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ANGINA AND EMOTIONAL RESPONSES TO STRESS
Some people are more aware of their emotional responses to stress. Most of us from time to time will have been told by close friends or partners that we are irritable or bad-tempered when things get on top of us. But for some people the emotional response may be overwhelming and lead to further problems in coping with the events that triggered the stress response. People tend to show they are stressed in one of three ways, but these are not, of course, mutually exclusive. There is the anxiety response, the hostility response and the depression response.
The anxiety response
The anxiety response may show itself in one of three ways: through our thoughts, feelings or behaviour. Sometimes it can be expressed in all three ways. In addition to the physiological responses of arousal described above, there are some thoughts and feelings which are characteristic of someone who is feeling anxious. Worry and dread are classic responses for someone who is anxious. These will often describe themselves as ‘a bit of a worrier’ and tell you how they dread everything from the next electricity bill coming in to going on holiday in case they get burgled whilst away. Anxious people with angina will often worry about the next angina attack in case it is the one to cause a heart attack, and dread going to the post office because it sometimes brings on angina. If you are a worrier, it is very easy to form a vicious circle of worry about angina symptoms and triggering more angina.
You may find it difficult to concentrate and little irritating thoughts may play like a broken record in your mind. At times your mind may seem to be crammed full of trivial irritating thoughts which simply won’t go away. It can be very difficult to relax and switch off these thoughts and it requires a great deal of effort to do so. Tiredness and irritability may also be signs of anxiety, as is a loss of interest in sexual relations. But the one symptom which is most important for someone with angina is the muscle tension which accompanies anxiety. Chronic tension can result in aches and pains in various parts of the body, and some of these pains, if occurring in the chest or arms, may be interpreted as angina. This can cause the person who experiences these pains to believe they have got very severe heart disease and that they should avoid exercise and cause them to become over-concerned, preoccupied or even obsessed with their condition. This can lead to avoidance of normal activities which maintain good health. Clearly, this vicious circle has to be broken.
Case history
John had thought that he had coped with his heart attack particularly well. But his first angina attack after leaving hospital served to remind him of the ordeal. So he began to take it easy He very quickly found that he could only walk short distances before experiencing angina. This worried John, and he could feel himself becoming very anxious at the thought of having another angina attack. It very quickly got to the stage where John had begun to think that the next angina attack would be the one that would trigger another heart attack and so he began to do less and less physical activity. It was only after attending the cardiac rehabilitation classes that John realized how out of condition he had allowed himself to become. It took six months for John to realize that it is possible to exercise safely with angina and that providing he stopped when the pains became severe, it would not cause another heart attack.
The anger response
Anger is a strong emotion and all strong emotions can tip the scale of oxygen supply and demand and trigger an angina attack.
When we feel angry we may only be aware of the bodily sensations which may include an increased heart rate, sweating, stomach churning or nausea. Most people are aware when they feel their ‘hackles rising’. However, accompanying these feelings are thoughts which may help to perpetuate the feelings. These thoughts may be ones of ‘it’s just not fair’, ‘why me?’, ‘I look a fool’, ‘I can’t let that person get the better of me’, all of which trigger the body to feel more angry. These two are very closely linked and sometimes people will talk of feeling angry as an automatic reaction to a provocation. It is not automatic but it may be happening quickly and the person may be concentrating more on the anger feelings.
Different people behave differently to anger. Some slam doors, shout or hit out, thereby expressing it. Some sulk, become withdrawn or sarcastic thereby suppressing it. There is no evidence to suggest that either expressing or suppressing anger is better. However, it may be more harmful if you have angina to continually slam doors than it would be to take yourself out of the situation and think before you react. Case histories
Bill used to shop at the same supermarket each time. One day the cashier made a mistake and short-changed him. Bill’s immediate reaction was to think she had done it on purpose because she was stealing money from the till, and he got very angry. He shouted at her and threw the groceries down from the shelf by the checkout. He was asked to leave once his money had been returned. Bill is now unable to walk past that supermarket without remembering the incident, feeling aggrieved and experiencing a mild angina attack. He blames the shop assistant for bringing on his angina. Sue has been a heavy smoker since senior school. She developed angina symptoms whilst out gardening one day. After many investigations and much worry she was told she had coronary disease and must stop smoking. This she did immediately. When the angina did not go away, Sue began to blame the medical staff for deceiving her into believing it would. She began to experience more angina and eventually underwent a coronary artery bypass operation. This was not completely successful and she remains very angry at the ‘incompetent, deceitful medical staff and also at herself for beginning to smoke in the first place.
The depression response
This is the third response in the triad of emotional reactions. It does not mean those days when we feel a bit low or ‘not quite 100 per cent’ but it is a more extreme reaction which includes thoughts, feelings and behaviour which form a pattern of a depressed mood state.
Thoughts: If you feel depressed you may see yourself as useless, incompetent and blameworthy. You may have repetitive trivial thoughts or grossly exaggerate the worst outcome of an event. You may feel your thoughts are sluggish and almost seem to have a will of their own, popping up at the most unlikely times. You may lose interest in things and people or have a general feeling of impending doom for no apparent reason.
Feelings: You may feel frustrated, sad, hopeless and helpless. You may feel unworthy of the attention and help people offer you. An extreme form of depression is when you feel your life is not worth living and you may even make attempts to finish it.
Behaviour: You may appear lethargic, slow, clumsy and may look dopey and sad to outsiders. Sleeplessness is common, with waking up in the early hours and being unable to stimulate any enthusiasm for starting the day. People with angina who respond to stress by becoming depressed may stop exercising and this will lower the amount of exercise you can do before angina occurs. If you are unfit you will have angina at a lower workload and a lower heart rate than someone who is that little bit fitter.
Case history
June was prone to depression when stressed. A number or events in the family got on top of her and she began the characteristic ‘wind down’. She lost her job because she couldn’t get up in the morning and began staying in bed later and later. She found that the physical effort needed to get the shopping and housework done was just too much and she began having more angina attacks. This upset her and made her feel that the future was hopeless. After some time and help from a psychologist June began to see how her thoughts caused her to behave in ways that made her feel more depressed. By planning more activities she felt she could achieve at, like taking on a new job to pay for help in the home, and by talking over her thoughts and putting them into perspective, she was able to lift her feelings of depression. Breaking into the vicious circle helped her to overcome the depressive aspects of her response to stress.
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