level. I've seen references to a study that revealed that the telomeres which are the end of our chromosomes, shorten secondary to stress. Scientists generally believe that when a telomere shortens to a certain length, typically a cell undergoes apoptosis or cell death.

Along comes a meta-analysis study by Tom Russ, MRCPsych, of the National Health Service Scotland, and colleagues that reviewed 10 British cohort studies that showed that the risk of all-cause mortality or reasons for death in adults with the lowest level of psychological distress -- termed subclinically symptomatic -- was significantly higher than that of asymptomatic adults at an age- and sex-adjusted hazard ratio of 1.20 (95% CI 1.13 to 1.27). In other words, stress increases your likelihood to die from any number of reasons.

To quote medpagetoday.com, "The study measured the association of psychological distress with death by any cause, cardiovascular death, cancer death, and deaths from external causes using data from the Health Survey for England. The survey included data from 1994 to 2004 on 68,222 adults ages 35 or older, mean age 60 years, who were free of cardiovascular disease and cancer, and who lived in a private household in England at baseline."

As an observational study, in which results are observed as opposed to created, the study has its limitations. For example, we don't know the cause and effect relationship. Did people who became unhealthy develop more stress and therefore die at higher rates or did people who became more stressed thereby became unhealthy, which led to their death? There is no good way to do a high quality study of this kind because you can't have a group that you stress out to see if the stress will kill them. So, we are left with correlative studies such as this one as our best science. Notwithstanding, I think we can all agree that stress is not a good thing.

I know that whenever I hear about the dangers of stress to my health it raises my stress. It's like someone telling you not to think about something and you start thinking about it incessantly. The mind is a wonderful machine that still escapes our full understanding. Still, we have to work with what we know and that is it is better to be somewhat relaxed than somewhat stressed. In the book, The Longevity Project, by Doctors Friedman and Martin, we learn that a little bit of neuroticism is a good thing. I wrote about this some time ago. It's healthy to be aware of your surrounding and potential dangers. It's normal to worry about finances and relationships. It becomes unhealthy when you are consumed by such thoughts.

So how do we find a healthy balance between legitimate worries and irrational thoughts? I think the answer is focus. Ask yourself what is the focus of your life? Is it on potential and possibilities or what has gone wrong? Is it on tomorrow or yesterday? Is it on things you have to be grateful for or things that bother you? For some people making these choices is easy. If you are one of them and your focus is on the positive, I suspect that you enjoy life more than most. If you are hampered by a continuous stream of consciousness that accentuates the negative, you need to address this proactively. You can't ignore it; you need a plan. Speak to your clergyman, a doctor, or anyone you think may help.

I share these concerns about stress because despite the fact that it may raise you stress in the short-term, you will be better off in the long term by developing effective ways to lessen its toll on you.

As the studies suggest, living with stress means dying early from stress. Don't let yourself become a statistic.

Thoughts Are Not Facts

It is very hard to lose an argument in your own mind. That’s because there is no one to successfully argue the other side. It is not possible to live and not be exposed to events that are likely to cause stress. These events can include changing jobs, buying a home or car, getting married, having a child, losing a friend or relative, etc. Nevertheless, most people adapt to these stresses well and continue to lead useful lives. Some do not and the stress can become debilitating and disease promoting. Why? There are a number of reasons why each person reacts to stress differently. For most it is the contexts of which the stress occurs and other factors that mitigate or dissipate that stress. The key is not to see the source of the stress as the final arbiter.

When I was a third year medical student at New York University, I was assigned to the Bellevue Hospital Psychiatric Ward as part of my psychiatry rotation. One day, I was asked to process the admission of a man, whom I will call John, who was in his late-twenties, who presented himself to the emergency room as being depressed and suicidal. Accordingly, he was admitted to the hospital for a period of observation. When I did my admission evaluation with him, I asked him why he was depressed. His response caught me off guard and still resonates with me today, some 30 years later. He responded, “I always get screwed.” My initial reaction was that he was exaggerating but that he nevertheless believed it to be true. 

I probed deeper why he felt that way and he simply responded that everything went wrong for him and he was very depressed and wanted to kill himself.  I hoped we could do something for him but I wasn’t sure as a mere third year medical student how one deals with such a predicament. Over the ensuing few days, John underwent psychiatric counseling but still seemed to remain fairly depressed.  After about three days, he summarily informed me that he wished to go home. I dutifully advised the attending physician who felt that John was not ready. The concern was that depressed patients who contemplate suicide are more likely to perform the act once they are more energetic. Therefore, if John was really feeling less depressed, then he was in a particularly dangerous zone. When I told John the doctor did not feel it was time to go home just yet, John became quite agitated, arguing that he had brought himself to the hospital and that he now felt better and was insisting on going home. There was little I could do to assuage John who became increasing petulant. I went back to the attending physician and explained John’s reaction and the doctor remained steadfast in his opinion that John was not ready to be released. Over the next 24 hours whenever John and I spoke, he repeatedly expressed his growing anger about the doctor refusing to let him go home.

