When Dan was 32 years old, he had a custom-built house that was a piece of art, a Washington area contracting business that had just grossed $1 million, three new cars, a 2-year-old son he adored and a heart attack waiting to happen. Four years later he sits in an Adams-Morgan apartment he has just remodeled for a friend and remembers those days when he was in an "80-hour-a-week workaholic trap," on a roller coaster, high-speed ride that took him right into his second divorce.
"After the divorce happened," he says, "I just didn't care anymore. I started smoking cigarettes again, I did too many drugs and I went off the low-cholesterol diet." Dan has a condition called hypercholesterolemia -- higher than normal cholesterol in his blood. He knew his breakneck pace, smoking and a bad diet could kill him. "I wanted out," he remembers. "The business was getting beyond me. I knew I was being self-destructive, but I couldn't find a way to ease myself out."
About 10 p.m. one Saturday night, while sitting parked in his brown, three-quarter-ton pickup truck, talking with his woman friend, it happened. "My mouth got very dry and then the dryness went down my throat and there was a burning in my sternum . . . the burning became unreal."
At Washington Hospital Center, Dan's doctors told him this was his second heart attack. He remembered once eating a Spanish omelet at a restaurant and feeling that burning. Dan had lost two-thirds of his heart function. He was 33 years old.
IN EDWARD BELLAMY'S classic utopian view of 20th-century America, Looking Backward, Julian West awakes in the year 2000 to a society of full employment, material abundance and social harmony. Bellamy believed technology and economic reorganization would correct in the 20th century what they had made a mess of in the 19th. About now, we should be enjoying what he called the "universal reign of comfort."
Bellamy did not envision our world where environmental stress is creating an epidemic of diseases: ulcers, hypertension, heart disease, allergies, immune system disorders, asthma, migraines and anxiety severe enough to lead to such symptoms as insomnia, hives, nightmares and depression. The "universal reign of comfort" was not supposed to be a state of health in which three of the six largest-selling prescription drugs are used to treat stress-related illnesss: hypertension (Inderal), ulcers (Tagamet) and anxiety (Valium).
What happened? "The world requires much more behavioral adjustment than it used to," says Dr. Herbert Benson, a Harvard physician and director of the hypertension and behavioral medicine programs at Beth Israel Hospital in Boston. "And whatever causes a behavioral adjustment is our working definition of stress."
The changes have not been sudden. In the mid-1960s a cardiologist noted that in families he treated, sons were having heart attacks on the average 13 years sooner than their fathers, a fact he found foreboding. And so do I, because those people are no longer statistics in medical journals, they're my friends, like Dan. And they are me.
When I moved across the country two years ago from California to Washington, I left a job that had been like a close-knit family where I had become the bad sister. I felt ousted, without the identity I'd cultivated for six years. I wanted to jump into a new job quickly, something involving but different. Like a person in a bad marriage, I wanted to escape the sense of loss I felt without confronting it. This was my first mistake in stress management.
I took a job as director of a new, nonprofit public interest group. I would be responsible, among many other things, for raising money. That was the second mistake. The combination of a cross-country move, a new job, old pain and financial insecurity was too much to ask of myself.
A little more than a year ago, I woke up one morning and found myself living in a one-room, roach-filled apartment I'd rented to save money, working double-time, living on foundation grants, never knowing if I could put together enough to make the payroll from week to week, and wondering why I felt so stressed out. I looked for old escapes.
I smoked after not smoking for four years, I began gaining lots of weight and eating junk food as though I were a 13-year-old. I took work home every night. Sometimes I couldn't sleep until 3 a.m. I had migraines. I drank gin and tonics to relax. Some people thought I was getting a little "paranoid."
Then what had been an intermittent ulcer became full-blown. I decided I had to do something. I stopped bumming cigarettes, went on a diet, stopped drinking hard liquor, forgot about coffee and joined the YMCA. That, as it turned out, wasn't enough.
Just before a very important meeting last spring, I broke out in hives. For the next six months, I carried a pink bottle of calamine lotion in my purse, dabbing at the itchy little red spots that every couple of weeks would emerge all over my body. Finally, I got really sick with something that felt familiar -- mononucleosis? I was thrilled. Maybe I could go to sleep for a year.
I went to see a doctor. He said I had some kind of severe viral infection, similar to mono, but not mono. I would get well in a couple of weeks with lots of rest. "Rest," he said over and over again. Then he said: "Is your blood pressure always this high?"
