When the Body Says No: The Cost of Hidden Stress (30 page)

Depending on individual predisposition, asthmatic attacks may be set off by everything from allergens to exercise, cold temperatures or medications such as Aspirin, to crying and laughing, viral respiratory infections and emotional arousal. Asthma is one of the few diseases recognized by mainstream medicine to have a significant mind-body component.

Emotions can play a major role in making a person susceptible, no matter what the immediate trigger may be—Aspirin or cold air or anxiety. Chronic emotional stresses sensitize the immune system, so that it becomes overly reactive to any number of triggers.

Another way emotions affect the inflammation in asthma is through hormones. Glucocorticoid hormones—anti-inflammatory steroid hormones, most notably cortisol—are secreted by the adrenal glands on signals from the hypothalamic-pituitary system in the brain. A diminished cortisol response by an impaired HPA axis would promote
inflammation. At the University of Trier, Germany, a study found that children known to suffer from atopic dermatitis (eczema, itchy allergic rashes) or from asthma have a diminished production of cortisol in response to stress. “When asked to tell a story or to do mental math, these children show less increase in the glucocorticoid concentrations in their saliva than do healthy peers.”
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In fact, man-made cortisol-like hormones are a crucial part of the treatment for asthma.

Many studies of asthmatic children and adults have documented a strong association between disease severity and emotional states triggered by relationships.
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Researchers who looked at the interactions between parents and asthmatic children have identified characteristic patterns of insecure attachments. Separation anxiety has been observed in children with asthma to a greater degree, not only in comparison with healthy controls but also when matched with children suffering from cystic fibrosis, a congenital lung disease, more serious by far.
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The severity of the disease, in other words, was not the cause of the anxiety.

Under test conditions, one study examined the breathing patterns of asthmatic children between two and thirteen years of age, using a comparison group of healthy controls. Each child listened to recordings of his or her mother’s voice and that of a stranger. “Regardless of the tone of the voice, asthmatic children showed more abnormal respiratory patterns when listening to their mother’s voice than when listening to that of a strange woman. This interesting result suggested a specific emotional effect on breathing that was contrary to what one would have predicted if the child had seen the mother as being reassuring.”
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In German studies, asthmatic children were more likely than their healthy counterparts to engage in long, escalating, mutually negative interactions with both their mothers and fathers. Their parents tended to exhibit more critical behaviour toward them than the parents of other children.
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On objective measures, when asthmatic children felt frustrated or criticized, the flow of air from their lungs diminished, indicating airway narrowing. Decreased airflow has also been documented when children with asthma were asked to recall incidents of intense anger or fear.

The stresses that may induce asthma in a child are not necessarily recognized as such by either the patient or the family. Dr. Salvador Minuchin at the Philadelphia Child Guidance Clinic has studied asthma
and other childhood illnesses. In his view, highly sensitive children pick up subconscious cues from the environment, particularly about the emotional states of their parents. He has noted that family systems in which children develop disease have four features in common: enmeshment, overprotectiveness (controlling), rigidity and lack of conflict resolution. “A pathologically enmeshed family system is characterized by a high degree of responsiveness and involvement. This can be seen in the interdependence of relationships, intrusions on personal boundaries, poorly differentiated perception of self and of other family members, and weak … boundaries.”
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One of Joyce’s recent asthma flare-ups, which lingered several months after the original incident, occurred after a family get-together. The episode, in which she felt attacked by her older brother, brought up emotions of fright and suppressed anger from her childhood.

“When I was young, I operated in fear of the anger that was displayed. I was never hit, but there was a lot of anger around in my family—my father’s and my brother’s. My mother was complicit in that. She didn’t defend me from that anger. The anger wasn’t necessarily directed at me, but it was around me. I felt helpless in all of that. Part of my inability to say no has been always that fear of displeasing, of being in difficult situations. Even now, I find it very difficult to deal with problematic situations.

“It was this low level of anger all the time. My father was the righteous one. There would be an expression on his face, a tone in his voice. It was always so irrational, like a child’s response to the world. It wasn’t like an adult.

“I couldn’t take it—I was scared by it. I never felt safe. My father is now eighty-two. He doesn’t lash out as much because he’s pretty old. My brother is a very angry person; he lashes out all the time and it can be quite devastating.

“Just to say what happened this fall … At the end of November is my son’s birthday—six years old, and that’s a big deal. My parents came up from Seattle, and my brother joined us. We all had dinner together. He just went over the top—critical, angry, directed at me. That happened Friday. Saturday was my son’s birthday, and I felt completely upset. I woke up Monday morning and couldn’t talk, couldn’t walk, couldn’t do anything.”

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A recent Australian study pointed to the importance of positive social relationships in modulating stress. Five hundred and fourteen women who required breast biopsies were interviewed. Slightly fewer than half of the subjects were subsequently diagnosed with cancer, the others with benign tumours. The results “revealed a significant interaction between highly threatening life stressors and social support.
Women experiencing a stressor objectively rated as highly threatening and who were without intimate emotional social support had a ninefold increase in risk of developing breast carcinoma.”
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The investigators found themselves taken by surprise. They write, “Our finding of an interaction between severely threatening life events and the absence of social support was
somewhat unexpected
given the absence of independent effect.”

Yet this finding is no more startling than learning that non-swimmers without life jackets are not at risk of drowning—at least, not until they are thrown into deep water. The reader will remember from chapter one that medical students under the stress of exams were shown to have diminished immune system activity, but that the most isolated among them were the most vulnerable. The physiological functioning of human beings is inseparable—even in theory, let alone in practice—from the emotional and social connections that help to sustain us.

