mental health

Empathy vs Compassion

I recently read a fascinating book by psychologist Paul Bloom called Against Empathy: The Case for Rational Compassion. In this post I will discuss this book in more detail as well as review other evidence about the difference between empathy, theory of mind, and compassion. I will also discuss how Bloom’s book has been misused by some right wing Christians.

Empathy

Definition of Empathy

Most definitions of empathy include vicariously feeling the same emotions as another person and understanding another person’s perspective. Psychologists separate these two things. Vicariously feeling another person’s emotions or pain is called emotional empathy. It is neurologically distinct from understanding another person’s perspective, which is called cognitive empathy or theory of mind. Bloom focuses his critique on emotional empathy, not theory of mind.

Emotional Empathy

Emotional empathy is hard wired into us. It is a mostly unconscious response to another person’s distress. It can motivate us to be kind and helpful to the person or people who elicit this response. It can also lead to harm and even violence. Much more about that later in this post. Emotional empathy is a system 1 response. I’ll explain what that means below.

System 1 and System 2 modes of thinking

System 1 and system two are descriptions of of two ways that our minds operate. It is a somewhat simplified model, but it is consistent with current neuroscientific research. The best accessible description of system 1 and system 2 is a book by Daniel Kahneman called Thinking, Fast and Slow. I highly recommend reading it.

System 1 is what we use for most routine tasks in our lives. It is our fast, automatic, intuitive and emotional mode of thinking. It operates without conscious awareness and relies on mental shortcuts to make quick judgments and decisions. System 1 is essentially our brain’s “autopilot” mode, constantly monitoring our surroundings and making rapid assessments. It is essential to our lives, but , it’s also important to be aware of its limitations. It can sometimes lead to errors in judgment, particularly when dealing with complex or unfamiliar situations.

System 2 thinking is a deliberate, conscious, and effortful process used for complex tasks and decisions. It is characterized by logical reasoning, careful analysis, and consideration of multiple factors. Unlike System 1 (fast, intuitive thinking), System 2 requires focused attention and effort.

Emotional empathy as a system 1 mode of thinking

Emotional empathy happens without our conscious awareness. It is contextual. Bloom cites research that emotional empathy is influenced by what we think about the person we are empathizing with and how we judge the situation that person is in. In one study subjects were shown videos of people in pain said to be suffering from AIDS. Some of the people in the videos were described as having gotten AIDS from intravenous drug use and some were described as having gotten AIDS from a blood transfusion. Subjects showed much more empathy for the people who were described as having gotten AIDS from a blood transfusion than those described as having gotten AIDS from intravenous drug use.

Emotional empathy is also influenced by the group to which the other person belongs. Is it one of Us or one of Them? There was a study of a painful shock to the hand in European soccer fans. One person was shocked while others witnessed the person who was shocked. Subjects showed more empathy if the person was a fan of the subject’s team and much less empathy if the person was a fan of the opposing team. All of these responses were shown to be below the level of consciousness. When subjects were asked about the reason for the difference in their empathy scores, they denied that there was any bias.

Does high emotional empathy correlate with good behavior?

People do vary in how empathic they are. On one end of the spectrum are people who have a high emotional empathy response, and on the other end of the spectrum are people who have very little emotional empathy. We would expect that people with a high emotional empathy response would be more likely to take action to help. People with high emotional empathy feel peoples’ distress more strongly and this should motivate them to help if for no other reason than to reduce their own distress. Another way that they could reduce their distress, however, is to escape rather than help. We would also expect that people with very low emotional empathy would have more cruel or violent behavior.

It turns out that there is almost no correlation with empathy and good or bad behavior. A meta-analysis of all the studies showed that low empathy has no association with aggression, and high empathy has minimal to no effect on good behavior. To quote Bloom, “Being high in empathy doesn’t make one a good person and being low in empathy doesn’t make one a bad person.”

