Volume2 Number8, 1989

2ndInternational Montreux Congress on Stress November19-21, Hotel Excelsior, Montreux, Switzerland Stateof theart presentationson Stressand Cardiovascular Disease include the Pathogenesis of MitralValveProlapse in Anxiety Disorders and Stress, The Stress Connection to Sudden Deaith,Stress-Related Cardiovascular Hypeneactivity in the Pathogenesisof Atherosclerosisand CoronaryHeart Di€ease,The Role of Stressand the SympatheticNeruous System in the Pathogenesisol Hypertension,and Hypertension.asa Disorder af Communication.Other sessionsare devotedto Stress, Emotions,Personality and Health, and include an updateon PersonalityTraits As Predictorsof Mortality from Cardiovascular Diseaseand Cancerand the BeneficialEffects of StressReduction Strategies. Other segmentsare devotedto the Stress ReductionEffects of Spa Therapy,How to Designand Deliver an Effective Stress Reduction Program, Psychophysiologic Stress Assessment Techniques,etc. The concludingpresentations are devoted to the BiobehavioralEffects of Low Emission ElectromagneticEnergr and their usein the treatmentof insomnia,depression, anxiety and addictivedisrders.

In respone€ to a nurnber of requeste, we will be devoting certain iseuec of the Newcletter to apecific topics. The forraat will include an introductory general overview followed by curnlnary articlea reporting on recent relevant reeearch reporte. Thie issue focuses on 9tress and Sudden Deatt.

Stressand " in cases where expiration takes place in less than five minutes,If one adheresto the World SuddenDeath Health Organizationdefinition, then it is quite clear Sudden death is usually viewed as an unexpected that suddendeath is the leadingcause of mortality in expiration occurring within 24 hours of onset of the United States.Almost one-halfmillion individuals symptoms,in a previouslyambulatory individual. The "unex- are affected annually, with men having a four- to World Health Organizationdefines it as an fivefold gireaterrisk than wom€n. pected patients nontraumatic,non-self-inflicted htality in In most instancesdeath is dueto anabrupt disturbance preexistingdisease, with or without whodie withinsix in heartrhythm, or severefall in blood pressure,and hours of onsetof the terminalev€nt." Other authori- sometimesboth. Suddendeath may alsoresult from ties believe that the term should be reserved for damage to vital centers in the brain because of fatalities that occur within an hour after the onset of massivecerebral hemonhage in patientswith hyperten- phrase"instantaneous the terminaleventand usethe sion, congenital blood vessel defects, or following severetrauma. However, in these latter instances, ALSO INCLUDED IN THIS ISSUE NervousSystem Pathways of SuddenDeath ...... , 3 death is not as likely to be as instantaneous or dramatic. which occur within an hour or two Heart Attacks and SuddenDeath ...... 3 of onsetof symptomsareusuallytheresult of failureof Who Is At Risk for SuddenDeath...... 4 the heart'sability to functionas a pump.This is most common in patients with severe coronary artery Scaredto Death..,....,...... ,.....4 For further inlormation on the original source of abstracts and other CulturalShock and Sudden Death...... 5 reprints available on similar subjects, please send a self-addressed stamped envelope to: Reprint Division, American Institute of Stress, Personality,Emotions and Sudden Death ..,...... 6 124 Park Avenue, Yonkers, NY 10703.

