What is the difference between psychosomatic and psychophysiological disorders

Diagnostic and statistical manual of mental disorders , 3rd Edition, Revised. DSM-IV draft criteria. Bakal, D. The psychobiology of chronic headache.

New York: Springer. Beck, A. An inventory for measuring depression. Archives of General Psychiatry, 4 , — Bille, B. Migraine in childhood and its prognosis. Cephalalgia, 1 , 71— Bixler, E. Prevalence of sleep disorders in the Los Angeles metropolitan area. American journal of Psychiatry, , — PubMed Google Scholar. Blanchard, E. Management of chronic headaches: A psychological approach. Elmsford, NY: Pergamon Press. Non- drug treatments for essential hypertension. Buss, A.

An inventory for assessing different kinds of hostility. Journal of Consulting Psychology, 21 , — Bussye, D. Thorpy Ed. New York: Marcel Dekker, Inc. Diamond, S. Eliahou, H. Body weight reduction necessary to attain normotension in the overweight hypertensive patient. International Journal of Obesity, 5 Suppl. I , — Garrison, R.

Incidence and precursors of hypertension in young adults: The Framington Offspring Study. Preventive Medicine, 16 , — Hauri, P. The sleep disorders. Kalamazoo, MI: Upjohn. Hollandsworth, J. Physiology and behavior therapy. New York: Plenum Press. CrossRef Google Scholar. Holmes, T. The social readjustment rating scale. Journal of Psychosomatic Research, 11 , — Irvine, M.

Relaxation behavior therapy as sole treatment for mild hypertension. Psychosomatic Medicine, 53 , — A functional disorder is viewed as a medical condition that impairs normal functioning of bodily processes and remains largely undetected under physical examination, dissection, or by microscopic examination.

To meet the definition, there must be no exterior appearance of abnormality. A functional disorder contrasts with a structural disorder in which some part of the body is seen as being abnormal. An inadequate assessment can result in an inaccurate diagnosis of a functional disorder. Psychogenic disorders were never included in any edition of the American Psychiatric Association Diagnostic and Statistical Manual.

However, the term is included in ICD as other somatoform disorders, F Based upon ICD, conditions that can be categorized as being psychogenic include aerophagy, bruxism, cardiovascular disorder, constipation, cough, dissociative convulsions, dysmenorrhea, dysuria, gastrointestinal malfunction, genitourinary malfunction, globus hystericus, globus sensation, hyperventilation, musculoskeletal disorder, neurocirculatory asthenia, pruritus, pseudocyesis, seizures, teeth grinding, torticollis, and vocal cord dysfunction [ 87 ].

Psychogenic disorders are physical illnesses that are believed to have been caused by emotional or mental stressors or consequences of psychiatric or psychological disorders. In addition, it can be a physical abnormality or other biomarker that cannot be identified or cannot be explained by confirmatory testing within the capabilities of the examining physician.

It is a valid concept that physical illnesses can be caused or exacerbated by emotional or mental stressors by psychiatric or psychological disorders. However, the criterion that there is no physical abnormality or other biomarker that can be identified or explained is becoming an increasingly less valid concept.

Since the development and the expansion of brain imaging, neurochemistry, microarray technology, improved testing for somatic illnesses, and other advances, pathological changes can now be better identified. These pathological changes can be more readily identified in general medical as well as psychiatric illnesses. The absence of pathological anatomical findings may sometimes strengthen the possibility of a psychiatric or a psychosomatic illness, but the absence of a finding alone can never confirm the presence of a psychiatric illness.

No diagnosis is a diagnosis by default, including the diagnosis of mental illness. Despite this, it is a common practice to label a poorly understood condition as being psychogenic, even when there may have been no psychiatric evaluation, or an inadequate psychiatric examination with no evidence of a psychiatric etiology, or a competent psychiatric evaluation that reveals no evidence of psychiatric illness.

It is not included in ICD. It is considered a neurosis associated with wanting compensation from an insurance company. Neurosis is an outdated term that was defined as a relatively mild mental illness that is not caused by organic disease and involves symptoms of stress that may be depression, anxiety, obsessiveness, or hypochondriasis but without a radical loss of touch with reality. The clinical validity of this term is without any scientific support for diagnosis and classification, and there are ethical questions in the literature regarding the use of this term as a diagnosis.

