I never get angry, I grow a tumour instead says Woody Allen

In over two decades of family medicine, including seven years of palliative care work, I was struck by how consistently the lives of people with chronic illness are characterized by emotional shut down: the paralysis of “negative” emotions--in particular, the feeling and expression of anger. This pattern held true in a wide range of diseases from cancer, rheumatoid arthritis and multiple sclerosis to inflammatory bowel disorder, chronic fatigue syndrome and amyotrophic lateral sclerosis (ALS). Sufferers from asthma, psoriasis, migraines, fibromyalgia, endometriosis and a host of other conditions also exhibited similar inhibitions. People seemed incapable of considering their own emotional needs and were driven by a compulsive sense of responsibility for the needs of others. They all had difficulty saying no.

One of the terminally ill patients under my care was a middle-aged man, chief executive of a company that marketed shark cartilage as a treatment for cancer. By the time he was admitted to our palliative care unit his own recently diagnosed cancer had spread throughout his body. He continued to eat shark cartilage almost to the day of his death, but not because he any longer believed in its value. It smelled foul–the offensive stench was noticeable even at some distance away-- and I could only imagine what it tasted like. “I hate it,” he told me, “but my business partner would be so disappointed if I stopped.” I convinced him that he had every right to live his last days without carrying the burden of someone else’s disappointment.

As a workaholic physician, needing the whole world to love and admire me—and, above all, to need me--I also found it impossible to say no. No matter how busy I was, I always accepted one more patient, one more counseling client, one more difficult case. As I did so, there was less and less space for myself in my own life. The result was chronic back pain and a constant, low-grade depression. It was when my own difficulties finally dragged me into therapy--kicking and screaming in resistance, of course--that I began to recognize the same traits in others.

The observation that the inefficient processing of emotions predisposes to illness of all kinds has been noted by many clinicians in the past. It has been the subject of much research, all of it published in mainstream medical and psychological journals. In several studies in a number of different countries psychologists interviewing thousands of patients have been able to predict with overwhelming certainty who would and who would not develop cancer based simply on the degree to which an individual suppressed their feeling and expression of anger. Long term studies of medical students at Johns Hopkins and of Harvard undergraduates have confirmed that certain emotional traits in youth tend to be associated with illness later in life, quite apart from lifestyle influences such as smoking or drinking or exercise habits.

Science has now given us an understanding of how the interplay of emotions and physiology affects health. A new discipline, pscyhoneuroimmunology, studies the connections between the brain areas that process emotions, the hormone-secreting glands, the nervous system and the immune apparatus. And here we confront the inadequacy of language. Even to speak of connections implies that, somehow, separate entities are linked to each other. Reality knows no such separation. There is no emotional system distinct from the hormone-producing organs, no nervous system divided from the immune defenses. One can make these divisions only in the laboratory, in autopsy specimens or in textbooks. There exists in living persons one super-system of which the emotional centres, neurological pathways, hormonal glands and immune organs are all aspects. They are all wired together electrically by nerve fibers and they also speak the same chemical language. They do not and cannot function in isolation from each other.

A cursory visit to medical libraries or to online sites is enough to show the advancing tide of research papers, journal articles and textbooks discussing the new knowledge. Information has filtered down to many people in popular books and magazines. The lay public, ahead of the professionals in many ways and less shackled to old orthodoxies, finds it less threatening to accept that we human beings cannot be divided up so easily and that the whole wondrous human organism is more than simply the sum of its parts.

Since there is only one system, not four separate ones, whatever happens in any one part of it will affect the other parts. The key factor is stress.

Stress remains outside the frame of reference of mainstream medical thinking, despite its documented negative effects on the immune system and despite many studies that confirm an association between cancer and people's life stresses.