Stressand SuddenDeath in Animals ...... ,...... 6 The Newsletterof THE AMERICAN INSTITUTE OF STRESS Stressand SuddenDeath in Japan ...... 7 NEWSLETTERis publishedmonthly by The AmericanInstitute ofStress.Subscription rates: $35.00 annually. Copyrighto 1987 SuddenDeath and CircadianRhythms ...... ,.7 by The AmericanInstitute of Stress.All rights reserved. 2 7heNewsletter of THE AMERICANINSTITUiE oF STRESS only other situation in which these microscopic THEAMIRICAN INSTITUTT OF findings are seen occurs in patients with tumors that secretelarge amounts of these catecholamine chemicals.These hormones can also caus€ ventricu- lar fibrillation,a severedisruption in heart rhythm, which if not corrected, will result in death in a Paul Rotch, J. M.D.,F.A.C.P. matter of minutes.In suchinstances, there may be Editor-in-Chief little evidence of heart muscle damage since at ,it seemsquite likely that the mechanismof Contributlng Editon lrorn The Board of Trurtecr ol most suddencardiac deathsis due to the effectsof The Arnericnn lnetltute of Strece these stress-relatedhormones. f,obert Ader, Ph.D., Rochester,NY Ancient Veraue Modern Strecc Herbert Bcnlon, M.D., Boston,MA Our responsesto stressare automaticand stereo- Norrnan Courine, LosAngeles, CA Michael E. DeBakey, M.D., Houston,TX typed reflex reactions.They are the consequence Joel Elker, M.D., Louisville,KY of exquisite adaptive changes which have been John Laragh, M.D., NewYork,NY progressivelyrefined over the lengthy course of Jarnec J. Lynch, Ph.D., Baltimore,MD purposeful Kenneth B. Pelletier, Ph.D., M.D., Berkeley,CA man's evolution. Originally, they were Ray H. Rotenrnan, M.D., MenloPark, CA and life saving for our primitive ancestors, when Charlea F. Stroebel, Ph.D., M.D., Hartford,CT suddenlyconfronted by a potentiallylethal physical Alvin Toffler, NewYork, NY Sue Thomar, nN, Ph.D., Baltimore,MD threat, The great physiologist, Walter Cannon, labeled these complex but coordinated activities "fight the or flight" response.His careful research studies demonstrated that they were the conse- Stress and Sudden Death quenceof a marked stimulationof the sympathetic (Continuedfrom pageone) nervoussystem and an outpouringof adrenalin-like diseasewho suffer a myocardialinfarction.Autopsy substancesfrom the adrenalglands. These exerted studiesr€veal that threeout of four suddencardiac powerfuland widespread influences affecting almost death victims have advancedarteriosclerotic every organ and tissue in the body. There was an changesin their coronaryvessels, compared with increase in heart rate and blood pressure and anincidence of only38 percent for autopsypatients dilatation of the vesselssupplying blood flow to the in all categories.However, in such suddendeath brain, to aid in decisionmaking. The pupilswidened patients,the locationand extent of coronaryartery and vision was improved. Body fuel stores were diseaseis not distinctiveor evenparticularly remark- rapidly metabolizedto boost levelsof blood sugar able.Quite often it appearscompatible with many and nutrients for increased energy. The blood future yearsof a satisfactorycardiac function and clotted more quickly, reducing loss from lacera- life.This suggeststhe possibilitythat the fatalblow tions or internalhemorrhage. Blood flow and tension mighthave been severe coronary vasospasm causing was increasedin the large musclesof the arms and prolongedocclusion of a major vesselthat was legs,providing greater strength to fight, or speedier alreadynarrowed by atheroscleroticplaque. Much flight away from a sceneof potentialperil. more severecoronary diseaseis often seen in However,the nature of stressfor modern man is no individualsdying from accidentsor non-cardiac longeran occasionalphysicalthreatfrom a sabre- disorders,who have never experienced any signs or tooth tiger or ferocious assailant.Contemporary symptomsof heartdisease. stressesare more apt to be of emotionalorigin, and Theseobservations suggest that emotionalstress are frequently experienced several times a day. may triggersudden cardiac death in patientswho Unfortunately, our responsescontinue to remain wouldotherwise have enjoyed many future years of those that existed hundreds of thousandsof years active life. Further support comesfrom autopsy ago. While life-savingfor primitive man, they have studiesof patientswho died suddenlyfollowing now becomenot only inappropriate,but potentially extreme,but non-physicalstress. In most instan- harmful.Repeatedly called into play, it is not difficult ces,there is no evidenceof coronaryocclusion or to understandhow theycancontribute to hyperten- evensignificant atherosclerosis. However, caref ul sion,heart attacks,cerebral hemorrhage, and sudden examindtionwill usuallydisclose typical discrete death.Major psychosocialstresses, such as the loss areas of damage,which, under the microscope, of importantemotional relationships, persistent frus- revealcharacteristic "contraction bands" consis. tration, feelingsof helplessnessand hopelessness, are apt to be more insidiousand chronic than the tent with chemicaldestruction of heart muscle "fight tissue.These findingsare identicalto those ob- acute challengeswhich trigger the or flight" servedin laboratoryanimals following injections of response.Nevertheless, as we shall see, they are largeamounts of adrenalinand nor-adrenalin.The (continuedon page3) TheNewsletter of THEAMERICAN INSTITUTE OF STRESS