All examinations of "compensation neurosis" as an illness entity, using standard criteria of diagnostic validity, do not support the view that such a distinct disease exists [ 88 ]. However, the term is listed in ICD. Psychogenic seizures are also called psychogenic nonepileptic attacks, psychogenic nonepileptic seizures, dissociative seizures, and pseudoseizures. During these episodes, patients manifest complex partial seizure activity, but seizure activity is not demonstrated on electroencephalograms EEG.

It is therefore, considered a diagnosis by exclusion [ 89 ]. These episodes may be accompanied by myoclonic jerks. No evidence can be found demonstrating a psychodynamic explanation for these seizures or the myoclonic jerks that may accompany these episodes. Physicians have mixed opinions regarding the etiology of what is called psychogenic seizures [ 90 ].

Unfortunately, partial seizure activity that is localized deep within the brain cannot always be measured with the current diagnostic technology that measures seizure activity on the surface of the brain [ 91 ].

A thorough history and clinical assessment, nasopharyngeal leads, sleep EEG recordings, hour EEG monitoring, computerized EEGs, single-photon emission computed tomography, video-electroencephalogram, and empirical treatment with anticonvulsants can result in a diagnosis of complex partial seizures in many who were previously diagnosed as having psychogenic seizures. Emotional distress and hyperventilation can lower seizure threshold in a patient who is prone to seizure activity.

However, when emotional distress lowers seizure threshold, it is a psychiatric contributor but not a true psychogenic seizure. It is considered to be a pain disorder that is associated with psychological factors.

A patient who is given this diagnosis is viewed as having complaints of pain that do not match the symptoms recognized by the evaluating physician. It is considered that some mental conditions, such as anxiety and depression, may increase the focus upon and the sensitivity to pain. It is a diagnosis by default and is made only when all other causes of pain have been ruled out [ 92 ]. Pain and fatigue, which are considered to have a psychiatric origin, are believed to be significant symptoms in diagnosing bodily distress disorder.

Fear, anxiety, and depression can clearly exacerbate a perception of pain [ 93 , 94 , 95 ]. Emotional distress can result in muscle guarding and autonomic reactions that cause pain [ 96 , 97 ]. In these cases, it is important to clarify the psychodynamics and the pathophysiological processes that result in the perception of pain. It is a rigidly fixed belief of being infested with pathogens, even when presented with evidence and appropriate reassurance to the contrary.

It is not a single disorder but can be secondary to numerous other conditions [ ]. The closest DSM-5 diagnosis is delusional disorder, However, most patients with delusional disorder have multiple delusions, not a single delusion such as parasitosis. The closest ICD diagnosis may be psychotic disorder with delusions due to a known physiological condition F Some patients complain of formication, which is a sensation of crawling under the skin. Recognized somatic causes of formication include menopause, pesticide exposure, reactions to dental chemicals, mercury poisoning, diabetic neuropathy, skin cancer, syphilis, Lyme disease, Morgellons disease, herpes zoster shingles , alcohol withdrawal, and stimulant intoxication with methamphetamines or cocaine [ , ].

Although patients experiencing formication describe it as a stinging sensation with a sensation of bugs crawling under their skin, most patients with formication can be reassured that the sensation of bugs under their skin is instead a neurological symptom.

Delusional parasitosis can easily be confused with Morgellons disease, which is a skin condition characterized by the presence of multicolored filaments that lie under, are embedded in, or project from skin. Clinical studies supporting the opinion that Morgellons disease has a delusional etiology have considerable methodological flaws and often neglect the fact that mental disorders can result from underlying somatic illness.

By contrast, rigorous experimental investigations have shown that this skin affliction results from a physiological response to the presence of an infectious agent.

Investigations have determined that the cutaneous filaments found in these patients are composed of the cellular proteins, keratin and collagen, and result from overproduction of these filaments in response to spirochetal infection [ , ]. Symptoms such as fatigue, aches, pain, cognitive impairments, mood dysregulation sensory complaints, etc. This belief system was quite evident in both the IDSA Lyme disease guidelines and the review of the guidelines [ 40 , ].

