Ulcer Related Quotes

Medicine is a social science, and politics nothing but medicine on a large scale,

A large percentage of what we think of when we talk about stress-related diseases are disorders of excessive stress-responses.

In a world of stressful lack of control, an amazing source of control we all have is the ability to make the world a better place, one act at a time.

It takes surprisingly little in terms of uncontrollable unpleasantness to make humans give up and become helpless in a generalized way.

Something roughly akin to love is needed for proper biological development, and its absence is among the most aching, distorting stressors that we can suffer.

Subjected to enough uncontrollable stress, we learn to be helpless—we lack the motivation to try to live because we assume the worst; we lack the cognitive clarity to perceive when things are actually going fine, and we feel an aching lack of pleasure in everything.

The defining feature of a major depression is loss of pleasure. If I had to define a major depression in a single sentence, I would describe it as a “genetic/neurochemical disorder requiring a strong environmental trigger whose characteristic manifestation is an inability to appreciate sunsets.

Everything in physiology follows the rule that too much can be as bad as too little. There are optimal points of allostatic balance. For example, while a moderate amount of exercise generally increases bone mass, thirty-year-old athletes who run 40 to 50 miles a week can wind up with decalcified bones, decreased bone mass, increased risk of stress fractures and scoliosis (sideways curvature of the spine)—their skeletons look like those of seventy-year-olds. To put exercise in perspective, imagine this: sit with a group of hunter-gatherers from the African grasslands and explain to them that in our world we have so much food and so much free time that some of us run 26 miles in a day, simply for the sheer pleasure of it. They are likely to say, “Are you crazy? That’s stressful.” Throughout hominid history, if you’re running 26 miles in a day, you’re either very intent on eating someone or someone’s very intent on eating you.

if you want to increase your chances of avoiding stress-related diseases, make sure you don’t inadvertently allow yourself to be born poor.

Fear is the vigilance and the need to escape from something real. Anxiety is about dread and foreboding and your imagination running away with you. Much as with depression, anxiety is rooted in a cognitive distortion. In this case, people prone toward anxiety overestimate risks and the likelihood of a bad outcome.

This is the critical point of this book: if you are that zebra running for your life, or that lion sprinting for your meal, your body’s physiological response mechanisms are superbly adapted for dealing with such short-term physical emergencies. For the vast majority of beasts on this planet, stress is about a short-term crisis, after which it’s either over with or you’re over with. When we sit around and worry about stressful things, we turn on the same physiological responses—but they are potentially a disaster when provoked chronically. A large body of evidence suggests that stress-related disease emerges, predominantly, out of the fact that we so often activate a physiological system that has evolved for responding to acute physical emergencies, but we turn it on for months on end, worrying about mortgages, relationships, and promotions.

Males who do extreme amounts of exercise, such as professional soccer players and runners who cover more than 40 or 50 miles a week, have less LHRH, LH, and testosterone in their circulation, smaller testes, less functional sperm. They also have higher levels of glucocorticoids in their bloodstreams, even in the absence of stress. (A similar decline in reproductive function is found in men who are addicted to opiate drugs.)

Whenever you inhale, you turn on the sympathetic nervous system slightly, minutely speeding up your heart. And when you exhale, the parasympathetic half turns on, activating your vagus nerve in order to slow things down (this is why many forms of meditation are built around extended exhalations).

the average level of happiness increases in old age; fewer negative emotions occur and, when they do, they don’t persist as long. Connected to this, brain-imaging studies show that negative images have less of an impact, and positive images have more of an impact on brain metabolism in older people, as compared to young.

Genes are rarely about inevitability, especially when it comes to humans, the brain, or behavior. They’re about vulnerability, propensities, tendencies

This is thought to reflect the killer combination that these folks are often burdened with, namely, high work demands but little autonomy—responsibility without control.

Brain-imaging studies of drug users at that stage show that viewing a film of actors pretending to use drugs activates dopamine pathways in the brain more than does watching porn films. This

As Beck and other cognitive therapists have emphasized, much of what constitutes a depression is centered around responding to one awful thing and overgeneralizing from it—cognitively distorting how the world works.

Cognitive therapists, like Aaron Beck of the University of Pennsylvania, even consider depression to be primarily a disorder of thought, rather than emotion, in that sufferers tend to see the world in a distorted, negative way.

Memory can be dramatically disrupted if you force something that’s implicit into explicit channels. Here’s an example that will finally make reading this book worth your while—how to make neurobiology work to your competitive advantage at sports. You’re playing tennis against someone who is beating the pants off of you. Wait until your adversary has pulled off some amazing backhand, then offer a warm smile and say, “You are a fabulous tennis player. I mean it; you’re terrific. Look at that shot you just made. How did you do that? When you do a backhand like that, do you hold your thumb this way or that, and what about your other fingers? And how about your butt, do you scrunch up the left side of it and put your weight on your right toes, or the other way around?” Do it right, and the next time that shot is called for, your opponent/victim will make the mistake of thinking about it explicitly, and the stroke won’t be anywhere near as effective. As Yogi Berra once said, “You can’t think and hit at the same time.

By not talking about death with our loved ones, not being clear through advanced directives, DNR (do not resuscitate) orders, and funeral plans, we are directly contributing to this future ... and a rather bleak present, at that. Rather than engage in larger societal discussions about dignified ways for the terminally ill to end their lives, we accept intolerable cases like that of Angelita, a widow in Oakland who covered her head with a plastic bag because the arthritic pain of her gnarled joints was too much to bear. Or that of Victor in Los Angeles, who hung himself from the rafters of his apartment after his third unsuccessful round of chemotherapy, leaving his son to discover his body. Or the countless bodies with decubitus ulcers, more painful for me to care for them even babies or suicides. When these bodies come into the funeral home, I can only offer my sympathy to their living relatives, and promise to work to ensure that more people are not robbed of a dignified death by a culture of silence.