"High? How high is it?"
"170/90. That's pretty high for a person your age. Are you under a lot of stress?"
There are many reasons why a person develops hypertension, including family history. My mother has high blood pressure. But stress is integral to the development of hypertension in many people. I was left with no choice. I would have to find an effective, long-term way to manage stress.
THE BIG LIFE CHANGES that cause stress are obvious: marriage, divorce, birth, death, moving, changing jobs, serious illness. But smaller events involve stress too: new neighbors, new bosses, a visit from parents or in-laws, a flat tire on the morning of an important meeting. We sometimes forget that as a nation we are moving through a series of complex cultural changes that are stressful: the breakdown of traditional sex roles, a soaring divorce rate, increasing mobility, dramatic cycles of boom and bust in our economy, widespread use of confounding technology and a constantly expanding global information network that brings everything from cooking classes to famine in Ethiopia into our living rooms.
Ask any physician: stress plays a role in all illness from colds to cancer. Yet some people get sick from stress and some don't. Increasingly, researchers believe the reason may lie in our perception of the events that cause stress and how hard we try to cope.
Dr. David Rubinow is a psychiatrist at the National Institute of Mental Health in Bethesda. He oversees projects that research the intersection between the body and the mind. What he wants to talk about is . . . rats.
"Let me tell you about two animal experiments that illustrate how important it is for us to learn to separate external events from their interpretation if we are going to understand stress," he says, and then tells this story first:
Take two rats. Put them in cages A and B. Stimulate them with a shock they find noxious. The rat in Cage A soon discovers there is a wheel in its cage that it can turn to shut off the shock. The rat in Cage B has a wheel it can turn, too, but in its cage, the wheel does not turn off the offending shock. The rat in A learns to turn off the shock each time it occurs and suffers none of the physical symptoms associated with stress-related diseases. But the poor rat in Cage B stops even trying to avoid the shock by turning the wheel. This rat develops all the harmful biological changes of stress.
Next, the rats are switched to each other's cages. The rat that was in cage A can no longer turn off the shock with its wheel, but it tries anyway and remains protected biologically. The rat that was in Cage B now can turn off the shock with the wheel, but it doesn't even try.
"This is called learned helplessness," Rubinow says. "It tells us that the early experience is the formative experience, and it has broad implications for how we learn to manage or mismanage stress." In trying to cope with stress, we may perceive we are coping with it, and it is the trying that prevents us from being harmed.
The other experiment in stress perception Rubinow describes concerns long-term effects of stress. In this case, rats who had their brains stimulated once with a small electrical current at first suffered only a mild reaction. When the shock was administered again and again, the same small charge began to produce seizures, then larger seizures.
"The repetitive nature of the experience," Rubinow says, "may alter biological and physiological response." Whatever the reason, the lesson seems clear: the longer we are under stress, the sharper our perception of it becomes and the more physical damage the stress is likely to produce.
A demand on us to adjust our behavior is met by our bodies in the same manner a physical threat is met -- through evocation of a "fight- or-flight response." The proc which begins in the brain's hypothalamus, was first outlined in 1932. But it was not until 10 years later that Dr. Hans Selye, an Austrian physician who lived in Montreal, pioneered modern stress research by mapping most of the hormonal chain reaction that begins with the fight- flight response.
Selye found the fight-flight response increases blood sugar, raises the heart rate and cholesterol level, increases blood pressure, speeds up the body's metabolism as it pulls fat in storage into the blood and produces an increase in blood flow to the muscles. Most important, Selye was the first to say that these changes are nonspecific, meaning any event that the mind and body perceive as stressful sets the fight- flight response in motion.
Selye spent years in his lab testing animals. He found that frequent and chronic evocation of the fight-flight response leads to high blood pressure, ulcers, allergy, rapid development of atherosclerosis and inhibition of the body's immune system, which he called the "diseases of adaptation." The animal experiments taught him that the body's capacity for adaptation is finite; after a while, repeatedly adapting our behavior wears out our bodies.
Selye worried that modern man would "squander adaptability recklessly" in overwork, overworry and underrecognition of this unique, nonrenewable resource. "Both on the cellular and interpersonal level," he lamented, "we do not always recognize what is and what is not worth fighting for."