Emotional empathy as a spotlight

Emotional empathy acts like a spotlight. To quote Bloom again, “making visible the suffering of others making their troubles real, salient and concrete.” The spotlight effect is a weakness as well as a strength. When you point a spotlight at something, everything else is in darkness. What you see depends on where you point the spotlight. This focus effect makes you more vulnerable to bias. It also leads to something called “the identifiable victim effect.” This sets up a situation where one identifiable victim elicits more emotional empathy than than a thousand victims. Stalin once said “One death is a tragedy; one million deaths is a statistic.” We also see this effect in deaths from the COVID pandemic. Eighty percent of Americans do not know anyone who died from COVID, though over a million Americans died from the COVID pandemic. The people who died were disproportionately elderly, black or poor. For people outside of those groups there was no emotional empathy spotlight effect. That is likely why so many people were not convinced that COVID was a serious disease.

The dark side of emotional empathy

Emotional empathy where there is conflict between groups can exacerbate conflict, even wars. People on one side feel empathy for members of their group who feel they have been harmed by the other side. Empathy with your side leads to the desire to punish the perpetrators. Of course people in the group on the other side of the conflict feel emotional empathy for the people on their side and therefore want to punish the other group. In these kind of situations emotional empathy exacerbates rather than mediates conflict between groups.

Burnout

People in the helping professions (doctors, nurses, therapists) do not do well when they experience high emotional empathy with all their clients. Experiencing the pain and suffering of patients, even though empathic suffering is not as severe as the suffering of the patient, is not pleasant. Over time, symptoms of burnout can develop. These include fatigue, poor concentration, lack of energy and effectiveness, cynicism and detachment.

Manipulating emotional empathy

The emotional empathy response can be manipulated for good causes, but also for things that are morally suspect or wrong.

Charities

Charities understand that eliciting emotional empathy will increase donations. They do this by showing images of individual people or animals who are obviously in distress. Stories go with the images about the suffering of this individual person or animal. Since we have an increased emotional empathy response to children in distress, the charity ads often use images of children. The emotional empathy response is not a good way to decide which charities should get your donations. Some charities do much more good for a lot more people than others. All charities, both good and not so good use the same techniques to manipulate emotional empathy. There is a better way to decide which charities should get your donations. More about that later in this post.

Politicians

Politicians often highlight individual people to manipulate the emotional empathy response to recruit people to vote for them or to take one side or the other in political and policy battles. Once again, this is not a good way to choose which politician or which policies you want to support.

The Christian right

There have been several recent books by right wing Christian authors who have cherry picked Paul Bloom’s critique of emotional empathy. Essentially anything or anyone that elicits empathy that contradicts their view of Christianity is termed “toxic empathy.” This is just another manipulation of empathy in a negative sense that promotes a particular religious viewpoint.

Compassion

Definition of compassion

Psychologist Paul Gilbert defines compassion as basic kindness with a deep awareness of the suffering of oneself and of other living things coupled with the wish and the effort to relieve that suffering.

Compassion as system 2 thinking

Understanding (rather than feeling) the suffering of a person or group of people uses system 2 thinking. That understanding facilitates the desire to help in the most effective way possible. Determining the most effective way to help requires logical reasoning, analysis, and consideration of multiple factors. These are characteristics of system 2 thinking.

Awareness of the vast amount of suffering in the world does not mean that an individual person can help relieve the suffering of all sentient beings. Compassion involves choosing both how and whom one can help the most.

Compassion in the helping professions

As noted above, emotional empathy alone can lead to burnout. It can also lead to less than ideal doctor-patient relationships. Patients are not interested in doctors or nurses feeling their pain. They want compassionate competent care. Doctors, nurses and therapists must of necessity maintain a certain emotional distance from their patients in order to provide that compassionate care. Compassionate care clearly involves mostly system 2 thinking. Unlike emotional empathy, understanding and compassion lead to the opposite of burnout. Multiple studies have shown that compassionate care is good for both patients and their clinicians. Here is a link to a review of a book by Dr. Anthony Mazzarelli and Dr. Stephen Trzeciak: Wonder Drug: Scientific evidence that serving others is best medicine.