"Most people do not fully realize to what extent the spirit of scientific research and the lessons learned from it depend upon the personal viewpoints of the discoverers," wrote the great Canadian stress researcher, Hans Selye. "In an age so largely dependent upon science and scientists, this fundamental point deserves special attention." Stress is excluded from consideration by most clinicians and researchers precisely because in our society it is so ubiquitous as to be taken for granted. It is accepted as part of the normal scheme of things, not—as it really is—something foreign to the natural design and quite inimical to health.

It was Dr. Selye who first pointed out that stress of any sort, whether physical or emotional, has certain characteristic effects in the body, and in particular on the immune system. He noted that stressed laboratory animals had shrunken spleens, lymph glands and thymus glands, all important elements of the organism's immune functioning.

Since his pioneering work six decades ago, we have learned much more about the damaging impact of stress on the human hormonal system and immune apparatus. In fact, we have learned that the two are not separate systems at all: They comprise one system whose components are intricately interconnected with each other. This "super-system" also includes the nervous system and the brain's emotional centres. Nerve fibres electrically wire together all these crucial tissues and organs. Shared molecular messengers ensure that they all speak and understand the same chemical language. Factors, including psycho-emotional ones, affecting any one part of this super-system will exert effects in all parts of it. We can now map the complex pathways through which stress may contribute to the causation of many diseases, including cancers.

A class of lymph cells called natural-killer (NK) cells is in the vanguard of the body's immune surveillance against cancer. Research has shown that women with breast cancer whose NK counts are low are at greater risk for metastatic spread of their malignancy. Research has also shown that NK cells decline with ongoing stress, as for example in medical students facing examinations. "It may be said without hesitation," Hans Selye wrote, "that for man the most important stressors are emotional."

Just how prescient he was is evident when we see that in this same study of medical students, those who were the loneliest had the poorest NK counts. In studies of the spousal caregivers of people with Alzheimer's disease, immune functioning was found to be significantly depressed, with the most socially isolated the most affected.

In the light of such findings -- all readily available in mainstream medical publications -- it is not surprising that a recent Australian study should have concluded that "women experiencing a stressor objectively rated as highly threatening, and who were without intimate emotional social support, had a nine-fold increase in [the] risk of developing breast carcinoma." Nor is it surprising that men who are currently married -- as opposed to previously married -- are less likely to be diagnosed with metastatic cancer of the prostate.

Even a clearly identified environmental carcinogen like tobacco smoke does not exert its effect without a contribution from stress. Smokers who are emotionally repressed, for example, and have trouble feeling and expressing anger, are much more likely to develop lung cancer. In fact, smokers who do not have that repressed emotional coping style do not seem at greater risk for lung cancers than non-smokers—although, of course, they are still much more prone to suffer from heart disease, emphysema, and a host of other ailments.

The stresses of modern life have grown palpably more severe over the past several decades. For many people, there is also growing personal isolation following from the loosening of traditional social bonds. If we take to heart the lessons taught by Hans Selye, we will seek the causes of malignancy not only in what we ingest but also in how we have come to live our lives.

As far as orthodox medical practice is concerned, the mind-body research all falls into some Bermuda Triangle, lost without a trace. The medical system continues to operate as if the new science did not exist. Psychoneuroimmunology has yet to enter the curricula of most medical schools. Illnesses are looked at only from the perspective of their physical manifestations. That they occur in the context of the real lives of real people is rarely considered. It’s as if a person’s relationships, emotional life and day-to-day stresses had nothing to do with how his or her body functions on the biological level. Patients may see specialists for years without the scientifically proven unity of mind and body ever being brought to their attention.

Why this neglect?

Prior to the development of powerful medications, instruments and diagnostic tools in the past century, physicians had to rely on awakening the healing forces within the patient if treatments were to succeed. That meant having to know people as individuals, cultivating a relationship with them, becoming acquainted with their lives. The advent of modern pharmacology and medical technologies vastly increased the capacity of physicians to help their patients, but reliance upon the new modalities has caused an atrophy of the age-old human wisdom that used to inform medical practice. At the beginning of the twentieth century Sir William Osler, the Canadian who is considered to be one of the greatest clinicians and medical educators of all time, was highly conscious of the mind-body unity. Osler’s name is still honoured but the spirit of his teachings has long vanished from the practice of medicine. Instead of coming along-side the traditional insights, modern medical science has completely displaced them.

