We know stress can be dangerous, although treatment is not lacking. Pharmaceuticals abound, and more are in development. But reports are emerging that drugs may be addictive, they don’t work well in mild or moderate cases, and it's hard to wean off them. What’s a patient to do?
A Confusion of Terms
Discussing stress and anxiety invites confusion, as these diagnostic terms are often interchanged, and their causes poorly identified.
- Stress, the force exerted by a “stressor,” can be internal or external, emotional or physical. The definition of physical stress (pressure or tension exerted on a material object) is also applicable to biological stress.
- The emotional and psychological reaction to the stress is called anxiety, which refers to the “feelings” engendered by the physical stress.
Careful use of the terms, even in research proposals or write-ups, is wanting - often because they are interrelated. External stressors may be chronic – like a bad boss, or acute, such as sudden bereavement; or physical, such as being struck by lightning or suffering chronic back pain or carpal tunnel syndrome, where repetitive hand motions, like jackhammering, compress the median nerve on the back of the wrist. Even if the precipitating cause is physical, stressors can elicit emotional reactions, called anxiety or worry, experienced as apprehension or fear.
Chronic emotional stress can lead to post-traumatic stress disorder (PTSD), triggering both physical and emotional reactions, such as the inability to sleep or dramatic outbursts. Anxiety can lead to depression and trigger the body’s flight or fight response, which, when uncontrolled, can compromise the cardiovascular or immune systems, leading to heart disease and cancer. Recent treatment approaches that focus on reigning in or redirecting the mental effects of the stress-anxiety continuum reportedly produce good results. But there are issues.
Selective Serotonin Reuptake Inhibitors (SSRI)
Treating the anxiety and depression of stress is commonly accomplished by prescribing “antidepressants” – more specifically, selective serotonin reuptake inhibitors (SSRI), although different pharmaceuticals target other physiologic modulators. Many patients stay on these drugs for life.
The lack of serotonin, the “magic molecule,” was once believed to be the root cause of emotional evils, and serotonin boosters were widely prescribed for both anxiety and stress-related disorders. The first wave, tricyclics, came to the fore in the 1960s, but suicides by overdose soon surfaced. By the 1980s, they were replaced by the much safer SSRIs. By the 1990s, SSRI use became so prevalent they became known as “lifestyle” drugs, prescribed for normal emotional upsets such as bereavement or work burn-out. Their use is still rising, with antidepressants one of the most commonly prescribed medications in the United States.
As the serotonin hypothesis is being dismantled and bias in previous research exposed, we are finding getting off the drugs carries its own vexations – the longer the duration of therapy, the greater the risk of withdrawal symptoms. And once started, there doesn’t seem to be any impetus to stop. A quarter of Americans using antidepressants have been taking them for a decade or more.
The fly in the ointment
Current research indicates SSRIs are less effective than once thought, suggesting that mild and moderate symptom remission is often due to a placebo effect. [1] Side effects can be severe, including stroke, falls, seizures in older people, and withdrawal symptoms on cessation. Weaning off the drugs is complex and governed by precise protocols.
So fraught with difficulty is the cessation process that one patient advocate set up a website, SurvivingAntidepressants.org, offering tips on tapering off the drug. She also reviewed the literature on the topic and published her findings in Therapeutic Advances in Psychopharmacology. Tapering off antidepressants can take months or years of meticulous, not just a few weeks, as was once believed. Some individuals were started on these medications as children or adolescents without their independent buy-in and feel locked into a tough-to-extricate situation as they mature.
Doctors rarely suggest patients should stop taking the drugs. And no one would deprive a patient of medication in the throes of an acute panic attack. But some are now saying that for less acute conditions, it might be better not to start these drugs or, when indicated, to stop them as soon as practicable- in a carefully tapered process. On the other hand, chronic stress and anxiety are natural and still require care.
What’s a Patient to Do?
Recent research suggests that practicing mindfulness works as well as antidepressants in treating “anxiety-related disorders” (although the relevance to related stress is unclear) One study evaluated 276 people diagnosed with generalized anxiety disorder, social anxiety disorder, panic disorder, and agoraphobia (fear of heights) of varying severity, randomized into two groups; 106 patients were prescribed the antidepressant escitalopram (Lexapro), an SSRI, and 102 patients were treated with eight weeks of mindfulness-based stress reduction classes (MBSR). The technique included in-person guided meditation, breath awareness, body scan, gentle movement meditation, and home-based guided meditation via audio recordings. No significant differences in results were noted – with MSBR working about as well as the drugs. Still, serious adverse events were more prevalent in the drug treatment group, causing two to drop out of the study.
It’s not clear how the MSBR technique works. On the other hand, it’s not clear how antidepressant drugs work either. Anxiety disorders often involve habitual thoughts and behaviors, and it is believed that mindfulness may disrupt those habits.
“In other words, mindfulness practice helps people see thoughts just as thoughts and not become overidentified with them or overwhelmed by them.”
– Dr. Elizabeth Hoge, Department of Psychiatry, Georgetown University Medical Center
There are still other mindfulness-related alternatives, which mostly seem to be a form of distraction, but multiple approaches abound on the internet. One system put out recently by the Mayo Clinic network seems particularly comprehensive.
Mindfulness techniques, however, are not indicated to treat physical aspects of the stress response, and if the anxiety has gone on too long or too often, neither mindfulness nor any “alternative” treatment may suffice to counter the physical assaults of the stressors. And mindfulness, too, has its “side-effects.” Obsessive reliance on the technique has come under attack- at least by users.
‘In their book, The Wellness Syndrome, Carl Cederström and André Spicer observe that wellness and mindfulness have become a moral obligations.”
But leave it to high-tech companies to capitalize on mindfulness mania. Calming devices equipped with software to reduce anxiety, stress, and PTSD are on the market. Recently, manufacturers have sent these devices, including virtual reality systems [2], to Israel to alleviate wartime stress and the emotional suffering of citizens.
Is there anything else that might be done?
Exercise has also been touted as a treatment. There are even studies evaluating whether mindful or non-mindful exercise (like Yoga) works better. And there are still other alternatives.
Just Breathe
Recent research, this time using computational models with animal and human data, suggests enhanced breathing works on a biological level. Synthesizing multiple studies, researchers found the brain rhythm mimics breathing: when we inhale, we are more sensitive, taking in the outside world, and when we exhale, we release external influences along with our breath.
“[The]brain and breathing … actually impact our emotions, our attention and how we process the outside world….Difficulty breathing is associated with a very large increase in the risk for mood disorders such as anxiety and depression. We know that respiration, respiratory illness, and psychiatric illness are closely linked.”
- Professor Micah Allen, Dept. of Clinical Medicine, Aarhus University.
Another recent study, suggested an interconnection between our breathing, brain responses, emotional state, and subsequent behavior.
“When we are in an anxious state, often our breathing speeds up. In response we sometimes take a deep breath. Or when we are focusing, we tend to hold our breath.”
-Nanyin Zhang, Founding Director of the Penn State Center for Neurotechnology
Ask for Help
Like all physical conditions, stress has a genetic component, and some people are more predisposed or sensitive to its effects.
New research suggests social support seems to help the super-sensitive. The first step is acknowledging your need; the second is asking for help.
This might mean medication for some, and for others, (deep) breathing might be the best (and cheapest) alternative.
[1] The placebo effect is now being identified in other drug treatments, such as ketamine.
[2] XR Health offers headsets that guide patients in meditation, self-relaxation, and stress and anxiety relief “in 53 different virtual-reality environments.”