Compassion training

It is possible to enhance compassion through training. For over a thousand years buddhists have practiced a form of meditation on compassion called “loving kindness” meditation. It involves both compassion for self and then expanding to family, friends, and eventually all sentient beings. Here is a link to a website that describes this kind of meditation: Metta Meditation: A Complete Guide to Loving-Kindness. There are many other ways to enhance one’s ability to be compassionate including cognitively based compassion training, Stanford multidisciplinary research based training, as well as many others. They have all been shown to increase compassion, which in turn leads to helping others. Once again compassion for self and others is as good for the helper as it is for the one who is helped

Bottom Line

You cannot turn off emotional empathy, nor should you even try. It is an automatic system 1 response. When combined with understanding and compassion it is always a good thing. It makes suffering visible and salient. The important thing is to learn to recognize your emotional empathy system 1 response and then engage your system 2 understanding and compassion. Emotional empathy by itself is not good or bad, but can be either. Your capacity for understanding and compassion (which is essentially kindness) can be enhanced by training. We definitely need more kindness in our world today.

Autism: Is There Really An Epidemic?

Robert F. Kennedy Jr has reported that there is an epidemic of autism. It is clear that autism is being diagnosed more frequently in the last 10 years, but does that represent an increase in the incidence of autism or better diagnosis? In this post I will review the literature about autism in order to give an evidence-based answer to that question.

Diagnostic Criteria Changes Over Time

There is an excellent paper describing how the criteria for diagnosing autism has changed over time: Update on diagnostic classification in autism. The following information is taken from that paper.

The diagnosis of autism was first described in 1943 by Kanner. Prior to that children with severe autism symptoms were diagnosed as “schizophrenia of childhood.” In 1944 Ausberger reported on a group of children who had similar symptoms to the children Kanner described, but they had no intellectual deficits.

It was not until 1980 that the diagnostic criteria for autistic disorder were included in the Diagnostic and Statistical Manual (DSM)-III). Core features were onset prior to 30 months of age, pervasive lack of responsiveness to others, gross deficiencies in language development, peculiar speech patterns, and bizarre responses to the environment, including resistance to change and fascination with objects. This led to a marked increase in the diagnosis of more severe autism. In 1987, DSM-III-R expanded the menu of symptoms supporting the diagnosis of autism, and formally separated core features into three domains of impairment in social interaction, communication, and restricted or repetitive behaviors.

The next significant change occurred in the DSM -IV in 1994 with the introduction of the diagnosis of Asperger’s disorder. Aspergers’s disorder included what used to be called high functioning autism (autism without intellectual disability). The addition of diagnostic criteria for less severe forms of autism led to another increase in the diagnosis of autism.

In the years since the introduction of the DSM-IV criteria, advances in genetics found that all of the autism disorders had a strong genetic component and that the different forms of autism-like illnesses probably were manifestations of the same condition. In 2013 in DSM V, all of the the autism like illnesses including Asperger’s syndrome were combined into something called autism spectrum disorder.

Subsequent research showed that autism could be diagnosed as early as 18 months of age. This led to the recommendation by the American Academy of Pediatrics that all children should be screened for autism at 18 and 24 months of age. This universal screening has resulted in finding many more cases of autism at an early age that would have been missed previously, or the diagnosis delayed.

Causes of Autism

Genetics is a causal factor in 60%-90% of Autism. Autism is also is associated with prematurity, older parents, low birth weight, air pollution, and perhaps other environmental factors. Autism is not associated with any vaccines or with thimersol. Multiple large well designed studies have found no association between any vaccine, multiple vaccines, and thimersol with autism.

Neurodiversity

An alternate way to view the autism spectrum is not as a disorder, but as an example of neurodiversity. In the neurodiversity perspective, there is natural variation in human brains and minds and there is no single “normal” way to think, learn or behave. Neurodiversity encompasses the wide range of neurological differences, including those often associated with conditions like autism, ADHD, and dyslexia. The neurodiversity paradigm views these differences as strengths and not deficits, promoting acceptance and inclusion of all individuals. Organizations of persons with autism like the Autism Self-Advocacy network promote autism as neurodiversity rather than the medical model of a disorder.