Freud was fascinated with depression and focused on the issue that we began with—why is it that most of us can have occasional terrible experiences, feel depressed, and then recover, while a few of us collapse into major depression (melancholia)? In his classic essay “Mourning and Melancholia” (1917), Freud began with what the two have in common. In both cases, he felt, there is the loss of a love object. (In Freudian terms, such an “object” is usually a person, but can also be a goal or an ideal.) In Freud’s formulation, in every loving relationship there is ambivalence, mixed feelings—elements of hatred as well as love. In the case of a small, reactive depression—mourning—you are able to deal with those mixed feelings in a healthy manner: you lose, you grieve, and then you recover. In the case of a major melancholic depression, you have become obsessed with the ambivalence—the simultaneity, the irreconcilable nature of the intense love alongside the intense hatred. Melancholia—a major depression—Freud theorized, is the internal conflict generated by this ambivalence. This can begin to explain the intensity of grief experienced in a major depression. If you are obsessed with the intensely mixed feelings, you grieve doubly after a loss—for your loss of the loved individual and for the loss of any chance now to ever resolve the difficulties. “If only I had said the things I needed to, if only we could have worked things out”—for all of time, you have lost the chance to purge yourself of the ambivalence. For the rest of your life, you will be reaching for the door to let you into a place of pure, unsullied love, and you can never reach that door. It also explains the intensity of the guilt often experienced in major depression. If you truly harbored intense anger toward the person along with love, in the aftermath of your loss there must be some facet of you that is celebrating, alongside the grieving. “He’s gone; that’s terrible but…thank god, I can finally live, I can finally grow up, no more of this or that.” Inevitably, a metaphorical instant later, there must come a paralyzing belief that you have become a horrible monster to feel any sense of relief or pleasure at a time like this. Incapacitating guilt. This theory also explains the tendency of major depressives in such circumstances to, oddly, begin to take on some of the traits of the lost loved/hated one—and not just any traits, but invariably the ones that the survivor found most irritating. Psychodynamically, this is wonderfully logical. By taking on a trait, you are being loyal to your lost, beloved opponent. By picking an irritating trait, you are still trying to convince the world you were right to be irritated—you see how you hate it when I do it; can you imagine what it was like to have to put up with that for years? And by picking a trait that, most of all, you find irritating, you are not only still trying to score points in your argument with the departed, but you are punishing yourself for arguing as well. Out of the Freudian school of thought has come one of the more apt descriptions of depression—“aggression turned inward.” Suddenly the loss of pleasure, the psychomotor retardation, the impulse to suicide all make sense. As do the elevated glucocorticoid levels. This does not describe someone too lethargic to function; it is more like the actual state of a patient in depression, exhausted from the most draining emotional conflict of his or her life—one going on entirely within. If that doesn’t count as psychologically stressful, I don’t know what does.

It is never really the case that stress makes you sick, or even increases your risk of being sick. Stress increases your risk of getting diseases that make you sick, or if you have such a disease, stress increases the risk of your defenses being overwhelmed by the disease.

Now we have hundreds of carefully engineered, designed, and marketed commercial foods filled with rapidly absorbed processed sugars that cause a burst of sensation that can’t be matched by some lowly natural food. Once, we had lives that, amid considerable privation and negatives, also offered a huge array of subtle and often hard-won pleasures. And now we have drugs that cause spasms of pleasure and dopamine a thousand-fold higher than anything stimulated in our drug-free world.

Las Vegas casinos to keep defibrillators handy.

glucocorticoids in

by the year 2020, depression is projected to be the second leading cause of medical disability on earth.

growing strong from adversity is mostly a luxury for those who are better off.

Perhaps the best way to begin is by making a mental list of the sorts of things we find stressful. No doubt you would immediately come up with some obvious examples—traffic, deadlines, family relationships, money worries. But what if I said, “You’re thinking like a speciocentric human. Think like a zebra for a second.” Suddenly, new items might appear at the top of your list—serious physical injury, predators, starvation. The need for that prompting illustrates something critical—you and I are more likely to get an ulcer than a zebra is.

The impact of social relationships on life expectancy appears to be at least as large as that of variables such as cigarette smoking, hypertension, obesity, and level of physical activity.

Science provides us with some of the most elegant, stimulating puzzles that life has to offer. It throws some of the most provocative ideas into our arenas of moral debate. Occasionally, it improves our lives. I love science, and it pains me to think that so many are terrified of the subject or feel that choosing science means that you cannot also choose compassion, or the arts, or be awed by nature. Science is not meant to cure us of mystery, but to reinvent and reinvigorate it.

Another study that winds up in half the textbooks makes the same point, if more subtly. The subjects of the “experiment” were children reared in two different orphanages in Germany after World War II. Both orphanages were run by the government; thus there were important controls in place—the kids in both had the same general diet, the same frequency of doctors’ visits, and so on. The main identifiable difference in their care was the two women who ran the orphanages. The scientists even checked them, and their description sounds like a parable. In one orphanage was Fräulein Grun, the warm, nurturing mother figure who played with the children, comforted them, and spent all day singing and laughing. In the other was Fräulein Schwarz, a woman who was clearly in the wrong profession. She discharged her professional obligations, but minimized her contact with the children; she frequently criticized and berated them, typically among their assembled peers. The growth rates at the two orphanages were entirely different. Fräulein Schwarz’s kids grew in height and weight at a slower pace than the kids in the other orphanage. Then, in an elaboration that couldn’t have been more useful if it had been planned by a scientist, Fräulein Grun moved on to greener pastures and, for some bureaucratic reason, Fräulein Schwarz was transferred to the other orphanage. Growth rates in her former orphanage promptly increased; those in her new one decreased.