A seventeen-year follow-up study of residents of Alameda County, California, looked at the possible links between people’s social connectedness or sense of isolation and the onset of cancer. In this prospective study, none of the adults enrolled at the start had cancer. “The risk factor of major interest for women appeared to be social isolation, not only being isolated, but also of
feeling
isolated…. Given the effect of emotions on hormonal regulation, it is not unlikely that isolation may have a direct promotional effect on the development of this set of cancers.”
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The researchers grouped cancers of the female breast, ovary and uterus as hormone related.

We do not all mirror one another in how we are physiologically affected by social and interpersonal stressors or other external pressures. What, apart from inborn temperament, accounts for these individual differences?

A key factor is emotional development. Should the child in the first example require a further operation at the age of twenty-five, she will
no longer need her mother and father to hold her hand while the anaesthetic is administered. She will have enough self-regulation that neither her neurotransmitter activity nor her stress hormones would go out of balance without her parents’ immediate proximity. We cannot take it for granted, however, that with chronological adulthood we automatically attain emotional independence. At any age, our responses to potential stressors are deeply influenced by the degree to which our emotional functioning continues to be dominated by our attachment needs, fears and anxieties.

According to the family systems theory articulated by the late American psychiatrist Dr. Murray Bowen, illness is not a simple biological event in a separate human being. A family systems view recognizes the moment-to-moment interrelatedness of the physiological functioning of individuals. Self-evident in the relationship of mother and fetus, this physiological interrelatedness does not end with birth or even with physical maturation. As we have seen, relationships remain important biological regulators throughout a whole life.

A fundamental concept in family systems theory is
differentiation
, defined as “the ability to be in emotional contact with others yet still autonomous in one’s emotional functioning.” The poorly differentiated person “lacks an emotional boundary between himself and others and lacks a ‘boundary’ that prevents his thinking process from being overwhelmed by his emotional feeling process. He automatically absorbs anxiety from others and generates considerable anxiety within himself.”
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The well-differentiated person can respond from an open acceptance of her own emotions, which are not tailored either to match someone else’s expectations or to resist them. She neither suppresses her emotions nor acts them out impulsively. Dr. Michael Kerr, a former colleague of Murray Bowen’s, is currently director of the Georgetown University Family Center, Washington, D.C. Dr. Kerr distinguishes between two types of differentiation:
functional differentiation
and
basic differentiation
. The two types may superficially appear to be identical, but from the perspective of health and stress they are worlds apart.

Functional differentiation refers to a person’s ability to function
based on his relationships with others
. For instance, it may be that I can do my work well only when other people—my employees, my spouse, my children—can absorb my unresolved anxieties by putting up with
my bad temper, unreliable habits, lack of emotional engagement or even abusive behaviour. Were they to reject the roles I assign them, I might fall apart. That would be an example of functional differentiation. On the other hand, if my ability to function is independent of other people’s having to do my emotional work for me—that is, if I can remain engaged with others while staying emotionally open to them and to myself—then I would be said to have basic differentiation. The less basic differentiation a person has attained, the more prone he is to experience emotional stress and physical illness.

In a study of stress, adaption and immunity, fourteen hundred military cadets at West Point were followed for four years. They were tested psychologically and had regular blood tests to study their susceptibility to the Epstein-Barr virus, the causative agent for infectious mononucleosis. Those most susceptible to contract the virus or to develop clinical disease had the following in common: they had high ambitions for themselves; they were struggling academically; they had fathers who were high achievers.
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We can see here the relationship between the stress and the perceived need to live up to parental expectation—that is, between the internal biological milieu and the child’s continuing need to gain acceptance.

In another study, married women were matched with an equal number of women who were divorced or separated. In the married group, marital quality and satisfaction were assessed by means of self-reports. Immune system activity was studied in blood samples drawn from each participant. Poorer marital quality was “strongly and positively” related to poorer immune response. In the divorced or separated group, the two psychological factors most closely associated with diminished immune functioning were the time elapsed since the breakup (the more recent the marriage failure, the greater the immune suppression) and the woman’s degree of attachment to the former spouse (the greater the emotional attachment, the worse the immune function).
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Women who were more self-regulated, less emotionally dependent on a relationship that failed to work for them, had stronger immune systems. Greater differentiation means better health.

The less powerful partner in any relationship will absorb a disproportionate amount of the shared anxiety—which is the reason that so many more women than men are treated for, say, anxiety or depression.
(The issue here is not
strength
but
power:
that is, who is serving whose needs?) It is not that these women are more psychologically unbalanced than their husbands, even though the latter may seem to function at higher levels. What is unbalanced is the relationship, so that the women are absorbing their husband’s stresses and anxieties while also having to contain their own.

We recall that Nancy, wife of a man with ulcerative colitis, was exasperated at the stress triggered for her by her husband’s obsessive and rigid controlling attitudes.
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Tim’s disease has been in reasonable control over the years. Nancy has effectively absorbed much of his anxiety, but at her own expense. Nancy is now being treated for depression and anxiety and says she is nearing the end of her rope. “It has felt like I have another child,” she says, “because he is very high maintenance. I now understand that I have four children I have been responsible for. I’m the parent for both of us. I’ve repressed my emotional needs for a very long time, without realizing it. It’s frightening to think now that I wasn’t even aware of that, until I had a mini-breakdown.” If Nancy lets go of her one-sided nurturing role in the relationship, Tim may experience a flare-up of his colitis—unless he learns to take more emotional responsibility for himself.