are apt to rcfer to such symptoms as severe or Stress and SuddenDeath prolongedangina or coronary insufficiency,The (continuedfrom page2) primarydistinction is that the interruptionof blood also associatedwith an increased incidence of flow to heart muscleis temporaryand not associ- suddendeath, via similarand other neurohumoral atedwith structuraldamage.There are permanent activities.As our understandingof the pathogenesis changesin the electrocardiogramor elevationin of suddendeath due to stresshas expanded, it has blood enzymes indicative of tissue destruction. "heart beenpossible to developavariety of preventiveand Most often,the term attack" usua[ydenotes stress-reductionstrategies that have been able to the occlusionof a coronaryartery (coronary thrombo- providesignificant protective benefits. sis)withresultant permanent heart muscle damage (myocardialinfarction). These terms were formerly "The often used interchangeablysince it was assumed older a man grows, the faster he could run as a that all myocardialinfarctions were the result of boy." coronaryartery occlusion and permanent interrup- RedSmith tion of the flow of blood to the affectedmuscle, Similarly,sudden death was usually assumed to be NervousSystem Pathways the resultof a massiveheart attack. That is stillapt to be the diagnosis physicians record on death Of SuddenDeath certificateswhen an autopsy is not performed. Acute stressactivates the frontallobe of the brain However,this is more a socialconvention, rather where thought processesoriginate, alerting the than a careful judgment based on scientific evi- hypothalamusto signal the sympatheticnervous dence.In point of fact, pathologistsreport that at systemand the adrenalgiandstoproduce noradrena- least half of such suddendeath patientsshow no Iin and adrenalin.Simultaneously, the vagusnerve evidenceof myocardialinfarction.In addition,large which exerts opposing parapsympatheticinflu- numbers of patients have been resuscitatedin enceson the cardiovascularsystem, is suppressed, recent yearsfrom what would have otherwisebeen blockingactivities that would normallybe activated fatal arrhythmiasand sudden death. In the vast to maintain the normal balance of physiologic majoritythere was no chestpain or electrocardio- processes.If sympatheticstimulation is intenseand graphicand serum enzymechanges to suggesta unopposed,the heartbeats very rapidly, and severe myocardialinfarction. disturbancesin rhythm mayresult in suddendeath. Over the pastfew decades,it has becomeincreas- However,under certain circumstances, counterreg- ingly evident that coronary occlusionmay occur ulatory rebound parasympatheticand vagalinflu- without myocardialinfarction, and that myocardial encesmay supervene.In such situations,sudden infarctioncan occur without coronary occlusion. deathmay actuallyresult from a markedslowing or Often, time has permitted the development of complete cessationof the heart beat (asystole). collateralcirculation to the tissue fed by the oc- This produces the sameeffect as ventricular fibril- cluded vessel. Conversely, under situations of lation,namely a marked and sustainedfallin blood severe stress,the sympatheticfibers innervating pressurethat interrupts the flow of blood to vital the heart muscle (myocardium) secrete excess organs, causing irreversibledamage and sudden amounts of nor-adrenalin,causing severe local death, muscle ,in the absenceof any relevant vascularobstruction. Severely stressful situations canalso cause prolonged constriction and spasm of "The future is no more uncertain than the present." - coronaryvessels, causing significant interruption in Walt Whitman the flow of blood to heart muscletissue. This may be of sufficientmagnitude to causemyocardialin- farctionwithout evidenceof permanentstructural coronaryocclusion at autopsy. HeartAttacks and Heart attacks or myocardial infarctions are most SuddenDeath apt to occur in the early morning period before 8 more Suddendeath is the majorcause of mortalityamong a.m. Sudden death tends to be common have Americans between the ages of 20 and 65. Most during waking hours. Several large surveys preponderance suddendeaths are of cardiacorigin, and areusually confirmeda of suddendeath events "heart assumedto be due to a attack." lndeed, on Mondays,the day one usuallyreturns to work "suddenly." presumed two-thirds of heart attack victifis die after a weekendof relativerelaxation. "heart "sudden However, attack," like death" is a Such observationssuggest that stressfulactivities term that can havedifferent meanings. Patients often and behaviorsrepresent important risk factors for useit to describean episodeof severeand prolonged sudden death above and beyond their acknowl- per chest pain due to coronaryvasospasm. Physicians edgedcontribution to heart attacks se. The Newsletterof THE AMERICAN INSTITUTE OF STRESS