Complex diseases can have different presentations in different individuals with symptoms that may overlap with other conditions. Many of these symptoms may by themselves not be specific to a unique diagnosis.

Fatigue, pain, cognitive impairments, mood dysregulation, and sensory impairments are complaints that can be validated objectively by a competent clinician and can be confirmed with mental status evaluations, psychological testing, several measurement scales, and brain imaging [ , , ]. Vague and non-specific symptoms can often indicate immune activation in response to chronic infections, cancer, and other serious conditions [ 57 , 59 , , ]. Complex diseases can have different presentations in different individuals with symptoms that may overlap with other conditions, and many of the complex disease symptoms may by themselves not be significantly specific for a unique diagnosis.

Although many symptoms may superficially be viewed as vague and non-specific, it is possible to recognize patterns of these symptoms accompanied by disease progression specific to a condition. Bodily distress disorder is closely related to bodily distress syndrome.

The medically unexplained symptoms criteria for somatoform disorder have been criticized for being unreliable, since they define a disorder based on the absence of identifying features rather than the recognition of a problem [ ]. In the transition from somatoform disorder to somatic symptom disorder, the most significant change was the removal of the invalid distinction between medically explained and medically unexplained somatic complaints.

A group of proponents in Europe salvaged the diagnostic category with a substitute phrase and were able to have it listed in the proposed ICD 6C These proponents renamed it bodily distress disorder and replaced the medically unexplained criteria with the concept of long-standing excessive distress and excessive thoughts, and behaviors towards pain that are considered of either known or unknown etiology [ ].

In contrast, bodily distress syndrome is associated with excessive thoughts and behavior that are considered of unknown medically unexplained etiology [ , ]. Bodily symptoms are also persistent, being present on most days for at least several months. Typically, bodily distress disorder involves multiple bodily symptoms that may vary over time. Occasionally, there may be a single symptom, such as pain or fatigue.

In the definition of bodily distress syndrome, there is a group of conditions that have little in common other than being distressing to deal with by some physicians. What these conditions are considered to have in common is the belief that there is a central sensitization syndrome, which is not supported by any neurophysiological evidence.

In addition to this deficiency, there is a failure to be scientifically defined as a diagnostic category, and from an evidence-based medicine perspective, it fails to establish that it excludes patients with medical conditions that require medical care. The flaws in the concept of bodily distress disorder and bodily distress syndrome are like the flaws that were revealed in the PACE study: Labeling patients in this manner results in poor treatment outcomes [ , ].

Since neither bodily distress disorder nor bodily distress syndrome are included in the DSM-5, and there is no indication it will ever be recognized as a valid diagnosis by the American Psychiatric Association, it poses a somewhat lesser threat to patients in the United States. Its inclusion in ICD, however, can particularly impact other countries. There may be a motivation to label patients with bodily distress disorder with a belief it will reduce short-term healthcare costs.

Instead, it may have a long-term adverse effect upon the health of tens of millions of suffering patients across the globe, which makes it a concern for ethics as well as science [ ].

In addition, better insight in this area may help prevent errors and inaccuracies on the part of third parties, which may otherwise lead to misdirected financial resources and regulatory effort. A review of the definitions raises some significant issues that need further discussion.

Many of the terms discussed are shown in Table 1 and have the potential to be misused and abused. Many psychiatric terms, previous and current, have misuse and abuse potential. In any given situation, it is difficult to determine if emotional distress causes somatic symptoms, somatic distress causes emotional symptoms, or a multisystem condition causes both.

There may also be a very complex cause—effect relationship, or there may be a high level of true medical uncertainty regarding the cause and effect relationship. The medical uncertainty may be impacted by the limited knowledge of the examining doctor. This is demonstrated in Figure 1. The relationship between psychosomatic, somatopsychic, multi system illness, and medical uncertainty. The number and the complexity of these symptoms may be overwhelming to the patient, and the patient may be labeled as being hypochondriacal, having a psychosomatic illness, or having bodily distress disorder or somatic symptom disorder.