What Wilkinson and others have shown is that poverty is not only a predictor of poor health but, independent of absolute income, so is poverty amid plenty—the more income inequality there is in a society, the worse the health and mortality rates.

Interestingly, traumatic stress early in life (abuse, for example) greatly increases the risk of IBS in adulthood. This implies that childhood trauma can leave an echo of vulnerability, a large intestine that is hyperreactive to stress, long afterward.

Finally, the stressor is over, the lion pursues some other pedestrian, you can return to your dinner plans. The various hormones of the stress-response turn off, your parasympathetic nervous system begins to slow down your heart via something called the vagus nerve, and your body calms down.

A critical realization roared through the research community: the physiological stress-response can be modulated by psychological factors. Two identical stressors with the same extent of allostatic disruption can be perceived, can be appraised differently, and the whole show changes from there.

For the vast majority of beasts on this planet, stress is about a short-term crisis, after which it’s either over with or you’re over with. When we sit around and worry about stressful things, we turn on the same physiological responses—but they are potentially a disaster when provoked chronically

A large body of evidence suggests that stress-related disease emerges, predominantly, out of the fact that we so often activate a physiological system that has evolved for responding to acute physical emergencies, but we turn it on for months on end, worrying about mortgages, relationships, and promotions.

This is great. But what I’m grasping at is an idea about a subtler goal. This thinking owes a lot to conversations with Manjula Waldron of Ohio State University, an engineering professor who also happens to be a hospital chaplain. This feels embarrassingly Zen-ish for me to spout, being a short, hypomanic guy with a Brooklyn accent, but here goes: Maybe the goal isn’t to maximize the contrast between a low baseline and a high level of activation. Maybe the idea is to have both simultaneously. Huh? Maybe the goal would be for your baseline to be something more than the mere absence of activation, a mere default, but to instead be an energized calm, a proactive choice. And for the ceiling to consist of some sort of equilibrium and equanimity threading through the crazed arousal. I have felt this a few times playing soccer, inept as I am at it, where there’s a moment when, successful outcome or not, every physiological system is going like mad, and my body does something that my mind didn’t even dream of, and the two seconds when that happened seemed to take a lot longer than it should have. But this business about the calm amid the arousal isn’t just another way of talking about “good stress” (a stimulating challenge, as opposed to a threat). Even when the stressor is bad and your heart is racing in crisis, the goal should be to somehow make the fraction of a second between each heartbeat into an instant that expands in time and allows you to regroup. There, I have no idea what I’m talking about, but I think there might be something important lurking there. Enough said.

The subject of one experiment is a rat that receives mild electric shocks (roughly equivalent to the static shock you might get from scuffing your foot on a carpet). Over a series of these, the rat develops a prolonged stress-response: its heart rate and glucocorticoid secretion rate go up, for example. For convenience, we can express the long-term consequences by how likely the rat is to get an ulcer, and in this situation, the probability soars. In the next room, a different rat gets the same series of shocks—identical pattern and intensity; its allostatic balance is challenged to exactly the same extent. But this time, whenever the rat gets a shock, it can run over to a bar of wood and gnaw on it. The rat in this situation is far less likely to get an ulcer. You have given it an outlet for frustration. Other types of outlets work as well—let the stressed rat eat something, drink water, or sprint on a running wheel, and it is less likely to develop an ulcer.

Thus wailing and pounding the walls in grief or leaping about and shouting in ecstasy can place similarly large demands on a diseased heart. Put another way, your sympathetic nervous system probably has roughly the same effect on your coronary arteries whether you are in the middle of a murderous rage or a thrilling orgasm.

What the data show: the fewer social relationships a person has, the shorter his or her life expectancy, and the worse the impact of various infectious diseases. Relationships that are medically protective can take the form of marriage, contact with friends and extended family, church membership, or other group affiliations.

when it comes to the bread and butter of human misery, try a major depression. It can be life-threatening, it can destroy lives, demolish the families of sufferers. And it is dizzyingly common—the psychologist Martin Seligman has called it the common cold of psychopathology. Best estimates are that from 5 to 20 percent of us will suffer a major, incapacitating depression at some point in our lives, causing us to be hospitalized or medicated or nonfunctional for a significant length of time. Its incidence has been steadily increasing for decades—by the year 2020, depression is projected to be the second leading cause of medical disability on earth.

Parts of the book describe work carried out in my own laboratory, and these studies have been made possible by funding from the National Institutes of Health, the National Institute of Mental Health, the National Science Foundation, the Sloan Foundation, the Klingenstein Fund, the Alzheimer’s Association, and the Adler Foundation.

Perhaps the best moral is that when doing science (or perhaps when doing anything at all in a society as judgmental as our own), be very careful and very certain before pronouncing something to be the norm—because at that instant, you have made it supremely difficult to ever again look objectively at an exception to that supposed norm.