Bottom Line

It is clear that the increased sensitivity to diagnosing autism as well as the universal screening of children at 18 and 24 months has led to the increase in the diagnosis of autism from one in 150 in 2000 to one in 36 in 2020. There is no evidence that there is an epidemic of autism, but rather that diagnosis has improved tremendously. Children on the autism spectrum, even the ones with the severe form of the condition do much better when diagnosed early. There is no cure for autism (and the autism advocacy movement would say that no cure is needed), but the earlier it is diagnosed and interventions begun, the better the long term outcomes.

Diagnosis and Treatment of Depression

Robert F. Kennedy Jr, now head of HHS, recently said that antidepressant medicines are addictive and as hard to quit as heroin. As usual, this is misinformation and is not true. In this post I am going to write about the epidemiology of major depression, the subtypes of major depression and treatment options.

Unipolar Major Depression

This is the most common type of major depression. In the US 20% of adults (1 in 5) will have at least one episode of unipolar major depression at some time in their lives. The prevalence in any one year is about 8%. People who have one episode of depression have a 70% likelihood of have a recurrent episode of depression.

This is a bad disease and it can kill. To make the diagnosis symptoms must include at least five of the following:

Sadness or irritability, lasting most of the day
Loss of interest in the majority of activities that were enjoyable before
Change in appetite, or sudden weight loss/gain
Difficulty falling asleep, or wanting to sleep more than before
Feelings of restlessness
Lack of energy and increased tiredness
Feelings of worthlessness or guilt, often linking to things that normally wouldn’t have this kind of effect
Difficulty concentrating, making decisions and thinking
Suicidal or self-harming thoughts

Two to eight percent of people with unipolar major depression commit suicide.

Major depression is not a disease just of modern times. Abraham Lincoln had severe depressions, which he called “melancholy.” Winston Churchill also had severe depressions. He called it the “black dog.” The famous author William Styron, who wrote Sophie’s Choice and The Confessions of Nat Turner also had bad depressions. He wrote a book about his experience of depression called Darkness Visible. It is worth reading in order to understand how depression is felt.

Risk factors for unipolar depression

There is a genetic component. Unipolar depression tends to run in families. Other risk factors include social isolation, chronic stress, history of psychological trauma, unresolved grief or loss and substance abuse.

Treatment of unipolar major depression

Medicines

When I first went into practice the only antidepressant medicines we had was a class of medicines called tricyclic antidepressants. Examples include amitriptyline and imipramine.These were actually quite effective, better than the medicines we use today, but tricyclics had a major problem. They were very dangerous in overdose. They could cause lethal cardiac arrhythmias that were difficult or impossible to treat.

We almost never use the tricyclics anymore because of the overdose danger. The medicines we use now are called SSRI’s (serotonin re-uptake inhibitors) or SNRI’s (serotonin and norepinephrine re-uptake inhibitors). The first of SSRI was fluoxetine (Prozac). Others in this class include sertraline (Zoloft), citalopram (Celexa) and paroxetine (Paxil). SNRI’s include things like venlaxafine (Effexor) and duloxetine (Cymbalta). The SSRI’s and SNRI’s are not quite as effective as the tricyclics, but are much safer. An overdose can be unpleasant, but it will not kill you.

How well do SSRI’s and SNRI’s work?

Clinical trials of antidepressants show a large placebo effect, up to 35% in adults and up to 40% in adolescents. That means that a little over 1/3 of people have improvement of their symptoms of depression taking only a placebo. The placebo effect is real. People actually measurably get better. It is not just that they just think they are getting better. The response to antidepressants in these trials show a response rate of about 50%. Thus overall the effectiveness of antidepressants in these trials is modest. In practice, however, we find that most people respond well to antidepressants although some do not. The difference may well be that people who respond well are getting medicine effect plus a context effect that comes from having a relationship with a trusted physician who prescribes the medicine. A good relationship with a trusted physician can promote healing in addition to medicines.

