Do I Have a Stress-Related Illness?

The man who has come to see me clearly does not think I can help him. He might be right. Mr G, now in his late 50s, is humoring his neurologist, who has referred him to me, a psychiatrist. Mr G has spent the past 20 years of his shrinking life trying to find someone who can help him with the ringing in his ears, the severe tinnitus that has cost him his job as an accountant and his social life, but not yet his marriage. His wife, who comes with him to all his appointments, has also had her life shrunk by his tinnitus.

My task appears more difficult when Mr G hands me a meticulous list of the specialists he has seen over the years and the treatments tried by neurologists, ENTs, speech therapists, dentists, chiropractors, acupuncturists, and physical therapists. When I ask him if he thinks his tinnitus is “stress-related,” he gives me a condescending look, as if he’s been waiting for this one, glances at his wife, and then says, “Of course stress sometimes makes it worse, but that doesn’t mean it’s all in my head, Doctor.”

He then reminds me, in case I need to be schooled in the physical dimensions of chronic severe tinnitus, that he has documented high-frequency hearing loss, left greater than the right, Meniere’s disease with several falling spells, and cervical stenosis requiring periodic spinal injections for left arm numbness and weakness. “It’s a physical condition,” his wife explained, to help me appreciate the size of the mountain we were climbing. “They gave him disability early retirement.”

When I ask him what kind of monitoring he’s done for his tinnitus, he gives me a blank look, glances at his wife, and I see that, through no fault of Mr and Mrs G, we are starting our climb at the very bottom of the stress-related illness mountain. No one has ever asked him to monitor the severity of his tinnitus daily. His worry has been nearly constant, his monitoring has been only occasional.

Definition of a Stress-related Illness

If you have ever wondered whether you have a stress-related illness, you may know that the first problem we face, like hikers without trail maps, is that “we” in the culture of modern medicine don’t work with a common definition of what qualifies as a stress-related illness. We may talk in vague ways about stress as a factor that worsens illness, but ask ten clinicians to define “stress-related illness,” and you will get 10 different definitions, most of them hard to operationalize in the clinic.

Consider that a useful working definition requires two steps. First, we need a list of illnesses for which there is substantial evidence in a range of relevant populations that a sound measure of stress contributes to the onset or progression of a specific illness. Some well-known examples that meet this criterion include diabetes, hypertension, coronary heart disease, and obesity. The evidence for these common illnesses may be stronger than for tinnitus, for example, because there has been more research on the role of stress in the more common illnesses. Such a list, when we create one, will arrange the illnesses that have been studied along a spectrum of strength of evidence that toxic stress may contribute measurably to the course and severity of that illness.

Second, since people vary in how much stress contributes to the course of a specific illness, the clinician and the patient need to collect daily monitoring data for a substantial period of time to establish whether stress is temporally related to key markers for the severity of this person’s specific illness. For example, what happens to Mr G’s daily severity of tinnitus ratings when his anxiety ratings go up, and when they go down, over three months? A tight temporal relationship between the stress measures and the illness measures can establish a convincing and useful picture of a stress-related illness.

Stress and Illness Measurements

These daily illness diaries have become common practice for finding out if blood sugar improves with a certain insulin regimen or blood pressure improves with a certain diet. And of course, there are apps that help with this kind of monitoring, graphing the results over time. Add some specific stress measures to this practice, and you can answer the stress-related questions for that person and that illness.

However, identifying patterns in a relationship of several variables over time during a complex chronic illness is not a trivial process. Some software does that better than others, and it is not yet clear which apps do this best. More research and more market competition will eventually identify the reliable leaders. And seasoned experts may be needed to help identify these patterns.

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The Stress Consultation Service

The question that anchors our interest in stress-related illnesses is: How much can stress management improve the course of that illness? This is a difficult question to answer for each patient, but a necessary first step on this journey is the stress profile. Analogous to a neuropsychological profile for people with cognitive difficulties, which describes a person’s assets and deficits, based on a battery of assessments, along with recommendations for management, modern medicine needs a service that provides stress profiles for people with chronic illnesses who screen positive for toxic levels of stress. Does this person have a stress-related illness?

This stress consultation service does not yet exist in any broad sense around the US. But it should. This is a gap we can’t afford to ignore. Ideally, this service will be staffed by health psychologists trained to collect a) self-reported measures of distress over several months, b) a life stress inventory of exposures and responses, and c) physiologic measures of stress responses relevant to the illness of interest, both through daily monitoring and through selected stress lab testing.

This comprehensive assessment will provide the basis for the stress profile and for the recommendations for management. Where staffing is available, collaboration by the psychologist with the primary care or specialist clinician on the implementation of the recommendations will increase the chances that stress management achieves improved illness outcomes over the coming months and years.

Until then…

While we build this new service, somehow and somewhere, we clinicians will continue to improvise with what we have. Through a series of monthly appointments over a year, I managed to find out with Mr G and his illness diaries on paper (he’s a tech-phobe) what happens to the severity of his tinnitus when his anxiety levels drop, either with clonazepam or yard work or the right dose of grandchildren to distract him from his worries. On his best days, his tinnitus ratings drop from the 7-9 range down to the 2-4 range when he can get his anxiety under 5 out of 10. It took over six months for him to believe this relationship meant that his underlying problem was his obsessive patterns of worrying about his ringing ears, and his lifelong habit of worrying in general. This gave us a rough trail map.

In a makeshift way we have established that Mr G’s tinnitus is a “stress-related illness,” and we have developed a stress management plan that works for him and his wife. He has demoted his tinnitus from tyrant to tolerable nuisance. That’s good for him, his family, and the specialists he used to see.

But, when we clinicians can agree on a common definition for stress-related illnesses, and when the imagined “stress consultation service” becomes as commonplace as neuropsychological testing services, it will no longer take people like Mr G 20 years to demote their tyrants. We can do better.