TWENTY-EIGHT YEARS ago, Dr. Meyer Friedman, a San Francisco cardiologist, identified a behavioral response to stress that he called "Type A behavior." Type As are hard-driving, competitive, aggressive, impatient people who are always trying to achieve more in less time and consistently do more than one thing at once (eat and read, talk on the phone, watch TV and look at the newspaper). Most of us recognize those people who speak quickly, interrupt others, hate waiting and generally run madly from appointment to appointment. We know who we are.
Friedman reported that people with this personality type produce stress hormones in greater quantity, have higher blood pressure, higher cholesterol levels and that this led him to believe Type As are at a far greater risk of heart disease. In men, it is as great a risk factor as these: a soking habit, high blood pressure and lots of cholesterol in the blood.
Type A men have five or more times the chance of developing coronary heart disease than do men who relax, slow down and are less competitive and more trusting of others. Trust, in fact, is believed by Type A researchers at Duke University and other scientists to be the key behavioral trait missing in Type As. Many media accounts of the Duke study reported that the most destructive Type A characteristic was anger and hostility. But the Duke doctors had looked deeper at anger and found that the Type A patients they studied were really suffering from "cynicism," a quality that kept the patients in a "state of vigilance," and that turned out to be the Type A trait that is the most biologically damaging.
Friedman, himself a reformed Type A, thinks the behavior pattern comes from what Rubinow called a "formative experience" that teaches low self-esteem. Lack of parental affection and recognition, or as Selye would have it, "constant censure" by one or both parents as a child, is by Friedman's logic the original stressor.
Friedman says Type As become self-destructive from the unrelenting stress load they carry. They want to break down. More than half the coronary patients Friedman has interviewed say they looked forward to their heart attacks.
Washington seems to many of those I know to be the Type A of cities. Stress City, I call it. "In Washington, stress is a status symbol," one psychologist told me. "To be stressed out shows you're working for The Cause. It's also an extraordinarily competitive city. People are so competitive in Washington they compete over recreation!"
I AM WAITING FOR THE elevator, pacing and chewing gum. I hate waiting. As I walk back and forth, I go over the day's events in my mind.
Let's see, what did I not get done? My mother. I should have called my mother. I am a bad daughter. Now, why didn't I call my mother? Too busy raising money. I wonder if we'll be able to meet the payroll this week? I should have made some more calls. Where is that elevator? I could have made some more calls. Why does this dumb relaxation class meet at 4 in the afternoon anyway? Don't they know people are trying to pack a few more things into their day before 5?
I think about going back to the office. Then I remember the pink bottle of calamine lotion I used to carry, the blood pressure, the ulcer. I'm trapped here like one of Rubinow's rats looking for a wheel.
Dr. Manuel Gerton, a clinical psychologist at the George Washington Medical School and a local stress specialist, greets me. I complain about the scheduled hour of the class. "You think it's going to be a waste of your time?" he shoots back at me.
I had already attended a one-hour seminar on stress management given by Gerton a few weeks earlier. There he outlined a number of steps to take to reduce stress (see box page 5) and to short-circuit "burnout" before it happens. Gerton says he sees lots of burnouts -- people suffering from chronic fatigue and a sense of purposelessness -- especially lawyers and aides on congressional staffs. The reason people burn out, Gerton says, is a compelling need to "seek control over everything in life."
After the seminar he elaborates: "Until you acknowledge that you can't control everything, you won't be able to relax . . . you're going to burn out. You may achieve quite a bit on your way to it. But when you get there, success isn't going to mean as much to you."
Gerton and I and another man walk into the conference room and sit down to begin relaxing. Several expected stressed-out people who had been enrolled in the class have not shown up. We introduce ourselves. The man in the coat is a bureaucrat in a large government agency.
"I want you to sit back, close your eyes and I'm going to ask you to tense and relax certain muscles," Gerton says. "At the end, I'm going to give you a copy of this relaxation tape to take home. I want you to practice this exercise twice a day and then next week we'll report back on how it went."
Gerton's voice is soothing, calming. I find I am almost able to relax. At the end, he asks us to open our eyes and says, "Well, you see, that didn't take very long. How long do you think it took?"
"About 30 minutes," I respond, priding myself on an impeccable sense of timing.
He looks at the man, who says, "I don't know how long it took, I lost all track of time." I knew instantly he had given the right answer.
"You," Gerton directs me in a voice teachers use, "you need to learn to let go a little more. And by the way, it was almost exactly 30 minutes."