What about Kennedy’s claim that they are addictive? Addiction is a chronic disease that involves compusive use of a substance or engagement in an activity despite harmful consequences. It can be physical or psychological. SSRI’s and NSRI’s do not cause compulsive use or generate any craving for the drug, so they do not meet the definition of being addictive.

What about his claim that they are harder to get off of than heroin? About 20% of people who suddenly stop an SSRI or NSRI have unpleasant symptoms called antidepressant discontinuation syndrome. It is more likely to happen to people on high doses or who have been on antidepressants for a long time. Symptoms are usually mild and last for a week or two. Symptoms can include flu-like symptoms, nausea, trouble sleeping and anxiety. Tapering the antidepressant slowly usually prevents this syndrome, but a few people still get it and it can rarely be severe. It is least likely to happen with long acting antidepressants like Prozac and more likely to happen with short acting antidepressants like Paxil and Zoloft. It is nothing like withdrawal from heroin, which usually requires medication assistance with suboxone or methadone to successfully treat the addiction.

Psychotherapy

Many kinds of psychotherapy work for depression. The most commonly used psychotherapy for depression is cognitive behavioral therapy (CBT). It has been compared to antidepressants in multiple studies and has been found to be just as effective (but not more effective) than antidepressant medicines. Interestingly, studies where both antidepressant medicine and CBT are used together are not more effective than either used alone.

The problem with CBT is not its effectiveness, but its availability. It is time consuming, expensive, and insurance sometimes does not pay for it. There are not nearly enough CBT practitioners to treat everyone suffering from major depression.

Other Treatments for Unipolar Depression

Electroshock therapy

This is an old treatment but it is still used for severe depression that is resistant to other treatments. Techniques have been improved so that there are no permanent brain changes from electroshock treatment.

Stimulation of the vagus nerve

Some studies have shown that stimulation of the vagus nerve can reduce symptoms of unipolar depression.

Psilocybin

There was a very promising randomized trial of a single dose of the hallucinogen psilocybin given with psychological support. It produced marked improvement in unipolar depression that persisted for at least 43 days, which was as long as the subjects were followed. There were no adverse effects. Here is a link to that paper in the Journal of the American Medical Association (JAMA): Single-Dose Psilocybin Treatment for Major Depressive Disorder

Bipolar Disorder

Bipolar 1 disorder

This used to be called manic-depressive illness. It is characterized by episodes of mania. People with mania have markedly elevated mood, and feelings of euphoria and invincibility. They sleep very little, have rapid pressured speech, and often have very inappropriate behavior, including sexual impulsivity and other impulsive behaviors. They may purchase things they can’t afford. These manic episodes may last for days or weeks, but are followed by episodes of severe depression. Bipolar 1 disorder has a different neurochemical basis than unipolar depression. It has a very strong genetic component. There is no one gene for bipolar 1 disorder. Many genes are thought to be involved. Bipolar disorder of either type is much less common than unipolar depression. Only about 4% of people will have bipolar disorder in their lifetime.

Bipolar 2 disorder.

Bipolar 2 disorder is very similar to bipolar 1 disorder but less severe. People with bipolar 2 disorder can have fairly long episodes of normal functioning between episodes.

Treatment of Bipolar Disorder

Treatment of bipolar disorder always involves medicines. Antidepressants can be used for the depressive phase, but are usually avoided because they can precipitate mania. The most common medicine used for bipolar disorder is lithium. Lithium prevents both manic and depressive phases in bipolar disorder. Other medicines can be used but those are specialized anti-psychotic medicines that are beyond the scope of this review.

Bottom Line

Unipolar depression is common, causes significant disability and can lead to suicide. Antidepressant medicines are effective treatments for most but not all people with unipolar depression. Psychotherapy, especially cognitive behavioral therapy works as well as medicines in the treatment of unipolar depression. SSRI’s and SNRI’s are not addictive. Sudden stopping of antidepressant medicines can lead to unpleasant symptoms in about 20% of patients. These symptoms are usually mild and last about 2 weeks. They can almost always be prevented by tapering down the medicines over the course of a couple of weeks. Bipolar disorder is much less common, is primarily genetic, and is treated with different medicines from unipolar depression.