Who Is At Risk paperreports of suddendeath, eight life settings were For Sudden Death identified: 1. hearingnews of the collapseor deathof a close Ever since history has been recorded,there have person(2L7'); been descriptionsof suddendeath in association 2. experiencingthe threat of immediate loss of with There is probably phenome- severestress. no such a person(97o); non as popularor pervasivein the folkloreof every 3. duringmourning, or on the anniversaryof the cultureas suddendeath while in the throes of anger, deathof a closeperson (3%); humiliation f.ear,rage, , depression or , anxiety. 4. experiencingpublic humuliationand lossof self While such accountsare anecdotaland to apt be esteem(6%); embellished and exaggeratedwith repetition,their 5. duringperiods of extremepersonal danger or validityis supportedby modern research, scientific threat of injury (27'/'); The availabilityof ambulatoryelectrocardiographic 6, shortly after the danger has passedand the monitoring,electrophysiologic testing and improved realization of its significancebecomes measurementtechniques for evaluatingstress respon- apparent(7%h have ses expandedour understandingofthe mechan- 7, duringthe excitementof a reunion,hiumph, or isms of action involved.Common risk factors for happyending (67o). suddendeath include: In analyzingthe data, it becameapparent that the 1. Coronary artery disease common denominatorin allof these situationswas 2. Hypertension that they representedcircumstances which were 3. Alcoholabuse impossiblefor the victim to ignore,and to which the 4. Smoking onlyresponse was an overwhelmingfeeling of marked excitation or a senseof complete resignationand 5. Obesity "giving 6. Age up," or both. 7. Sedentarylifestyle (not enoughexercise) Some illustrative examples which have practical 8. Low bloodlevels of potassiumor magnesium implicationsfollow. A 44-year-oldfemale who had no medical problems Certain types of electrocardiographicabnormali- was seenfor purposesof a routinephysicalexamina- ties, myocarditis, valvular and congenitalvascular tion, which included obtaining a sample of blood. abnormalitiesor enlargementof the heart are also Becausethe patient was very fearful of this and associatedwith sudden death. Of all of these, usuallyfainted, the precautionwas taken of having coronary artery diseaseis the most important.In her lie downduring the procedure.However, within a 20-25percent of sudden cardiac deaths,this event few secondsof the needlepuncturing the vein, she representsthe first manifestationof any known complainedof feelingweak, broke into a cold sweat, heart disorder. turned pale,and went into cardiacarrest. No heart The importantrole of psychologicalstresshas long soundscould be heard,no pulsesfelt, there was no pupils been recognized. Sudden death has frequently spontaneousbreathing and her becamewidely been observed as a consequenceof a violent dilated.Cardiopulmonary resuscitation was instituted argument, witnessinga tragedy, learning of the immediatelyand sheregained consciousness approxi- death of a loved one, suddenand severefinancial mately two minutes later, Recwery was complete disaster, etc. However, as will be seen, even withinfifteen minutes. She refused hospitalization and emotionallycharged happy events, such as a family left the officeon her own power. When examineda reunionwith longlost relatives,or a weddingcan be yearandahalf later,she was perfectlynormaland had sufficientlystressfulto cause sudden death. remainedquite well during the interveningperiod. A 5S-year-oldman with a history of a prior heart attack, was beingexamined in the emergencyroom "If we had to tolerate in others all that we permit in for complaintssuggestive of a secondinfarction, when ourselves, life would become completely he suddenly went into ventricular fibrillation and unbearable." - GeorgesCourteline cardiac arrest. Fortunately,he was successfully resuscitatedin a few minutes. When interviewed severaldays later, he reportedthat he was pain free Scaredto Death andrelatively comfortable untilthe internbegan what provedto be an unsuccessfulattemptto perform an It is not unusualto hear or read about someonewho arteriai puncture. The patient became extremely died suddenlyfollowing a severefright. That associa- apprehensiveand concemed about the physician's tion is so wellrecognized,that being"scared to death" competenceand overwhelmedwith the realizationof is actuallypart of our language.In one report which beingpowerless to examinedthe circumstancessurrounding 275 news- do anythingabout his situation.In (continuedon page5) The Newsletterof THE AMERICAN INSTITUTE OF STRESS