However, more commonly, hypochondriasis and psychosomatic illnesses begin in childhood and are lifelong conditions that vary in intensity depending upon life stressors [ , , ]. If a complex illness with a multitude of both mental and physical components begins later in life, the likelihood that this is an immune mediated, multisystem disorder is greater than it being a psychosomatic disorder [ , ].

The name bodily distress disorder implies there is distress associated with bodily functioning to such an excessive degree that it is called a disorder. There are proposed criteria for bodily distress disorder in ICD [ 55 ]. The definition can easily be impacted by the limits of the examination, the conceptual abilities, the bias of the examining physician, or the financial goals of the insurance company or the single payer.

Some patients with Lyme disease are viewed as having an excessive concern for their symptoms. In contrast, using objective criteria, a National Institute of Health study found chronic Lyme disease patients had pain comparable to post-surgical pain, and fatigue comparable to multiple sclerosis patients [ ].

Fatigue is a lack of energy unrestored by rest [ , ]. Fatigue can commonly be associated with a proinflammatory state and sickness syndrome, which can be evoked by infections, cancer, allergies, injury, etc.

In contrast, fatigue can cause mental distress. In the progression of multisystem illness, fatigue is an earlier symptom, and depression is usually a later and less common symptom. Fatigue as well as sickness syndrome without fever and chills can be a part of major depression [ 54 ]. Although fatigue is associated with major depression, it is difficult to find a psychodynamic explanation that fatigue can have a psychogenic basis.

Maintaining respect for the patient, protecting the integrity of the physician—patient relationship, and preserving individualized healthcare are high priorities in healthcare. Issues that have the potential to undermine the adequacy of assessment and medical judgment include third party intrusions with pressure for adherence to dogmatic, third-party controlled diagnostic and treatment guidelines, an incorrect application of research findings to individualized situations, flawed guidelines, and economic pressures that limit the adequacy of assessment.

Guidelines based upon inaccurate terms and concepts harm patients, especially when they are accompanied by efforts to convert the guidelines into standards of care [ 40 , ].

Failures in these areas can result in misdiagnosing someone who has a multisystem disorder with an erroneous diagnosis of somatic symptom disorder or some other error [ ]. Bodily distress syndrome and bodily distress disorder are ethically distressing concepts.

There is an ethical mandate based upon the Hippocratic Oath to defer to the needs of the patient when conflicts of interest arise. This raises ethical concerns with how we make diagnoses: When making a diagnosis of bodily distress disorder, whose distress are we really trying to relieve? A more valid term might be diagnostic distress syndrome. In science and medicine, when a finding is incompatible with a hypothesis and diagnosis, the hypothesis and diagnosis need to be questioned.

Clarifying the mind—body interaction in any given patient requires adequate psychiatric and general medical assessments. This approach has been a concept in medicine that has existed since Hippocrates. Sir William Osler, who is considered the Father of American Medicine, emphasized the significance of clinical observation, a thorough examination and individualized judgment when assessing a patient. Some of the better-known aphorisms supporting this position include [ ]:.

Let not your conceptions of disease come from the words heard in the lecture room or read from the book. See and then reason and compare and control. But see first. In medicine, we treat patients, not diseases. Patient care is compromised when medical practices emphasize population-based standards of care rather than individual patient needs and experiences [ ]. It is a concern that current clinical practice guidelines, which many doctors follow, are aimed primarily at managing single diseases.

These guidelines are of little help in aiding physicians when it comes to treating patients who have multiple conditions. In addition, many of the clinical guidelines are written by disease-specific specialists who may not consider the clinical picture beyond their area of specialization. Because of these issues, physicians should rely less on clinical guidelines for managing single diseases and more on their own clinical judgment to create treatment plans that meet the needs of individual patients [ 5 ].

Caring and empathy are also critical components of the physician—patient relationship. These are sometimes overlooked when there is an excessive emphasis upon the scientific component of the practice of medicine [ ]. The best researched scientific evidence available can be contradictory or equivocal. Scientific research is perhaps viewed as being on a continuum of different degrees of knowledge.