After a day or so, the doctor relented and agreed to let John go if he signed a form releasing the hospital of any liability for his medically ill-advised release. John angrily signed and I was asked to fetch John’s street cloths which the hospital had taken into storage. However, when I tried to do so, I was informed that John’s leather coat had gone missing.  I was afraid to tell John because of his now constant overtly manifested anger that he was without a coat in the middle of winter because the hospital had either misplaced it or had allowed it to be stolen.  Sheepishly, I approached John with the bad news expecting him to blow up at me. Then something eerily memorable happened. I told John and he did not react. I thought perhaps he had not heard or understood me and so I repeated myself. Again, he did not react. Finally, I asked John why was he not reacting and he responded, “I told you. I always get screwed.”

Is it possible that some people truly experience more than their share of bad luck? Is life for some a Greek tragedy where fate determines how they ping pong from one misfortune to another?

John thought so, but he was wrong. There is always a certain amount of predetermination in our lives. We can’t control who our parents are and the nature of the environment they create for us, including who we get for siblings. We can’t control the level of affluence we are born into and how that determines how we live, where we live, and what role money plays in our lives. We can’t control if we are born during a peaceful time or during a threatening war.  We can’t redo our childhoods regardless of its influences.

So what can we control? Just about everything else. Even though we may have certain genetic predispositions towards particular diseases, our lifestyle will to a great extent, scientists say 70%, will determine whether we develop chronic diseases like diabetes, heart disease, and cancer, the leading killer of Americans.  We may not be able to choose relatives, but we can to a great extent choose friends and significant others.  Louis Pasteur once said, that “chance favors the prepared mind.” While he was referring to the field of observation, his words ring true for virtually everything in our lives.

My older patients often tell me of aches and pains they suffer. Once I determine that the cause is not serious, I tell them the following. Life is full of aches and pains. It is what makes us feel alive. We can become victims and captives of such nuisances or we can ignore them and live our lives to the fullest. The twists and turns in our lives is what gives life color and flavoring. We can wallow about things that didn’t quite work out the way we wished. Or we can recognize that life may not be perfect but it doesn’t need to be to still be worth living and enjoyable.

 Two personal anecdotes bear evidence to the truth of these statements. One involved my first health care service company which I had founded with investment from others. The investors proved to be meddlers and I spent much of my waking time complaining about them rather than doing something about it. I thought I was stuck. Then one day after complaining about my predicament as had become my norm to an almost stranger (a friend of a friend), I got a wake-up call when he responded that I “sounded pathetic.” It was a rude awakening to say the least. I did not see myself as a whining, pathetic person, but that is what I had become. I had invested too much time and energy in what was wrong as opposed to in finding solutions. Those words changed my perspective and I took action that ultimately made everyone happy, including my investors.

A second anecdote took place more recently. Having grown up lower middle-class where money always factored into limitations and issues, I always thought that selling my company some day for enough money that would allow me to retire would be the highlight of my life. Little did I know the truth, but I found out. About three years ago, I retired after selling my company and I began to wallow in self-pity that I now longer had purpose in life. I had money, the freedom to pursue any hobby or activity, but yet I was miserable. I had always wanted to get more physically fit but I could not find the motivation to do so. I thought that if I only ran my old company again, all would be well. Well I got the opportunity and that reminded me why I sold it in the first place.  It was unfulfilling and I realized that my though process was flawed. It became clear to me that no external factor would be the genesis of my ultimate happiness.  I came to appreciate that happiness, satisfaction, and wellbeing had to be generated from within. Over the past year, I have discovered what it takes to be happy and healthy. It takes finding ways to help others. It takes finding meaning and pleasure in whatever we do whenever we do it. It takes being thankful for what we have and blocking out what we don’t need. It takes nurturing relationships with family, friends and strangers alike.  It takes realizing that “thoughts are not facts” and to spend less time thinking about what will make me happy and more time practicing it.

So if you want to focus on what is wrong in your life, no one can stop you. But that would be a shame because you would miss out on all the ways to find true happiness many of which cost nothing but a new perspective.