The education of doctors leaves them ill-prepared to counsel patients on the relationship between stress and illness. On a more personal level, medical training is an intensely stressful experience. The men and women who undertake it are highly capable but often highly driven individuals. They are all too willing to ignore their own needs as they learn and practice their craft. Like I have been, many of them are workaholics whose professional lives fill up the spaces where a deeper, more rounded personal existence should be. From such a vantage point, they are not likely to have awareness of other people’s emotional stresses, or empathy for them. And, from a purely financial perspective, our fee-for-service system actively discourages physicians from spending the time with patients that an empathic and thoroughgoing discussion of emotional issues would demand.

Finally, at the heart of the denial is the desperate fear humans have of being blamed for their own troubles. It was a vogue in the New Age 1970’s to speak of people having “invited” diseases into their bodies as “guides.” Owing to such nauseatingly self-righteous attitudes patients felt they were being held culpable for the very fact of having fallen ill. In her famous 1978 essay, “Illness As Metaphor,” the writer Susan Sontag—then herself suffering from cancer—wrote that "The current myth(s) about cancer propose that one is responsible for one's disease. But the cancer imagery is far more punishing. There is mostly shame attached to a disease thought to stem from the repression of emotion. The view of cancer as a disease of the failure of expressiveness condemns the cancer patient; it evinces pity but also conveys contempt." Thus was the baby thrown out with the bathwater. Living in a culture of blame, we are obsessed with blame. The fear of it makes us afraid to embrace scientific truths.

“You may feel that there is no conceivable relationship between the behaviour of our cells, for instance and inflammation, and our conduct in everyday life,” wrote the outstanding Czech-Canadian physician and researcher, Hans Selye. “I do not agree.” Selye, who coined the word stress in its modern usage, described with mock pride how der stress, le stress and lo stress entered the German, French and Italian languages respectively. He understood stress as a set of physiological events in the body, in response to any loss or threat, real or perceived. He attached no blame to it, any more than Osler did when he suggested in 1892 that rheumatoid arthritis “had a nervous origin.” Selye also recognized that in modern life the most important stressors acting on human beings are psychological ones.

...in modern life the most important stressors acting on human beings are psychological ones.

The omission of stress from the medical lexicon has unfortunate consequences. Patients often feel frustrated, not listened to, their most intimate concerns ignored. There is plenty of evidence that psychological interventions can have positive effects in the healing of a wide range of conditions. Mind and body links have to be seen not only for our understanding of illness, but also for our understanding of health. In healing, every bit of information, every piece of the truth may be crucial. Not to inform people of the links between emotions, stress and physiology is to deprive them of a powerful tool.

The issue is responsibility without blame. All of us dread being blamed, but we would all would wish to be more responsible--to have the ability to respond with awareness to our circumstances, rather than just reacting. We want to be the authoritative person in our own lives: in charge, able to make the authentic decisions that affect us. There is no true responsibility without awareness. None of us are to be blamed if we succumb to illness and death. Any one of us might succumb at any time, but the more we can learn about ourselves, the less prone we are to become passive victims.

Stress reduction includes obvious measures such as healthy eating patterns, sleep hygiene, and exercise. It also requires living a life that balances the physical, emotional and spiritual needs of human beings. Those are the three pillars of health; ignoring any of them leads to dis-ease and illness. The most difficult aspect of that triad is the psycho-emotional one, because for so many of us the driving dynamics of our psychic functioning operate in the difficult-to-see regions of the unconscious. Stress management, therefore, requires a careful and committed attention to what is not working in our lives, to what does not feel right. None of us need be victims, but to be actively and authentically in charge of our lives we need to take full responsibility for all aspects of our existence.