The health risk of poverty turns out to be a huge effect, the biggest risk factor there is in all of behavioral medicine—in other words, if you have a bunch of people of the same gender, age, and ethnicity and you want to make some predictions about who is going to live how long, the single most useful fact to know is each person’s SES.

when we get into a physiological uproar and activate the stress-response for no reason at all, or over something we cannot do anything about, we call it things like “anxiety,” “neurosis,” “paranoia,” or “needless hostility.” Thus, the stress-response can be mobilized not only in response to physical or psychological insults, but also in expectation of them.

One last bit of bad news. We’ve been focusing on the stress-related consequences of activating the cardiovascular system too often. What about turning it off at the end of each psychological stressor? As noted earlier, your heart slows down as a result of activation of the vagus nerve by the parasympathetic nervous system. Back to the autonomic nervous system never letting you put your foot on the gas and brake at the same time—by definition, if you are turning on the sympathetic nervous system all the time, you’re chronically shutting off the parasympathetic. And this makes it harder to slow things down, even during those rare moments when you’re not feeling stressed about something. How can you diagnose a vagus nerve that’s not doing its part to calm down the cardiovascular system at the end of a stressor? A clinician could put someone through a stressor, say, run the person on a treadmill, and then monitor the speed of recovery afterward. It turns out that there is a subtler but easier way of detecting a problem. Whenever you inhale, you turn on the sympathetic nervous system slightly, minutely speeding up your heart. And when you exhale, the parasympathetic half turns on, activating your vagus nerve in order to slow things down (this is why many forms of meditation are built around extended exhalations). Therefore, the length of time between heartbeats tends to be shorter when you’re inhaling than exhaling. But what if chronic stress has blunted the ability of your parasympathetic nervous system to kick the vagus nerve into action? When you exhale, your heart won’t slow down, won’t increase the time intervals between beats. Cardiologists use sensitive monitors to measure interbeat intervals. Large amounts of variability (that is to say, short interbeat intervals during inhalation, long during exhalation) mean you have strong parasympathetic tone counteracting your sympathetic tone, a good thing. Minimal variability means a parasympathetic component that has trouble putting its foot on the brake. This is the marker of someone who not only turns on the cardiovascular stress-response too often but, by now, has trouble turning it off.

Suppose a major traumatic stressor occurs, of a sufficient magnitude to disrupt hippocampal function while enhancing amygdaloid function. At some later point, in a similar setting, you have an anxious, autonomic state, agitated and fearful, and you haven’t a clue why—this is because you never consolidated memories of the event via your hippocampus while your amygdala-mediated autonomic pathways sure as hell remember. This is a version of free-floating anxiety.

Gerontologists studying the aging process find increasing evidence that most of us will age with a fair degree of success. There’s far less institutionalization and disability than one might have guessed. While the size of social networks shrink with age, the quality of the relationships improves. There are types of cognitive skills that improve in old age (these are related to social intelligence and to making good strategic use of facts, rather than merely remembering them easily). The average elderly individual thinks his or her health is above average, and takes pleasure from that. And most important, the average level of happiness increases in old age; fewer negative emotions occur and, when they do, they don’t persist as long. Connected to this, brain-imaging studies show that negative images have less of an impact, and positive images have more of an impact on brain metabolism in older people, as compared to young.

Neuropsychologists are coming to recognize that there is a specialized subset of long-term memory. Remote memories are ones stretching back to your childhood—the name of your village, your native language, the smell of your grandmother’s baking. They appear to be stored in some sort of archival way in your brain separate from more recent long-term memories. Often, in patients with a dementia that devastates most long-term memory, the more remote facets can remain intact.

In general, the monkeys under the most social stress were most at risk for plaque formation. Kaplan showed that this can even occur with a low-fat diet, which makes sense, since, as will be described in the next chapter, a lot of the fat that forms plaques is being mobilized from stores in the body, rather than coming from the cheeseburger the monkey ate just before the tense conference. But if you couple the social stress with a high-fat diet, the effects synergize, and plaque formation goes through the roof.

What does clean relations mean? Think of the idea as having enjoyable relationships with those we love in which there are few resentments that are not being talked about. Clean relations are the ones you might describe as having a fair and equitable exchange of love and energy. Chances are, you can name several relationships you are currently participating in that are of a messier nature. Resentments are the natural result of not expressing unmet expectations. When held for too long, they cause internal conditions that I think of as ulcerations of the spirit.

A major depression, these findings suggest, can be the outcome of particularly severe lessons in uncontrollability for those of us who are already vulnerable. This may explain an array of findings that show that if a child is stressed in certain ways—loss of a parent to death, divorce of parents, being a victim of abusive parenting—the child is more at risk for depression years later. What could be a more severe lesson that awful things can happen that are beyond our control than a lesson at an age when we are first forming our impressions about the nature of the world?

Major depression. As will be detailed in chapter 14, major depression is utterly intertwined with prolonged stress, and this connection includes elevated glucocorticoid levels in about half the people with major depression. Yvette Sheline of Washington University and others have shown that prolonged major depression is, once again, associated with a smaller hippocampus. The more prolonged the history of depression, the more volume loss. Furthermore, it is in patients with the subtype of depression that is most associated with elevated glucocorticoid levels where you see the smaller hippocampus.

First, can fetal or childhood exposure to synthetic glucocorticoids have lifelong, adverse effects? Glucocorticoids (such as hydrocortisone) are prescribed in vast amounts, because of their immunosuppressive or anti-inflammatory effects. During pregnancy, they are administered to women with certain endocrine disorders or who are at risk for delivering preterm. Heavy administration of them during pregnancy has been reported to result in children with smaller head circumferences, emotional and behavioral problems in childhood, and slowing of some developmental landmarks. Are these effects lifelong? No one knows.