Chronic Stress Response: It Can Make You Sick or Kill You

All mammals, including humans have an innate response to perceived threat or stress. The more common name for it is the “flight or fight” response. Our remote ancestors faced many real threats. Let’s say for example one encountered a saber tooth tiger. As soon as he (or she) saw the tiger, several things happened. Epinephrine and norepinephrine were released, speeding up the heart rate in preparation for running away. A surge of cortisol was also released, which increased glucose in the bloodstream for fuel for muscles and the brain. Cortisol also increases mental alertness. Inflammatory molecules were released to promote wound healing should that be needed.

This kind of acute stress response is a good thing. People or animals with this kind of response were more likely to survive and reproduce. Once the acute threat was over, all the hormones and neurotransmitters quickly returned to their baseline levels.

In today’s world, threats from predators are not a problem for the vast majority of people. The threats we perceive are things like poor work conditions; experiencing discrimination, hate, or abuse; poverty; homelessness; divorce or other family discord; having little control over outcomes; feeling overwhelmed.

These are all things that produce the stress response, but unlike our remote ancestors, these threats are chronic. They are either lifelong or at least last a long time. Instead of returning to normal, the stress hormones and neurotransmitters stay elevated for long periods of time. A chronic stress response is definitely not a good thing!

Allostatic Load

The medical term for the acute stress response is called allostasis. Here is the definition of allostasis from Wikipedia: “Allostasis is the efficient regulation required to prepare the body to satisfy its needs before they arise by budgeting those needed resources such as oxygen, insulin etc., as opposed to homeostasis, in which the goal is a steady state.” Allostasis is an adaptive response to acute stress. Allostatic load on the other hand is the long-term result of failed allostasis, resulting in dysregulation (abnormal function) of multiple systems including the neuroendocrine, cardiovascular, immune, and metabolic systems.

Allostatic load is measured traditionally by 10 indicators of chronic stress. Primary indicators are the hormones and neurotransmitters released by stress. Secondary outcomes are measurements of the systemic effects of the primary indicators. All of these indicators are associated with the perception of stress. Below is a table showing the 10 indicators, how they are measured, and which body systems are affected. Here is a link to the full article from which this table comes: Allostatic Load: Importance, Markers, and Score Determination in Minority and Disparity Populations

Category	Marker	Functional purpose
Primary mediators	Dehydroepiandrosterone sulfate (DHEA), serum	Secreted by the adrenal glands. When high with stress it tends to lower cortisol and be protective in the stress response.
	Cortisol, urinary	Integrated measure of 12-hour hypothalamic–pituitary–adrenal axis activity. Secreted by the adrenal glands. Has multiple effects in stress response.
	Epinephrine, urinary	Integrated indices of 12-hour sympathetic nervous system activity. Sympathetic nervous system activation increases heart rate and blood pressure.
	Norepinephrine, urinary
Secondary outcomes	Systolic blood pressure	Indices of cardiovascular activity and major risk factor for vascular disease
	Diastolic blood pressure
	Waist–hip ratio	Index of long-term levels of metabolism and adipose (fat) tissue deposition. High value means fat around internal organs which increases inflammation and increases LDL (bad cholesterol) and triglycerides.
	High-density lipoprotein cholesterol	Index of atherosclerotic risk protection. Low value increases risk of heart disease.
	Total cholesterol	Index of long-term atherosclerotic risk
	Hemoglobin A1C	Integrated measure of high blood sugar over 2–3 months

Each indicator that is a certain distance out of the normal range counts as one point. The score can range from zero to ten. The higher the score, the greater the risk of illness or death.

Other Indicators

Although the ten indicators were the ones described in the original papers about allostatic load, other indicators have been used as well.

Heart rate variability is the normal beat to beat variability in the heart rate. In a healthy heart there is slight variation in the timing of one heartbeat to the next. Chronic stress reduces or even eliminates this beat to beat variation.
High sensitivity C-reactive protein (CRP). This is a measure of systemic inflammation that can result from chronic stress.