Scaredto Death (continuedfrom page4) there,many immigrated to the UnitedStates, living a few minutes, he felt flushedand the chest pain mainly in large cities.Shortly after their arrival, a returned and persisted.It was when the intern left surprising number of healthy young men died the room to find someoneto help with the pro- suddenlyin their sleep,leaving no physicaltraceof cedure,that he suddenlywent lnto cardiacarrest. any cause. Such sudden death has occurred in A forty-year-oldfather slumps dead as he cushions individualsas young as twenty, with an averageage the headof his son lyinginjured in the streetbeside underthirty-five. In onereport of sixty suchvictims, his motorcycle. alihadbeen in excellentprior health,had no cardiac A man aged43 diesfour hoursafter his lS-year-old history, and died suddenlyin their sleepbetween "lf son,faking a kidnapcallover the phonesays, you the hours of 11 pm and 8 am, "will want to seeyour son alive,don't callthe cops." Some authoritiesbelieve that these deaths A 3S-year-oldman accused of robbery tells his prove to be the resultof the interactionof psycho- "l'm lawyer, scaredto death," then collapsesand logical culture and physical factors" still poorly dies. understood.The Hmong have only had a written alphabet for thirty years. However, even well- In one case,a desk clerk in a motelwassuddenly educatedSoutheast Asians experien ce severestress young confrontedby a derangedlooking man who after arrival in the United States.Severaltheories paper demandedshe fill a brown bag with money. havebeenproposed. Some believe that the Hmong gave Terrified, she the robber what she had and are particularlysusceptible to stress and died of police, then calledthe They took her to the station fright, homesickness,and Of particular inter- gasping for srief. house where she began breath and est with respect to psychological-culturalinflu- clutchingherchest and she was immediatelyrushed ences, is that Hmong traditions and language prior to a nearby hospital.Although there was no embraceconcepts and terminologyclosely parallel- pressure "night history of any heart diseaseor high blood ing the nocturnal anxiety crises we call shesuddenly expired, less than two hoursafter the terrors" or nightmares,One of theseoneiric experi- robbery.One yearlater, the robberfound himself in which may by significant jury ences be accompanied court faced with a charge.The was physiologic reactions, includes attack by an informed that autopsy studies showed damaged incubus, da chor that presseson the dreamer's heart muscle tissue,consistent with the chemical chest.Relocating from the remotedeserted moun- injury causedby adrenalin-likesubstances that are tain jungles of Laos to the crowded highrises of secretedin massiveamounts in individualswho are metropolitancities must obviouslyresult in various testimony under severe stress. This and the of extr emeemotional demands and shockingcultural other expert witnesseswas deemedsufficient by changesthat many of theseindividuals are not able the jury to find the 2O-year-oldrobber guilty of "scaring to tolerate for any sustainedperiod of time. felony murder by literally someone to This pattern resemblesa series of unexplained death." sudden deaths among young Filipinos and Hawaiians reported several decades ago. That "bangutgut" "Everyone hasa right to his opinion, but no man has phenomenon was called after the a right to be wrong in hisfacts." Filipino word for nightmare.In Japan, there has - BernardBaruch beena recentincrease in a differentform of sudden deathdue to stressknown assudden death different form of sudden death ("pokkuri byo") known as "."These victims are primarily middle-aged, Cultural Shochand workaholic executives,who feel perpetuallydriven SuddenDeath to perform and excel for their companies. In Abrupt changesin socialstatusand culturalnorms addition to cardiac deaths, stress-relatedimmune have also been associatedwith increasedsudden systemdepression may also contribute to mortality, deathin variousgroups of individuals.The Hmong tribe in Laos were alliesof the UnitedStates in the Vietnamese.They were war against the North "Despair in the in theself, and so toughwarriors, loyalfriends, and helpfulcollabora- is a sickness spirit, airmen. When the it mayassume a tiple form: In despairat not being tors in hiding downed U.S. . in no fromlndochina,the Hmong consciousof havinga self . . despairat being UnitedStates withdrew willing to be victims a brutalrevengecampaign by willing to be oneself;in despair at becamethe of oneself'" the victorswho reportedlyresorted to toxic chemi -s. Kierkegaard cals and nerve gas to exterminate them. Many escaped to refugee camps in Thailand and from The Newsletterof THE AMERICAN INSTITUTE OF STRESS