Obviously, a theme of this book is just how many things can go wrong in the body because of stress and how important it is for everyone to recognize this. However, it would be utterly negligent to exaggerate the implications of this idea. Every child cannot grow up to be president; it turned out that merely by holding hands and singing folk songs we couldn’t end all war, and hunger does not disappear just by visualizing a world without it. Everything bad in human health now is not caused by stress, nor is it in our power to cure ourselves of all our worst medical nightmares merely by reducing stress and thinking healthy thoughts full of courage and spirit and love.

Beginning in the early 1980s, various researchers, including myself, showed that this “glucocorticoid neurotoxicity” was not just a pharmacological effect, but was relevant to normal brain aging in the rat. Collectively, the studies showed that lots of glucocorticoid exposure (in the range seen during stress) or lots of stress itself would accelerate the degeneration of the aging hippocampus. Conversely, diminishing glucocorticoid levels (by removing the adrenals of the rat) would delay hippocampal aging. And as one might expect by now, the extent of glucocorticoid exposure over the rat’s lifetime not only determined how much hippocampal degeneration there would be in old age, but how much memory loss as well.

First, the enormous potential energies of the two elephants are consumed balancing the seesaw, instead of being able to do something more useful, like mowing the lawn or paying the bills. This is equivalent to diverting energy from various long-term building projects in order to solve short-term stressful emergencies. By using two elephants to do the job, damage will occur just because of how large, lumbering, and unsubtle elephants are. They squash the flowers in the process of entering the playground, they strew leftovers and garbage all over the place from the frequent snacks they must eat while balancing the seesaw, they wear out the seesaw faster, and so on. This is equivalent to a pattern of stress-related disease that will run through many of the subsequent chapters: it is hard to fix one major problem in the body without knocking something else out of balance (the very essence of allostasis spreading across systems throughout the body).

By using two elephants to do the job, damage will occur just because of how large, lumbering, and unsubtle elephants are. They squash the flowers in the process of entering the playground, they strew leftovers and garbage all over the place from the frequent snacks they must eat while balancing the seesaw, they wear out the seesaw faster, and so on. This is equivalent to a pattern of stress-related disease that will run through many of the subsequent chapters: it is hard to fix one major problem in the body without knocking something else out of balance (the very essence of allostasis spreading across systems throughout the body). Thus, you may be able to solve one bit of imbalance brought on during stress by using your elephants (your massive levels of various stress hormones), but such great quantities of those hormones can make a mess of something else in the process. And a long history of doing this produces wear and tear throughout the body, termed allostatic load.

You will see that the most powerful and highly placed men let drop remarks in which they long for leisure, acclaim it, and prefer it to all their blessings. They desire at times, if it could be with safety, to descend from their high pinnacle; for, though nothing from without should assail or shatter, Fortune of its very self comes crashing down.8 The deified Augustus, to whom the gods vouchsafed more than to any other man, did not cease to pray for rest and to seek release from public affairs; all his conversation ever reverted to this subject—his hope of leisure. This was the sweet, even if vain, consolation with which he would gladden his labours—that he would one day live for himself. In a letter addressed to the senate, in which he had promised that his rest would not be devoid of dignity nor inconsistent with his former glory, I find these words: "But these matters can be shown better by deeds than by promises. Nevertheless, since the joyful reality is still far distant, my desire for that time most earnestly prayed for has led me to forestall some of its delight by the pleasure of words." So desirable a thing did leisure seem that he anticipated it in thought because he could not attain it in reality. He who saw everything depending upon himself alone, who determined the fortune of individuals and of nations, thought most happily of that future day on which he should lay aside his greatness. He had discovered how much sweat those blessings that shone throughout all lands drew forth, how many secret worries they concealed. Forced to pit arms first against his countrymen, then against his colleagues, and lastly against his relatives, he shed blood on land and sea. Through Macedonia, Sicily, Egypt, Syria, and Asia, and almost all countries he followed the path of battle, and when his troops were weary of shedding Roman blood, he turned them to foreign wars. While he was pacifying the Alpine regions, and subduing the enemies planted in the midst of a peaceful empire, while he was extending its bounds even beyond the Rhine and the Euphrates and the Danube, in Rome itself the swords of Murena, Caepio, Lepidus, Egnatius, and others were being whetted to slay him. Not yet had he escaped their plots, when his daughter9 and all the noble youths who were bound to her by adultery as by a sacred oath, oft alarmed his failing years—and there was Paulus, and a second time the need to fear a woman in league with an Antony.10 When be had cut away these ulcers11 together with the limbs themselves, others would grow in their place; just as in a body that was overburdened with blood, there was always a rupture somewhere. And so he longed for leisure, in the hope and thought of which he found relief for his labours. This was the prayer of one who was able to answer the prayers of mankind.