How is the stress reaction triggered?

The stress reaction begins in the brain. Something in the environment is perceived in a part of the front of the brain called the prefrontal cortex. This is the executive decision maker in the brain. If the prefrontal cortex perceives something in the environment as a threat, then it sends messages to the limbic system (the part of the brain that is involved with emotions). It also sends messages to centers lower in the brain, especially the hypothalamus. The hypothalamus sends messages to the adrenal glands which secrete cortisone, norepinephrine and epinephrine. The hypothalamus secretes DHEA. Messages from the hypothalamus are also sent to the white blood cells which secrete inflammatory chemicals called cytokines. All of this prepares the body to deal with the perceived threat. Different people may perceive different things as a threat. It is the reaction to perceived threats that causes allostatic load. If another person experiences the same thing in the environment as not a threat, then there is no stress reaction.

Diseases associated with high allostatic load (high chronic stress)

A high allostatic load score is not disease in itself, but if chronic stress continues then disease in the cardiac, metabolic, neuroendocrine and immune system can occur. Here is a list of diseases associated with persistent high allostatic load.

Heart disease, primarily progressive blockage of the coronary arteries. This can lead to angina and/or heart attack. Congestive heart failure and arrhythmia like atrial fibrillation can also occur
Peripheral arterial disease. That is blockage in arteries in the legs and sometime fingers.
High blood pressure
Stroke
Autoimmune diseases like rheumatoid arthritis or lupus
Diabetes
Fibromyalgia
Chronic Fatigue Syndrome
Dementia or decreased cognitive function
Depression
PTSD
Cancer, particularly breast and ovarian cancer. The increase in cancer is probably related to decreased immune system function

Allostatic Load and Mortality

Many studies have shown that people with persistently hight allostatic load have about a 25% higher premature death rate than people with low allostatic load.

Disparities in Health Outcomes

The response to chronic stress (allostatic load) may explain some of the disparities we see in health outcomes. We know, for example that Adverse Childhood Events (ACE), which include things like abandonment and abuse, increase the risk of many chronic diseases in adulthood. Studies have shown that adults with a history of ACE have high allostatic load scores.

African Americans have higher incidence of many cancers, as well as poorer outcomes from those cancers. They also have worse outcomes from heart disease, high blood pressure and diabetes. While a good portion of these poorer outcomes are related to lack of access to health care, these disparities persist to some degree even in middle class and upper middle class African Americans. Almost all African Americans have experienced or still experience racism on a chronic basis. African Americans of all social classes have higher allostatic load scores than caucasians. Chronic stress and response to it may be the common denominator for these disparities as well as for health outcome disparities in other marginalized populations.

How to reduce allostatic load

There is typically a long time between the presence of indicators of allostatic load and illness and death caused by diseases associated with these indicators. That presents an opportunity to reduce allostatic load before the chronic stress response leads to illness and death. So how do we reduce allostatic load?

Some of the things that cause allostatic load can only be reduced by societal changes. Things like poverty, structural racism and homelessness cannot be decreased by individual effort. Even these causes, though, can respond to the mind body methods discussed below. On the other hand, if you don’t have enough to eat, have no home, or have a job that gives you no control of your life, it is not likely that you will have the energy or the will, or the financial means to do many of the mind body methods discussed below. We should not be distracted from working to decrease the inequities that are responsible for societal causes of chronic stress.

Mind-Body Medicine

Remember that an external threat is first received by the peripheral nervous system and transmitted to the pre-frontal cortex. In order to reduce allostatic load we can either reduce the threat perception in the prefrontal cortex (top down) or reduce the transmission of threat in the peripheral nerves (bottom up).

Top Down Treatments

Top down treatments start with intentional activity in the prefrontal cortex. The idea is to decrease activation of the limbic system and the hypothalamus. This can be accomplished by mindfulness meditation, hypnosis (including self hypnosis), mental imagery and progressive muscle relaxation. All of these techniques when done regularly have been found to decrease allostatic load indicators and to reduce the risk of stress related illnesses.