Personality, Emotions they faced. Once identified,the doomed victim retreatedto his hut, and wasinevitably found dead "the And Sudden Death shortly thereafter.As Cannon stated, sug- AL7-year-oldbridesmaid dropped dead during the gestion which I offer, therefore, is that 'voodoo processionalfromthe weddingaltar. A lS-year-old death'maybe real,and it may be explainedas due contestantin a MissTeenage America contest died to shocking emotional stress - to obvious or suddenlyin front of an audiencein a department repressedterror." store. Neither had a prior history of poor health, drug use,or evidenceof heart disease. "The In patients who have had a heart attack within the deepest need of man is to overcome his pasttwo months,it hasbeen possible to predictthe separateness,to leave the prison of his aloneness." likelihoodof futuresudden death solely on the basis - Erich Fromm of psychologicalevaluation. At particularrisk are those with extreme Type A behavior patterns, severedepression, and what has been labeledthe "Sisyphus" reaction,This term describesan effort- Stress and Sudden Death orientedperson who strivesagainst odds with very little sense of accomplishmentor satisfaction,In In Animals Greek mythology,Sisyphus, a Corinthianking, was There are many kinds of reactions to emotional condemnedto Hades where he was required to stress.Animal studies have demonstrated both the "fight pusha largeboulder to the top of a steephill, only to or flight" mechanismsof Cannon, but also haveit roll down just as he reachedthe summit.In withdrawalactivities that give the appearanceof someways, Sisyphus can be likenedto an extreme death.Charles Darwin observed this latter phenom- Type A, working harder and enjoyingit less,and enon in birds, and it is common knowledgethat neverbeing able to experiencea senseof fulfillment someanimals, such as the opposum,use pseudo- or satisfaction. death withdrawalreactions for protection, hence "playing Anthropologistsstudying primitive cultures have the term possum,"When apesare placed reportedmany tales of suddendeath as a resuitof a in stressfulexperimental situations, such as re- curse or hex put on the individualby a medicine quiringthe useof a leverto preventelectricalshock, man or tribal leader.The famousstress physiolo- prolonged activity may produce frustration and gist, Walter Cannon, was intrigued with these complete resignation,resulting in sudden death, accountsand personallyinvestigated the phenom- Soviet researcherswere able to produce vascular "voodoo enon of death." A typical example he lesionsand suddendeath in monkeysby disrupting recountedwas that of suddendeath brought about their socialrelationships.In one study,a dominant by superstitiousfearin an Africantribesman deep in malewas removed from his colony and placedalone the Congo. in an adjacentcage with a clear view of his former "The young Negro on a journey lodged at a friendb subordinatesfeeding and engagingin sexualactiv- house for the night. The friend had prepared for ity, The dominant male exhibited violent excite- their breakfast a wild hen, a food strictly banned by ment, rushing about frantically, attacking the wire a rule which must be inviolably observed by the netting, uttering furious and desperatecries and immature. The young fellow demanded whether it moans,and ultimately expiring. The suddendeath was indeed a wild hen. When the host answered, of wild animals upon capture or caging, is well 'No,'he ate of it heartily and proceeded on his way. knownto trappersand zookeepers. Experiments in A few years later when the two met to dine agan, the wild and domestic rats, also demonstrate that old friend asked the younger one if he would eat a inducinga senseof hopelessnessis accompaniedby wild hen. He answered that he had been solemnly an increasedincidence of suddendeath. In cock- charged by a wizard not to eat that food. There- roaches,fighting can result in the death of sub- ordinateswithout any evidenceof physicaldamage upon, the host began to laugh and askedhim why "death he refused it now, after having eaten it at his table and has been describedas from stress." before. On hearing this news, the Negro immedi- ately began to tremble, and so greatly was he possessed fear, that in less than 24 hours, he by "You wasdead." see, one thing is, I can live with doubt and "bone Cannon also recounted instancesof point- uncertainty and not knowing I have approximate ing" deaths, in which the victim was accusedof answers and possible beliefs and dilferent degrees having violated an important taboo, Guilt was of certainty about different things . . . it doesn't establishedby a tribal ritual using animal and frighten me." chicken bones which were shaken up and then - RichardFeynman (NobelLaureate) dispersedon the ground to seein whosedirection The Newsletterof THE AMERICAN INSTITUTE OF STRESS