When new evidence occurs, it can challenge the legitimacy of previous beliefs and scientific hypotheses. Diagnostic and treatment guidelines of different degrees of reliability are sometimes established to offer some assistance in clinical decision making. However, all guidelines should have a clear disclaimer stating that guidelines are not a replacement for prudent clinical judgment.

A forward-looking National Health Service would recognize that patient experience evidence should be respected, cherished, and used on an equal footing with medical evidence. It is time for the double standard to end.

Historically, there has been a tendency to label physical symptoms that could not be explained as being of a psychiatric origin. As a result, many patients with complex, confusing symptoms and poorly understood diseases who receive an inadequate assessment for their condition are often referred to psychiatrists until the time when the disease is better understood and defined.

Limited integration between psychiatry and general medicine, silo mentality, restrictive diagnostic criteria, and erroneous guidelines currently contribute to diagnostic errors. As more sophisticated technologies emerge to visualize the brain, to demonstrate brain pathophysiology, and to quantitate mental functioning, and the causes of mental illness become better understood, the validity of many of the previously used phrases that were based upon the absence of physical findings, such as psychogenic and functional disorders, are becoming less valid.

There is now an increasing amount of literature demonstrating somatopsychic and multisystem processes and the accompanying pathophysiology [ 57 ]. The diagnosis of any medical or psychiatric syndrome requires the presence of clearly defined signs and symptoms consistent with each diagnostic category.

Reliance upon the total clinical exam, including an adequate history, review of systems, psychiatric assessment, and clinical judgment, is more valid than reliance upon any single laboratory or diagnostic test. When using diagnostic testing, absence of proof is never proof of absence. Although the absence of a finding in a diagnostic test may raise the suspicion of a psychiatric illness, the absence of a finding alone can never confirm the presence of a psychiatric illness.

The diagnosis of a psychosomatic condition requires a causal psychodynamic explanation, and it is never a diagnosis of exclusion based upon a failure to confirm some other diagnosis. The onset of a multisystem illness is rarely, if ever, associated with a psychogenic etiology. The presence of a psychiatric diagnosis does not eliminate the possibility of a comorbid, somatic diagnosis or a comorbid somatic diagnosis causing psychiatric symptoms. We can learn from history.

Syphilis was once a difficult to understand multisystem illness with periods of latency and a broad spectrum of presentations including both psychiatric and somatic and symptoms. Now, we are attempting to understand other multisystem, complex, interactive infectious diseases that are far more complex than syphilis. Treponema pallidum syphilis has only 22 genes.

In contrast, Borrelia burgdorferi the bacterium responsible for Lyme disease has genes with plasmids that allow for rapid genetic changes and interactions with other tickborne and opportunistic infections [ ]. There are over one hundred other infectious agents that cause mental illnesses [ 57 ].

We always need to be alert to new and emerging diseases. We must recognize there is always some degree of medical uncertainty with any condition.

Not everything is well understood or categorized. Complex diseases require complex explanations, and there needs to be recognition of varying degrees of medical uncertainty. Everything is caused by something. Nothing is caused by nothing.

When clinical findings are puzzling, the ethical approach is to continue attempting to explain the symptom, search for its cause, and admit that we do not have the required knowledge to provide a cure or even complete symptom relief. Qualitative terms such as subjective, vague, and nonspecific can be used inaccurately.

Bodily distress disorder is highly subjective and is a scientifically unsupported and inaccurate term. Bodily distress syndrome is also highly subjective. It is dependent upon the flawed concept of medically unexplained symptoms and is a scientifically unsupported and inaccurate term.

A common diagnostic pitfall with all of these terms is the risk that something unexamined or not adequately understood can result in an improper diagnosis, inadequate treatment, and inadequate financial coverage by third party payers. No one has complete knowledge of all fields of medical sciences. Not all diseases have been discovered or are properly understood, and much remains to be learned.

Better education concerning the interface between medicine and psychiatry and the associated diagnostic nomenclature as well as utilizing clinical judgment and thorough assessment, exercising humility, and maintaining our roots in traditional medicine will help improve diagnostic accuracy and move both science and medicine forward.

The authors would like to thank Douglas Bransfield for legal and technical assistance; Huib Kraaijeveld and Jenna Luche-Thayer for research assistance and acknowledge the contributions from all the patients and others who provided a description and insight about their illness that will educate and help others. National Center for Biotechnology Information , U.

