Don’t stress about stress – Part 1

Stress gets a bad rap. Everywhere you look, stress seems to be getting the blame. Though as Richard Shweder wrote in the New York Times, “Imprecise and evasive language may be a disaster for science but it is a boon in everyday life. ‘I am stressed out’ is non-accusatory, apolitical and detached. It is a good way to keep the peace and, at the same time, a low-cost way to complain.” [1]

Selye said that, “Everybody knows what stress is, but no one really knows.” [2] Hans Selye is considered the father of modern stress research. He was one of the first scientists to conceptualise and measure this ethereal force.

As with some of the most important discoveries in the history of science, Selye came upon the discovery of what he termed the “alarm reaction” incidentally when he was injecting rats with impure ovarian extract, and noted that they became sick. He looked further at the physical changes in the rats and noted an unusual cluster of changes to their adrenal glands, thymus, spleen and gut [3]. He was able to reproduce the same responses by exposing the rats to cold temperatures, surgical injury, spinal shock, excessive muscular exercise, or intoxications with sublethal doses of drugs such as adrenaline, morphine or formaldehyde [4]. After years of research, he confirmed that ongoing exposure to the same physical conditions or drugs would follow the same three-stage process of initial physical changes, recovery and adaptation, then eventually exhaustion (and death). He called this model the “General Adaptation Syndrome.” [4]

The General Adaptation model was groundbreaking, and the sheer volume of work done by Selye brought his theories to the forefront of the scientific community. With time, the theory slowly descended from its place of adulation as other evidence came to light [5], but it has remained foundational, and Selye is still revered as the father of modern stress research.

The term stress “generally refers to experiences that cause feelings of anxiety and frustration because they push us beyond our ability to successfully cope.” [6] Scientifically, stress has been difficult to define. Different researchers often use different definitions of stress depending on what they’re studying or what field of psychology or science they belong to [7].

I wanted to look at stress from a different perspective. In the next series of posts, I want to look at the basic concepts of stress and its functions in nature. I will spend some time looking at different ways of conceptualising stress, and look at how they offer is life lessons on how to approach our stress. I’ll then have a look at what it is that helps us cope with stress.

A broad concept of stress

To gain a better understanding of stress, it’s useful to step away from the medical concept of stress, and think about what the term means in other fields.

When an engineer thinks about stress, it’s usually in relation to a physical force on a material object. My son is a huge Mythbusters fan. He was watching an episode the other day where the Mythbusters were testing the myth of Pykrete, a material that was nothing but wood shavings and ice. They were testing to see whether it was more durable than ice alone, whether it was bulletproof, and whether it could be used to build a boat! [8] In order to test out these crazy claims, they made some in their workshop and compared it with normal ice. How did they test it? By stressing it – placing weights on the end of the block of the ice/pykrete until it broke. (In the end, pykrete was ten times stronger than ice, was bulletproof, and they made a fully operational motor-boat from it!)

So the mechanical definition of stress is, “pressure or tension exerted on a material object.” [9] There are a few illustrations of mechanical stress, in our bodies and in everyday life, that are good metaphors for stress in our lives.

The Classical Stress/Productivity Curve

I confess I am NOT a musician. I’ve never learnt to read music or play an instrument. But I do know that when you first put a new string on the guitar, it’s unstretched – there is literally no force on it at all. If all you did was tied the two ends of the string to the tone peg and the tuning peg, the string would remain limp and lifeless. It wouldn’t be able to do anything useful. It certainly wouldn’t play a note.

When the tuning peg is twisted a few times, there is some tightness in the wire. The string is now under tension (i.e. stress). It is now able to play a note of some form, so it can do some work and fulfill some of the function of a guitar string. But the pitch isn’t good enough – the note is out of tune.

With a small adjustment, the string reaches its optimal tension and can play the correct note! This is the point where the string is fulfilling its designed purpose. Optimal stress equals optimal function.

With further tightening of the string, the perfect pitch is lost, but the string can still produce a sound of some form. With more tension, the string can still make a noise, but it sounds awful, and the fibres inside the cord are starting to tear. If the string were wound further and further, it would eventually break.

If this ratio of the tension of the string versus the usefulness of the string were to be plotted as a graph, it would look like an upside down “U”. This is the classic stress/productivity curve.

StressProductivityCurve_Final

The Exponential Stress/Productivity Curve

The second metaphor that I think illustrates a different concept of the stress/productivity relationship is a car.

As well not being a musician, I am also NOT a mechanic! I know the important things like where the petrol goes, and how to drive them, but otherwise cars are very mysterious and powerful devices, their mystery is only exceeded by their power.

What I do know is that the engine is very much like the guitar string. As more petrol is fed into the engine, the engine gets more powerful. Soon, the engine finds its “power band”, a zone of maximum torque that can be achieved at moderate revolutions. As the engine is given more gas, the power output declines from the middle of the power band. If the engine was maxed out then the amount of functional power coming out is reduced.