Bottom Up Treatments

Bottom up treatments decrease the threat transmission to the prefrontal cortex. They include yoga, Tai Chi, massage and biofeedback. These treatments have also been shown to decrease allostatic load and to reduce stress related illness.

Bottom up and top down are somewhat of an oversimplification. All of these treatments have some aspects of both top down and bottom up. Yoga, for example includes aspects of meditation. The same goes for Tai Chi. Biofeedback involves some attention from the prefrontal cortex. Massage also includes progressive muscle relaxation.

Bottom Line

The body’s reaction to a perceived threat includes a complex cascade of messages from the executive center in the prefrontal cortex to multiple body systems including the nervous system, the endocrine system, the cardiovascular system and the immune system. All of these things prepare the body to deal with the threat. As long as the threat is short term the stress response is very useful to the organism.

Perception of chronic stress leads to continuous secretion of all the stress hormones and inflammatory cytokines and this leads to dysfunction of multiple body systems and eventually to illness and death.

Mind body treatments, both top down and bottom up can reduce the allostatic load (chronic stress response) and reduce the risk of stress induced illness and death.

Many causes of chronic stress have to do with the structure of our society, such as poverty, homelessness and structural racism. Individual effort is not likely to ameliorate the effect of these causes of chronic stress. All of us should be working toward societal change to reduce chronic stress response in marginalized populations.

Seven Secrets to a Long and Happy Life

I will cover most of these topics in detail in other posts, but this is a good overview to get you started on the road to better health.

Nutrition

Follow Michael Pollan’s advice. Eat food, not too much, mostly plants. Food is anything your great grandmother would have recognized as food. Also don’t eat anything that has more than 3 ingredients you don’t recognize. Extra vitamins and minerals are unnecessary, except that women should take supplemental calcium with vitamin D.

Exercise

Buy a pedometer and get in the habit of putting it on every morning. Your goal should be 10,000 steps per day (about an hour and a half of brisk walking). Some people do better exercising with a group. If that’s you, then start a walking group or join a spinning class. Here is a website where you can order a pedometer, start a group and record your steps: http://www.everystepcounts.com. The accountability of recording your steps every day can help you keep going.

Relationships

We are social animals, and studies over the last 30 years have shown that the effects of relationships on health are just as powerful as cholesterol, blood pressure and smoking status. Spend time with your friends and family. Expand your social network. Don’t take work home at night or on weekends, and don’t check your email more than once a day. Unplug the TV and sit down to a nice dinner (of food, mostly plants, not too much) with your spouse, children or significant other.

Stress

Reduce the things in your life that are emotionally stressful if you can, and if you can’t, then learn some ways to reduce the effects of stress on your body-mind. Exercise helps. Learn meditation and/or yoga. Take walks in the woods. Use your vacation days to do something fun.

Alcohol

A little alcohol is actually good for you, but a lot is not. Also, drinking a little every day is better that a lot on the weekend. A healthy amount is no more than 1-2 drinks per day, with a drink defined as 1 1/2 oz of 80 proof alcohol, or a 4 oz glass of wine. For those who can’t stick with those limits, it’s better not to drink alcohol at all. There is some evidence that red wine is better for you than other kinds of alcohol.

Tobacco

Don’t smoke cigarettes or cigars, and don’t use chewing tobacco or snuff. If you are already a tobacco user, quit. If you are having trouble quitting, Vermont has an excellent resource called 802QUITS. They provide counseling and medication, including what appears to be the newest and most effective — Chantix.

Exercise your mind

Brains atrophy just like bodies do without exercise. Brain exercise is anything that engages your ability to think and create. This does not include watching television. Read some books. Read the newspaper. Subscribe to some blogs. Do crossword puzzles. Take a course online. Write something.

Will all this make you illness free and live forever? Absolutely not! Illness, suffering and death await all of us sooner or later. But if you do all of these things (or even most of them), you will enjoy your life more, and it’s likely to be longer and happier.