If you’re like most people, a string of nerve-racking incidents keeps you in fight-or-flight response—and out of homeostasis—a large part of the time. Maybe the car cutting you off is the only actual life-threatening situation you encounter all day, but the traffic on the way to work, the pressure of preparing for a big presentation, the argument you had with your spouse, the credit-card bill that came in the mail, the crashing of your computer hard drive, and the new gray hair you noticed in the mirror keep the stress hormones circulating in your body on a near-constant basis. Between remembering stressful experiences from the past and anticipating stressful situations coming up in your future, all these repetitive short-term stresses blur together into long-term stress. Welcome to the 21st-century version of living in survival mode. In fight-or-flight mode, life-sustaining energy is mobilized so that the body can either run or fight. But when there isn’t a return to homeostasis (because you keep perceiving a threat), vital energy is lost in the system. You have less energy in your internal environment for cell growth and repair, long-term building projects on a cellular level, and healing when that energy is being channeled elsewhere. The cells shut down, they no longer communicate with one another, and they become “selfish.” It’s not time for routine maintenance (let alone for making improvements); it’s time for defense. It’s every cell for itself, so the collective community of cells working together becomes fractured. The immune and endocrine systems (among others) become weakened as genes in those related cells are compromised when informational signals from outside the cells are turned off. It’s like living in a country where 98 percent of the resources go toward defense, and nothing is left for schools, libraries, road building and repair, communication systems, growing of food, and so on. Roads develop potholes that aren’t fixed. Schools suffer budget cuts, so students wind up learning less. Social welfare programs that took care of the poor and the elderly have to close down. And there’s not enough food to feed the masses. Not surprisingly, then, long-term stress has been linked to anxiety, depression, digestive problems, memory loss, insomnia, hypertension, heart disease, strokes, cancer, ulcers, rheumatoid arthritis, colds, flu, aging acceleration, allergies, body pain, chronic fatigue, infertility, impotence, asthma, hormonal issues, skin rashes, hair loss, muscle spasms, and diabetes, to name just a few conditions (all of which, by the way, are the result of epigenetic changes). No organism in nature is designed to withstand the effects of long-term stress.

In addition, it has been demonstrated that meditation can help with the following: lowering blood pressure decreasing symptoms in illnesses with a stress-related component (ulcers, for example) decreasing serum cholesterol levels reducing muscular tension reducing oxygen and energy consumption improving sleep In short, it has been scientifically proven that meditation is awesome.

DENGUE FEVER (BREAKBONE FEVER) Dengue fever is a viral infection found throughout Central America. In Costa Rica outbreaks involving thousands of people occur every year. Dengue is transmitted by aedes mosquitoes, which often bite during the daytime and are usually found close to human habitations, often indoors. They breed primarily in artificial water containers such as jars, barrels, cans, plastic containers and discarded tires. Dengue is especially common in densely populated, urban environments. Dengue usually causes flulike symptoms including fever, muscle aches, joint pains, headaches, nausea and vomiting, often followed by a rash. Most cases resolve uneventfully in a few days. Severe cases usually occur in children under the age of 15 who are experiencing their second dengue infection. There is no treatment for dengue fever except taking analgesics such as acetaminophen/paracetamol (Tylenol) and drinking plenty of fluids. Severe cases may require hospitalization for intravenous fluids and supportive care. There is no vaccine. The key to prevention is taking insect-protection measures. HEPATITIS A Hepatitis A is the second-most-common travel-related infection (after traveler’s diarrhea). It’s a viral infection of the liver that is usually acquired by ingestion of contaminated water, food or ice, though it may also be acquired by direct contact with infected persons. Symptoms may include fever, malaise, jaundice, nausea, vomiting and abdominal pain. Most cases resolve without complications, though hepatitis A occasionally causes severe liver damage. There is no treatment. The vaccine for hepatitis A is extremely safe and highly effective. You should get vaccinated before you go to Costa Rica. Because the safety of hepatitis A vaccine has not been established for pregnant women or children under the age of two, they should instead be given a gammaglobulin injection. LEISHMANIASIS Leishmaniasis occurs in the mountains and jungles of all Central American countries. The infection is transmitted by sand flies, which are about one-third the size of mosquitoes. Most cases occur in newly cleared forest or areas of secondary growth. The highest incidence is in Puerto Viejo de Talamanca. It causes slow-growing ulcers over exposed parts of the body There is no vaccine. RABIES Rabies is a viral infection of the brain and spinal cord that is almost always fatal. The rabies virus is carried in the saliva of infected animals and is typically transmitted through an animal bite, though contamination of any break in the skin with infected saliva may result in rabies. Rabies occurs in all Central American countries. However, in Costa Rica only two cases have been reported over the last 30 years. TYPHOID Typhoid fever is caused by ingestion of food or water contaminated by a species of salmonella known as Salmonella typhi . Fever occurs in virtually all cases. Other symptoms may include headache, malaise, muscle aches, dizziness, loss of appetite, nausea and abdominal pain. A pretrip vaccination for typoid is recommended, but not required. It’s usually given orally, and is also available as an injection. TRAVELER’S DIARRHEA Tap water is safe and of a high quality in Costa Rica, but when you’re far off the beaten path it’s best to avoid tap water unless it has been boiled, filtered or chemically disinfected (iodine tablets). To prevent diarrhea, be wary of dairy products that might contain unpasteurized milk; and be highly selective when eating food from street vendors.

Relieving Stress Stress is your reaction to outside stimuli pushing your mind, body or spirit out of balance. Adapting to new stimuli is how you increase your capabilities and develop new skills, i.e., the basis of growth. But, if the stimuli is too great or arrives so quickly that you are unable to adapt, then the resulting stress can lead to physical, emotional or mental problems. Stress can be triggered by many factors, including: physical, emotional or mental abuse; life changing events such as a new job, moving, pregnancy or divorce; work or school-related deadlines; high stress occupations; and uncomfortable social situations Exposure to stress affects us in stages: In the first stage, when we experience stress, our bodies automatically react with the characteristic “fight or flight” response, also known as an adrenaline rush. In life threatening situations this is helpful, as adrenaline causes our bodies to increases our pulse, blood pressure and rate of breathing, better preparing us to do battle or to escape. When the outside stimuli disappear, often with a good night’s sleep, we return to normal. Continued exposure to stress, without a break, results in the second stage. In today’s modern society, everyday stress from traffic jams, work, or just plain living, triggers this same reaction. We end up in a constant state of stress. We deplete our reserves, especially our adrenal glands, and lessen our ability to handle additional stress. Even our ability to sleep can be affected. The final stage results from the accumulation of stress over time and leads to exhaustion. Unable to return our body, mind and spirit to its normal state of balance due to overwhelming stress, we suffer physical, emotional and mental breakdowns. Warning signs are: weight gain or loss, ulcers, indigestion, insomnia, depression, anxiety, fear, anger, inability to concentrate, moodiness, and other problems. It can be argued that all disease is a consequence of stress.