For days the little white relaxation tape stared at me from on top of the bureau. I read Dr. Herbert Benson's book The Relaxation Response. At Beth Israel Hospital in Boston, Benson was dropping blood pressures 10 or more points, both systolic and diastolic, by combinations of relaxation and meditation, a fact he reconfirms. Still I resisted the tape.
Finally, on the day I was to return to Gerton and report on how well I've done, I played the tape. As I relaxed, I started to cry. And cry.
I go to see Gerton, who takes me into his office and asks how it went. I mumble about the tape taking too much time. He takes me through the relaxation exercise again and when I open my eyes, he says, "Are those tears I see?"
"No. It's just my contact lenses."
"Oh," he says. "Well." He pauses. "Wait a minute. You can't tell a psychologist 'It's only my contact lenses.'
I laugh. "Okay, okay. Then tell me why I cry."
"Lots of people cry when they relax," Gerton says. "We're very wound up. There's not a lot of caring and closeness in our society. Someone speaking to you in a soothing, caring manner feels good, even if it's on a tape. It makes people release tension by crying. It's not bad. You did a lot better than last week."
Earlier, Gerton had said that people in Washington have a tough time with stress because it is "a transient town. People come and go so relationships are hard to develop. Intimacy isn't there."
Intimacy? Is that what stress reduction is all about? I think about Friedman's coronary patients. Most of them never had time for close relationships until after their heart attacks.
What does that say about me? I had to admit to myself that on several occasions in the last week I'd hidden from people I knew because I did not want to take the time to speak with them. Was I saving time or storing up stress?
DR.SIDNEY WOLFE, Director of Public Citizen Health Research Group, would appear to be a classic Washington workaholic. I have known him for years and have always assumed he loved confrontation politics, read medical articles in bed at night and never missed a chance to talk shop.
His office tends to confirm such suspicions. He has a "pile storage" system that leaves stacks of books, articles, monographs, reports and other paperwork asll over desks and tables.
Wolfe agrees that Washington has special stresses. "The work product of this city is confrontation. That's stressful. At the end of the legislative session, for example, there's an avalanche of things happening. You can get killed with bad legislation. Lot's of people here are somehow involved in that process, so it raises the stress level of the whole city."
Wolfe is a runner, so I ask: "What about exercise?"
"Exercise is important," he says, "but more important is finding someone you are close to and can talk to honestly."
There it was again. "You mean intimacy?"
"Yes, intimacy. With people of the same sex or the opposite sex. Listen, once you decide that close friendships are important and you are willing to spend enough time to develop and keep close friends, you have made the most important step in stress reduction. Everything else follows from that."
"Are you telling me you don't take work home? You don't read medical journals in bed at night?"
"Never," he says. "I work 10 hours a day here, but I don't work at home. I used to do that. It's one of the things that led to the breakup of my first marriage. But not now. The richness of home and the relationships at home are hurt by it. I've learned to put boundaries and limits on the work."
My friend had slowed down. I imagined Hans Selye smiling.
TALES OF LIFE IN Stress City don't end neatly like 18th-century novels. I wish I could say that one friend no longer has coronary heart disease and that another's ulcer is gone, that my blood pressure is normal, but I can't. "Life is a process," sociologist Lillian Rubin wrote, "that, until death, does not lend itself to endings."
Life does, however, lend itself to change. For myself, I am only beginning the changes I have to make.
I listen to my little relaxation tape and try to do the exercises once a day. I make time to jog. I have dropped most caffeine and lots of fat and salt from my diet, and I have started meditating. I've discovered I'm something of a nature mystic; walking in the woods lowers my blood pressure.
I'm trying to let the small stuff roll off. Not everything really is worth fighting for; little is. I am making time to talk to people, to find out how their lives are going, to tell them something about myself and what I'm feeling, even if it makes me vulnerable. There aren't any short cuts to intimacy.
The other evening as I was walking home, I came across a lovely little old lady dressed in a purple suit, with a purple hat. She was bent over, trying to steady herself with a cane, staring at what appeared to be nothing and rocking back and forth. Forgetting about the perpetual rush I am in, I decided to engage.
"Are you okay?" I asked, leaning down to look in her face.
"Yes," she said. "Thank you for asking. I was just trying to figure out who that man is in the poster there on the trash can. He looks so much like one of our coal miners, don't you think?"
It was a poster of a Salvadoran refugee. "Yes, he does," I said, "especially around the eyes." I turned to go.
"Nice to talk to you," the lady said.
"Nice to talk to you," I shouted over my shoulder as I hurried up the street.