Stress and SuddenDeath duty, on vacation or gamblingin Las Vegas, is assumedto have a work-relateddisability and is In Japan compensatedaccordingly! Chief executives of at least 12 major Japanese companiesdied suddenlyin 1988,more than three times as many comparabledeaths as occurred in "Somepeople 1986.Furthermore, most were in their fiftiesand areso concemedabout the pastthat theyare backinginto the future." sixties, in a country where the averagemale life - expectancy is 75. Although the causesof death CharlesKettering ranged widely from pneumoniato heart attacks, manyJapanese feel strongly that the realcausewas the stressthat resultedfrom a 40o/"rise in the value Sudden Death and of Japanesecurrency. This caused sales and profits to decline because of decreasedexports. One Circadian Rhythms psychiatryprofessor commented that in Japan,the extreme obsessionwith perfection puts unusual pressure on executives.His prior researchalso Suddendeath, as well as heart attack and stroke, demonstratedthat the incidenceof heart attacks aremost likely to occurbetween the hoursof 6 a,m. among managers was nearly four times higher and noonthan other timesof the day.In one report duringthe oil crisesof 1974and 1979,as in the high which analyzedchanges in cardiacenzvme levels growth period oI L966 to 1968. Top Japanese releasedas a result of heart injury in over 700 patients, executivesare often workaholicswith littletime for threetimes as many heart attacksoccur. period familyand sociallife and eventhe latteractivities are red in the between 9 and 10 a.m. as usuallywork related.Frequent business entertain- comparedto 11p.m. and midnight.Another survey ingdoes not permitthem to relaxat homeor adhere of over 2,000 cases of sudden death showed a pattern. to diets but rather encouragesincreased alcoholic similar It has been suggestedthat the process andhigh-caiorie food intake which may also contrib- of wakingupis associated withthe secretion ute to the problem. of increasedamounts of stress-relatedhormones, In 1969, there were ten sudden deaths in top like adrenalinand cortisone.These tend to cause platelet executivescompared to approximately150 in 1987. clumping,accelerate blood clot formation, potassium, Sudden death due to overwork ("karoshi")is not lower serum and produce fataldistur- necessarilyconfined to stressedexecutives. It also bancesin heart rhythm. occurs among taxi drivers, teachers,journalists, There are a variety of rhythmic variations that govern salespeopleand maintenanceworkers. In contrast appear to certain body activities.Some to the United States,personal sacrifice and over- occur on a monthlybasis as in the menstrualcycle, timespent on thejob is lookedupon as an essential The secretionof certain hormoneshave 24-hour requirementto demonstratecompany loyalty. There rhythmicalcycles and are relercedto as circadian (around are tremendous pressuresto subordinatefamily rhythmsfrom the Latin circa dies the day). activities and personal desires to work-related The fact that sudden death, strokes and heart responsibilities.Workers often feel that company attacksalloccur much more frequentlyduring the obligationsare more important than their own samehours, suggest they are alldue to mechanisms individual rights. Researchersbelieve that many that followare influenced by smilarcircadianrhythms. factorscontribute to the increasedrates of sudden Thishas important implications for treatmentstrate- gies death, particularlythe excessivecompetition that since obviously medicationsprescribed to "Japan prevent permeateswork activities.One statedthat abnormalheartrhythms should be takenat produces lost (World War II) so we feel we have to work a time that maximalblood levelsduring periods, particularly harderthan Americansand Europeans. critical This is true in the case One suddendeath victim directed traffic on 24-hour of beta blocker drugs which blunt the effects of shiftsand sometimeslonger every other day, with adrenalin.These agentshave been demonstrated protection only six hours allowed for naps and meals. His to offer againstboth heart attacks and family was awarded compensationsince it was suddendeath. ruled that he had died of overwork. However, in more than 95ol'oI cases,workmen's compensation "lf benefitsare deniedbecause it is difficultto prove you are pained by any external thing, it is not the that the causeof deathwas work related,In the past thing that disturbsyou, but your judgment about it. it rvas necessaryto prove that the victim was And, it is in your power to wipe out this judgment overworkedon the day of death,but that has now now." beenextended to cover the pastweek. In contrast. - MarcusAurelius anypolice officer who developsa heartattack on or off Book Reviewso Meetingsand ltems of Interest Book Review The Wornan'e World, Furct, M.L. and Morce, D.R., Chicago,IL 60660.