At the West Edmonton Mall in Alberta, the dolphins developed stress-induced ulcers. Shopping malls are enough to drive most individuals insane, given enough time spent in them. For Edmonton’s dolphins, though, there was no escape. Every day was the same. Shows were performed twice a day. The water tanks never got any larger. The light always remained artificial. The crowds of shoppers never stopped coming. The enervating elevator music never stopped playing. So it was hardly surprising that all four of the mall’s dolphins suffered from stress-related afflictions.

For many years I was under the impression that TMS was a kind of physical expression or discharge of the repressed emotions just described. In fact, this is what I suggested in the first edition of this book. I had been aware since the early 1970s that these common back and neck pain syndromes were due to repressed emotions. Eighty-eight percent of a large group of patients with TMS had a history of other tension-related disorders, like stomach ulcers, colitis, tension headache, and migraine headache. But the idea of TMS as a physical manifestation of nervous tension was somehow unsatisfactory and incomplete. Most important, it did not explain the repeated observation that making a patient aware of the role of the pain as participant in a psychological process would lead to cessation of pain, to a "cure." (page 56)

Along with doubt about the accuracy of conventional diagnoses, there came the realization that the primary tissue involved was muscle, specifically the muscles of the neck, shoulders, back, and buttocks. But even more important was the observation that 88 percent of the people seen had histories of such things as tension or migraine headache, heartburn, hiatus hernia, stomach ulcer, colitis, spastic colon, irritable bowel syndrome, hay fever, asthma, eczema, and a variety of other disorders, all of which were strongly suspected of being related to tension.

For many years I was under the impression that TMS was a kind of physical expression or discharge of the repressed emotions just described. In fact, this is what I suggested in the first edition of this book. I had been aware since the early 1970s that these common back and neck pain syndromes were due to repressed emotions. Eighty-eight percent of a large group of patients with TMS had a history of other tension-related disorders, like stomach ulcers, colitis, tension headache, and migraine headache. But the idea of TMS as a physical manifestation of nervous tension was somehow unsatisfactory and incomplete. Most important, it did not explain the repeated observation that making a patient aware of the role of the pain as participant in a psychological process would lead to cessation of pain, to a “cure.” It was a psychoanalyst colleague, Dr. Stanley Coen, who suggested in the course of our working on a medical paper together that the role of the pain syndrome was not to express the hidden emotions but to prevent them from becoming conscious. This, he explained, is what is referred to as a defense. In other words, the pain of TMS (or the discomfort of a peptic ulcer, of colitis, of tension headache, or the terror of an asthmatic attack) is created in order to distract the attention of the sufferer from what is going on in the emotional sphere. It is intended to focus one’s attention on the body instead of the mind. It is a response to the need to keep those terrible, antisocial, unkind, childish, angry, selfish feelings (the prisoners) from becoming conscious. It follows from this that far from being a physical disorder in the usual sense, TMS is really part of a psychological process.

Some will have a scientific explanation, for example muscle spasms or migraines can be related to low magnesium levels, but some will have a unique meaning to us and it is down to us to decode them. I have a friend that has always said “By the time I get a mouth ulcer, I know that I have pushed myself too hard and my body is not getting enough nutrients to keep going.” I have taken note of that for myself. A cousin said that his stress always shows up as a feeling of toxins built up in knots in his shoulders. I recognize that one too!

I do love Shakespeare, but I relate more to Alexandre Dumas, Victor Hugo, C.S. Lewis. Oh, but Lewis is MAGICAL; reading Lewis is like leaving ground zero and rushing head-on into the universe a child in my heart once more, all ulcers healed and my pain a distant memory...

they also atypically crave sweets. This is an effect that is specific to stress.

expend 10 to 20 percent of their energy on digestion.

Along comes stress: turn off the parasympathetic, turn on the sympathetic, and forget about digestion.* End of stress; switch gears again, and the digestive process resumes.

But one of the additional factors is stress. Study after study, even those carried out after the ascendancy of the bacteria, show that duodenal ulceration is more likely to occur in people who are anxious, depressed, or undergoing severe life stressors (imprisonment, war, natural disasters). An analysis of the entire literature shows that somewhere between 30 and 65 percent of peptic ulcers have psychosocial factors (i.e., stress) involved.

The problem is that stress causes people to drink and smoke more. So maybe stress increases the risk of an ulcer merely by increasing the incidence of those lifestyle risk factors.

mostly thanks to estrogen working as an antioxidant, getting rid of damaging oxygen radicals.

Instead, complex food matter is broken down into its simplest parts (molecules): amino acids (the building blocks of protein), simple sugars like glucose (the building blocks of more complex sugars and of starches [carbohydrates]), and free fatty acids and glycerol (the constituents of fat). This is accomplished in the gastrointestinal tract by enzymes, chemicals that can degrade more complex molecules. The simple building blocks thus produced are absorbed into the bloodstream for delivery to whichever cells in the body need them.