This would plot as a similar graph to the U-curve of the stress/productivity curve. But cars not only have engines, but also a gearbox. The gears allow for multiplication of the work done (the productivity) for the same stress on the engine.

G-Force!

As a child, I didn’t dream of becoming an astronaut, but I was interested in space. The beauty of our night sky is as stunning as any forest, river or mountain. I would read of the astronauts in rockets and in space stations, floating around in zero gravity, swimming through the “air”. That sounded like a lot of fun.

But zero gravity isn’t particularly good for you. Some early astronauts had to be carried off their landing craft on stretchers because the effect of zero gravity would render these men weak and atrophied. They boarded the spacecraft at the peak of their physical strength and fitness, but after only a few weeks without gravity, their bodies resembled that of the elderly (although without the wrinkles) [10].

It’s a general principle of the human body that any tissue that isn’t needed shrinks in size – a process called atrophy. In zero gravity, the body doesn’t need as much muscle, so the muscles shrink. The body doesn’t need as much bone strength, so the bones weaken. There is no gravity to pull their blood away from their head, so the blood volume decreases. Because there is less muscle to pump blood to, and less blood to pump, the heart doesn’t work as hard, so the heart muscle atrophies. The net effect of zero gravity is to make you physically weak [10].

On the other hand, too much gravity is not great either. Animals can adapt to small amounts of hypergravity [11]. But large amounts aren’t so good. During astronaut training, NASA subjects the rookie spacemen to rigorous tests including placing them in a large centrifuge and spinning it very fast. The result is an increase in the gravitational forces applied to their bodies. The increased gravity makes everything in the body heavier and their blood is pulled towards the legs and away from the brain, which leads to what is known as G-LOC (Gravity-induced Loss Of Consciousness). In other words, the heart can’t fight the increased force of gravity and the brain loses its blood supply, which makes you pass out. Josh McHugh did an entertaining piece on his experience with G-LOC and the centrifuge in Wired (2003) [12].

In this sense, gravity is to us physically like stress is to us mentally. Without gravity, our physical bodies turn to mush as we slowly weaken from the inside. Too much gravity, and our physical bodies are slowly squashed by the invisible weight of the extra G’s. Our bodies work best at 1G.

In the next post in this series, I’ll look at how these different models of stress apply to our everyday.

References

  1. Shweder, R.A., America’s Latest Export: A Stressed-Out World. The New York Times, New York, 26 January 1997 http://www.nytimes.com/1997/01/26/weekinreview/america-s-latest-export-a-stressed-out-world.html
  2. What Is Stress. [cited 2013, July]; Available from: http://www.stress.org/what-is-stress/.
  3. Half a century of stress research: a tribute to Hans Selye by his students and associates. Experientia, 1985. 41(5): 559-78 http://www.ncbi.nlm.nih.gov/pubmed/3888652
  4. Selye, H., A syndrome produced by diverse nocuous agents. 1936. J Neuropsychiatry Clin Neurosci, 1998. 10(2): 230-1 http://www.ncbi.nlm.nih.gov/pubmed/9722327
  5. Fink, G., Encyclopedia of stress. 1st ed. 2000, Academic Press, San Diego:
  6. McEwen, B.S., Protective and damaging effects of stress mediators: central role of the brain. Dialogues Clin Neurosci, 2006. 8(4): 367-81 http://www.ncbi.nlm.nih.gov/pubmed/17290796
  7. Hackney, A.C., Stress and the neuroendocrine system: the role of exercise as a stressor and modifier of stress. Expert Rev Endocrinol Metab, 2006. 1(6): 783-92 doi: 10.1586/17446651.1.6.783
  8. Beyond Entertainment / Discovery Channel, The Alaska Special 2 (Season 7, Episode 2), Mythbusters: 2009 Discovery Channel, 44min. http://www.imdb.com/title/tt1427433/
  9. Oxford Dictionary of English – 3rd Edition, 2010, Oxford University Press: Oxford, UK.
  10. Gravity Hurts (So Good). NASA Science | Science News 2001 [cited July 2013]; Available from: http://science1.nasa.gov/science-news/science-at-nasa/2001/ast02aug_1/.
  11. van Loon, J.J., Hypergravity studies in the Netherlands. J Gravit Physiol, 2001. 8(1): P139-42 http://www.ncbi.nlm.nih.gov/pubmed/12650205
  12. McHugh, J., Surviving 7G. Wired, 2003. November(11),
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Autism Series 2013 – Part 3: The Autism “Epidemic”

Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4.

Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4.