(37217U-n25. (edc.). AMS Prece, New York, 19EE' 146 pp.' S32.50. Meetingof theSociety for Traumatic Oct. t7-30, Fifth"LeamingAnnual This is another volume in the AMS Stressand Modem Society StressStudies from Victim/Survivors:Insights for series. The authors had publisheda previous volume on the Prevention,Intervention, and Care,"San Francisco, CA. The same subject in 1982at the height of the Woman's Liberation Societyfor TraumaticStress Studies, P.O. Box 1564,Lancaster, Movementand, in some respects,this representsan updateor PA 17603. follow-up.It beginswith a brief overviewof the stressconcept, Nov. 2-4, CardiacWellness and Rehabilitation, St. Thomas,VI. tracing its relationshipto a variety of signs, symptoms, and MedicalEducation Resources, (800) 421'3756. diseases.A subsequentsection deals with common stresses Nov. 2.4, NeuroimmunologyM: TheState of theArt,Chicqgo, classesof modern women,particularly IL. Universityof ChicagoSchool of Medicine.(312) 702'1056. encounteredby various fo'r workplace.The concludingchapters are devotedto Nov. 2-5, 198923rd Annual Convention of the Association thosein the Therapy,Washington, DC, (2121 suggestionson howto identifustress andto manageit effectively. Advancementof Behavior physical 279-7970. This includes psychological and coping mechanisms, Medicine:An Exploratioltof as well as standardstress Nov. 4-5, TeachingHumanistic the role of nutrition, socialdiversions, Goals,Teihniques and Experiences, New York, NY, NYU Post managementtechniques such asmuscular relaxation and medita- GraduaqeSchool. (2L2\ 340-5295. tion are discussed.Distinctions between the natureof stressand Nov. i.19, Topics in Psychopharmacologyand Biolgglqrl stress responsesbetween males and femalesare emphasized. PsychiatryMosc6w, Samarkand, Tashkent, I enin$ad' USSR. However, surprisingly little discussion was devoted to Type A kofessionalSeminar Consultants, Inc. (800) 365-5357. behavior which seems to be increasing in femaleswho have to Nov. 9-11, AddictionMedicine: State of the Art California compete in a male-dominatedwork force where they still do not Societyfor theTreatment of Alcoholismand Drug Addiction, San have equal rights. Many authoritiesbelieve that this may be a Dego,CA (415)42&W91. major causeof the significantincrease in cardiovasculardisease Nov. U.20, 26thfurnual Psychiatric Institute o4 Group Behavior seenin certain femaleoccupation settings. This volume is well and Group Leadership,Peachtree City, GA, EmoryUniversity indexedand references,and its easyto readconversational style Schoolof Medicine.QAq 727-ffi96.. appears to be directed primarily towards a lay audience rather Nov. 19-21, SecondAnnual Intemational Montreux Congress than health professionals. on Stress,Montreux, Switzerland. American Institute of Stress (914)%3-1200. Dec. 3-7, IntemationalRound Table on SilentMyocardial Ischemia.For detailedinformation contact the CongressSecre- tariat,TelAviv; contact Kenes Ltd., P'O. Box 50@6,TelAviv Meetings and Iterno of Interest 61500. Dec. 7-9, Cardiac Wellnessand Rehabilitation'Acapulco, Sept.24, HealthyPleasures, Bo516n, ffi (M.l.T.)lnstituteforthe Studv Resources(see above for details- MargaretCaudill, M.D., ISHK/ Mexico.M-edical Education of Human Knowledge.Contact sameas August 4.) Boston.Box 1052,Cambridge, MA 02238. to HealthPromotion' Oct. 2-4,Neuropeptides and Immunopeptides, New York, NY. New Dec. 10-30,Wellness and lts Relationship (212) Protectionand DseasePrevention (Cruise: Rio De Janeiroto York Academyof Sciences,2 E. 63rdSt', NewYork, NY l@21' (212) 83&0230. BuenosAires, Argentina).Seminars and SSanposiaInc. Oct. 11.15, AmericanAcademy of Childand Adolescent Psvchology, 517-75n. NewYork, NY. (202)966-7300. Feb. 25-Mar 2, 1990,American Journal of HealthPromotion, Oct. 29-25, The Ecologyof Work: ImprovingProductivity and the Cancun,Mexico. (313) 258'3754. Qualityof Work Life.Toronto, Ontario. Contact Tom Chase' R.R. *2' Mar. 29-Apr. 1, 1990, AmericanSociety of Contemporary Box44a, Northwood, NH 03251. Medicinearid Sursery (Stressand Hypertension),Phoenix, OcL. 26129,Academy of PsychosomaticMedicine, Las Vegas, NE. Arizona. Academyof PsychosomaticMedicine, 5824 N. Magnolia,

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