Your body reverses all of the storage steps through the release of the stress hormones glucocorticoids, glucagon, epinephrine, and norepinephrine. These cause triglycerides to be broken down in the fat cells and, as a result, free fatty acids and glycerol pour into the circulatory system.

Just as obviously, you’ll have trouble mobilizing energy in response to the demands of daily life. And that is precisely what is seen in individuals with chronic fatigue syndrome, which is characterized by, among other things, too low levels of glucocorticoids in the bloodstream.

It takes energy to shuttle those nutrients in and out of the bloodstream, to power the enzymes that glue them together (into proteins, triglycerides, and glycogen) and the other enzymes that then break them apart, to fuel the liver during that gluconeogenesis trick.

As is well understood, there is “bad” cholesterol, also known as low-density lipoprotein-associated cholesterol (LDL) and “good” cholesterol (high-density lipoprotein-associated cholesterol, HDL). LDL-cholesterol is the type that gets added to an atherosclerotic plaque, whereas HDL-cholesterol is cholesterol that has been removed from plaques and is on its way to be degraded in the liver. As a result

For reasons that are just being sorted out, in some people the immune system decides that the cells in the pancreas that secrete insulin are, in fact, foreign invaders and attacks them (such “autoimmune” diseases will be discussed in chapter 8). This destroys those cells, leaving the person with little ability to secrete insulin.

you’re diabetic, you never want your insulin levels to get too low—cells are deprived of energy, circulating glucose levels get too high. But you don’t want to take too much insulin. For complex reasons, this deprives the brain of energy, potentially putting you into shock or a coma and damaging neurons.

How does chronic stress affect this process? First, the hormones of the stress-response cause even more glucose and fatty acids to be mobilized into the bloodstream. For a juvenile diabetic, this increases the likelihood of the now-familiar pathologies of glucose and fatty acids gumming up in the wrong places.

Another, more subtle problem occurs with chronic stress as well. When something stressful happens, you don’t just block insulin secretion. Basically, the brain doesn’t quite trust the pancreas not to keep secreting a little insulin, so a second step occurs. As noted earlier, during stress, glucocorticoids act on fat cells throughout the body to make them less sensitive to insulin, just in case there’s some still floating around. Fat cells then release some newly discovered hormones that get other tissues, like muscle and liver, to stop responding to insulin as well. Stress promotes insulin resistance.

In adult-onset diabetes (type 2, non-insulin-dependent diabetes), the trouble is not too little insulin, but the failure of the cells to respond to insulin. Another name for the disorder is thus insulin-resistant diabetes.

With enough fat stored away, the fat cells essentially get full; once you are an adolescent, the number of fat cells you have is fixed, so if you put on weight, the individual fat cells are distended. Yet another heavy meal, a burst of insulin trying to promote more fat storage by the fat cells, and the fat cells refuse—“Tough luck, I don’t care if you are insulin; we’re completely full.” No room at the inn.

Make a list of some of the things that can go wrong from the last two chapters: elevated insulin levels in the blood. Elevated glucose levels. Elevated systolic and diastolic blood pressure. Insulin resistance. Too much LDL-cholesterol. Too little HDL. Too much fat or cholesterol in the blood. Suffer from a subset of these, and you’ve got Metabolic syndrome (the formal diagnosis involves “one or more” from a list of some of these problems, and “two or more” from a list of the others).

The official numbers are that stress makes about two-thirds of people hyperphagic (eating more) and the rest hypophagic.* Weirdly, when you stress lab rats, you get the same confusing picture, where some become hyperphagic, others hypophagic. So we can conclude with scientific certainty that stress can alter appetite.

You might recall from earlier chapters that the hormone CRH is released by the hypothalamus and, by stimulating the pituitary to release ACTH, starts the cascade of events that culminates in adrenal release of glucocorticoids.

So with lots of stress, you get cravings for starchy comfort food and you pack it in the abdomen.

The sympathetic nervous system kicks into action during emergencies, or what you think are emergencies. It helps mediate vigilance, arousal, activation, mobilization. To generations of first-year medical students, it is described through the obligatory lame joke about the sympathetic nervous system mediating the four F’s of behavior—flight, fight, fright, and sex.

The nerve endings of this system release adrenaline.

the American terms, which will be used from now on, are epinephrine and norepinephrine.)

The other half of the autonomic nervous system plays an opposing role. This parasympathetic component mediates calm, vegetative activities—everything but the four F’s. If you are a growing kid and you have gone to sleep, your parasympathetic system is activated. It promotes growth, energy storage, and other optimistic processes. Have a huge meal, sit there bloated and happily drowsy, and the parasympathetic is going like gangbusters

(Steroid is used to describe the general chemical structure of five classes of hormones: androgens—the famed “anabolic” steroids like testosterone that get you thrown out of the Olympics—estrogens, progestins, mineralocorticoids, and glucocorticoids.)

After ACTH is released into the bloodstream, it reaches the adrenal gland and, within a few minutes, triggers glucocorticoid release. Together, glucocorticoids and the secretions of the sympathetic nervous system (epinephrine and norepinephrine) account for a large percentage of what happens in your body during stress. These are the workhorses of the stress-response.

Just as some glands are activated in response to stress, various hormonal systems are inhibited during stress. The secretion of various reproductive hormones such as estrogen, progesterone, and testosterone is inhibited. Hormones related to growth (such as growth hormone) are also inhibited, as is the secretion of insulin, a pancreatic hormone that normally tells your body to store energy for later use.

A great marker is turning out to be something called C-reactive protein (CRP).