It seems that autism is on the rise.  Once hidden away in institutions or just dismissed as odd, society is now faced with a condition that it is yet to come to grips with.  Some out in the community believe that it must be a toxin, or vaccines or mercury.  Others accuse doctors of simply giving in to the unreasonable demands of pushy parents to defraud the system of money – “Things have reached the point these days where any kid that’s not a charming little extrovert will be accused of being, ‘on the spectrum.’”[1]

So is there an epidemic of kids who are “not charming little extroverts”?  It depends on who you ask.

Take, for example, two articles written in the year 2000.  In the first, titled “The autism epidemic, vaccinations, and mercury”, Rimland said,

“While there are a few Flat-Earthers who insist that there is no real epidemic of autism, only an increased awareness, it is obvious to everyone else that the number of young children with autism spectrum disorders (ASD) has risen, and continues to rise, dramatically.”[2]

The other, written by Professor Tony Attwood, a world authority on Aspergers Syndrome, said,

“… is there an epidemic of people being diagnosed as having Asperger’s Syndrome? At present we cannot answer the question, as we are unsure of the diagnostic criteria, the upper and lower levels of expression and the borders with other conditions. Nevertheless, we are experiencing a huge increase in diagnosis but this may be the backlog of cases that have been waiting so long for an explanation.”[3]

I don’t think it’s very often Prof Attwood is lumped with ‘flat-earthers’.  But you can see the change in perspective from one side looking objectively to the other who need for there to be an “epidemic” of autism in order to strengthen their case.

So who’s right?  To see if this autism “epidemic” hypothesis has any real merit, we need to delve into some numbers.

First, some basic epidemiology – because part of the confusion in looking at the autism numbers is defining exactly what those numbers represent.  Here are some important epidemiology terms from the “Physicians Assistant Exam for Dummies”[4]:

Incidence: For any health-related condition or illness, incidence refers to the number of people who’ve newly acquired this condition.

Prevalence: Prevalence concerns the number of people who have this condition over a defined time interval.

Most autism figures are for prevalence, or often more specifically, point prevalence – “the number of people who have this condition at any given point in time.”

The other thing to remember from my last blog is that initially autism was only diagnosed on the strict rules of Kanner, and was considered to be a single disease caused mainly by bad parenting [5].  So through the 1960’s and 1970’s, only the most severe children were diagnosed as having autism because the high-functioning autism would not have met Kanners criteria, and even if they did, most parents didn’t want the label for fear of the social stigma.

So then, what are the numbers?  The early prevalence was estimated to be less than 5/10,000 or 1 in 2000[6], although in surveys done after 1987, the numbers began to rise past 7/10,000[7].  In the 1990’s, Autism prevalence climbed into the teens and the latest prevalence has been documented for autism is 20.6/10,000[7].

But that’s only about 1 in 485.  The CDC estimated a prevalence of 1 in 88 (113/10,000)[8].  Where did the other 400 people go?

This is where the importance of definitions is highlighted.  Autism is considered part of a spectrum, and at the time of the surveys reviewed by Fombonne, DSM III then DSM IV considered conditions like Pervasive Developmental Disorder and then Aspergers Disorder to be part of that spectrum.  Adding in the rate of PDD and you have a figure of 57.7/10,000 and adding in Aspergers gives you a combined rate of 63.7/10,000, or 1 in 157 people surveyed[7].

And yet even then, who you measure and how you measure makes much more of a difference, because a recent, rigorous study targeting all 7 to 12 year old children in a large South Korean populous found a prevalence of 2.64%, which is 264/10,000 or 1 child in every 38.  The authors noted that, “Two-thirds of ASD cases in the overall sample were in the mainstream school population, undiagnosed and untreated. These findings suggest that rigorous screening and comprehensive population coverage are necessary to produce more accurate ASD prevalence estimates and underscore the need for better detection, assessment, and services.”[9]

So if there has been a fifty-fold change in prevalence (from 5 to 264 cases per 10,000 people) in just thirty years, isn’t that an epidemic?

Well, no.  As much as some might ignorantly deny it, there is no real evidence for it.  Remember the definitions from the “Physicians Assistant Exam for Dummies”[4]:

Incidence: For any health-related condition or illness, incidence refers to the number of people who’ve newly acquired this condition.

Prevalence: Prevalence concerns the number of people who have this condition over a defined time interval.

It’s the rapid rise in the number of new cases diagnosed that defines an epidemic, which is the incidence and not the prevalence[10].  While the prevalence has changed a lot, the incidence has been fairly stable.  From Nature, “Christopher Gillberg, who studies child and adolescent psychiatry at the University of Gothenburg in Sweden, has been finding much the same thing since he first started counting cases of autism in the 1970s. He found a prevalence of autism of 0.7% among seven-year-old Swedish children in 1983 and 1% in 1999. ‘I’ve always felt that this hype about it being an epidemic is better explanation’, he said.”[11]

Fombonne agrees. “As it stands now, the recent upward trend in estimates of prevalence cannot be directly attributed to an increase in the incidence of the disorder.”[7]  He said later in the article that a true increase in the incidence could not be ruled out, but that the current epidemiological data which specifically studied the incidence of autism over time was not strong enough to draw conclusions.

While there’s no epidemic, there is the real issue of the genuinely increasing prevalence.  Why the rise in those numbers?  Fombonne went on to explain, “There is good evidence that changes in diagnostic criteria, diagnostic substitution, changes in the policies for special education, and the increasing availability of services are responsible for the higher prevalence figures.”[7]  Nature published a graph from the work of Professor Peter Bearman, showing that 54% of the rise in the prevalence of autism could be explained by the refining of the diagnosis, greater awareness, an increase in the parental age, and clustering of cases in certain geographic areas.

Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4. (Adapted from King, M. and Bearman, P., Diagnostic change and the increased prevalence of autism. International Journal of Epidemiology, 2009. 38(5): 1224-34 AND King, M.D. and Bearman, P.S., Socioeconomic Status and the Increased Prevalence of Autism in California. Am Sociol Rev, 2011. 76(2): 320-46.)

Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4. (Adapted from King, M. and Bearman, P., Diagnostic change and the increased prevalence of autism. International Journal of Epidemiology, 2009. 38(5): 1224-34 AND King, M.D. and Bearman, P.S., Socioeconomic Status and the Increased Prevalence of Autism in California. Am Sociol Rev, 2011. 76(2): 320-46.)

From Nature: “The fact that he still cannot explain 46% of the increase in autism doesn’t mean that this ‘extra’ must be caused by new environmental pollutants, Bearman says. He just hasn’t come up with a solid explanation yet. ‘There are lots of things that could be driving that in addition to the things we’ve identified,’ he says.”[11]

There is no autism epidemic, just medical science and our population realising just how common autism is as the definition becomes more refined, people become more aware, and some other biosocial factors come into play.

What can we take from the numbers?  That we’re being overtaken by Sheldon clones?  That soon there will be no more “charming little extroverts”?  If the CDC figure is accurate, then one person in every hundred is on the spectrum, so the world is hardly being overtaken by autism.  But the take home message is that Autism Spectrum Disorders are more common that we ever thought, and there are more people on the spectrum “hiding in plain sight”.  If the study from South Korea is accurate then one person in every thirty-eight is on the spectrum, but two thirds of them are undiagnosed.

Should there be more funding, more resources, or more political representation for people on the spectrum?  Perhaps, although the public and research funds are not unlimited, and other health concerns should also be treated fairly.  But since autism is life long and impacts on so many areas of mental health and education, understanding autism and managing it early could save governments billions of dollars into the future.

Rather, I think that the climbing prevalence of ASD is a clarion call for understanding and tolerance.  If we learn to tolerate differences and practice discretionary inclusion, then both the autistic and the neuro-typical can benefit from the other.  That’s a world which we’d all like to live.

REFERENCES

1. Bolt, A. If the autistic don’t get full cover, where’s the money going? 2013  2013 May 11]; Available from: http://blogs.news.com.au/heraldsun/andrewbolt/index.php/heraldsun/comments/if_the_autistic_dont_get_full_cover_wheres_the_money_going/.

2. Rimland, B., The autism epidemic, vaccinations, and mercury. Journal of Nutritional and Environmental Medicine, 2000. 10(4): 261-6.

3. Attwood, T., The Autism Epidemic: Real or Imagined, in Autism Aspergers Digest2000, Future Horizons Inc: Arlington, TX.

4. Schoenborn, B. and Snyder, R., Physician Assistant Exam For Dummies. 2012: John Wiley & Sons.

5. Pitt, C.E. Autism Series 2013 – Part 2: The History Of Autism. 2013  [cited 2013 2013 Aug 15]; Available from: https://cedwardpitt.com/2013/08/15/autism-series-2013-part-2-the-history-of-autism/.

6. Rice, C.E., et al., Evaluating Changes in the Prevalence of the Autism Spectrum Disorders (ASDs). Public Health Reviews. 34(2).

7. Fombonne, E., Epidemiology of pervasive developmental disorders. Pediatric research, 2009. 65(6): 591-8.

8. Baio, J., Prevalence of Autism Spectrum Disorders: Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2008. Morbidity and Mortality Weekly Report. Surveillance Summaries. Volume 61, Number 3. Centers for Disease Control and Prevention, 2012.

9. Kim, Y.S., et al., Prevalence of autism spectrum disorders in a total population sample. American Journal of Psychiatry, 2011. 168(9): 904-12.

10. “Epidemic vs Pandemic”. 2013  [cited 2013 Sept 03]; Available from: http://www.diffen.com/difference/Epidemic_vs_Pandemic.

11. Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4.