Journal List Healthcare Basel v. Healthcare Basel. Published online Oct 8. Robert C. Kenneth J. Author information Article notes Copyright and License information Disclaimer.

Received Jul 15; Accepted Oct 1. This article has been cited by other articles in PMC. Abstract There is often difficulty differentiating between psychosomatic, somatopsychic, multisystem illness, and different degrees of medical uncertainty. Introduction 1. Gaps, Restrictiveness, and Deficiencies in the Healthcare Systems Many physicians find it challenging when making a diagnosis involving the interface between general medical and psychiatric illnesses, and diagnostic errors harm patients.

Consequences of Diagnostic Errors Complex brain—body differential diagnoses are challenging to payers, physicians, and affected patients.

Guidelines All guidelines have limitations and disclaimers that individualized judgment is necessary. Materials and Methods Two case presentations are given to demonstrate some of the relevant issues when differentiating between psychosomatic, somatopsychic, and multisystem illnesses, and they are discussed herein. Results 3. Case Presentations and Discussion 3. Case Presentations Patient A is an year-old white female with multiple symptoms who had previously been healthy and adept at Taekwondo.

Discussion of Case Presentations In both cases, the complexity of a multisystem illness was not understood nor adequately pursued by the treating physicians. Defining Relevant Terms When dealing with complex, inadequately investigated conditions in which many symptoms identified on a thorough history and review of systems are insufficiently or wholly unsupported by commonly used clinical laboratory tests, it is best to begin with definitions. Mental Illness, Mental Disorder Mental illness is also called psychiatric illness and mental disorder.

Somatic Symptom Disorders Somatic symptom disorders are included in the APA DSM-5 and are associated with excessive thoughts, feelings or behaviors related to somatic symptoms and one of three of the following criteria which need to be present for at least six months: 1 health anxiety, 2 disproportionate and persistent concerns about the medical seriousness of the symptoms, and 3 excessive time and energy devoted to symptoms or health concerns [ 54 ].

Somatoform Disorders and Medically Unexplained Symptoms Somatoform Disorders Somatoform disorders were once considered to be a psychiatric condition marked by multiple, medically unexplained, physical, or somatic symptoms. Functional Disorders Functional disorders have never been included in any edition of the American Psychiatric Association Diagnostic and Statistical Manual.

Psychogenic Disorders Psychogenic disorders were never included in any edition of the American Psychiatric Association Diagnostic and Statistical Manual. Subjective vs. Objective Complaints and Symptoms Symptoms such as fatigue, aches, pain, cognitive impairments, mood dysregulation sensory complaints, etc.

Non-Specific and Vague Symptoms Complex diseases can have different presentations in different individuals with symptoms that may overlap with other conditions. Bodily Distress Disorder, Bodily Distress Syndrome Bodily distress disorder is closely related to bodily distress syndrome. Discussion 4. Table 1 Psychiatric diagnostic terms with misuse and abuse potential. Open in a separate window. Cause, Effect vs. Interactive Relationship In any given situation, it is difficult to determine if emotional distress causes somatic symptoms, somatic distress causes emotional symptoms, or a multisystem condition causes both.

Figure 1. Multisystem vs. Can Fatigue Be Psychogenic? Ethical Concerns Maintaining respect for the patient, protecting the integrity of the physician—patient relationship, and preserving individualized healthcare are high priorities in healthcare. Adequacy of Assessment Clarifying the mind—body interaction in any given patient requires adequate psychiatric and general medical assessments.

Conclusions Historically, there has been a tendency to label physical symptoms that could not be explained as being of a psychiatric origin. Acknowledgments The authors would like to thank Douglas Bransfield for legal and technical assistance; Huib Kraaijeveld and Jenna Luche-Thayer for research assistance and acknowledge the contributions from all the patients and others who provided a description and insight about their illness that will educate and help others.

Author Contributions R. Funding This research received no external funding. Conflicts of Interest R. References 1. Kohlmann S.

Singh Ospina N. Rubio D. Defining translational research: Implications for training. Dearborn, Michigan, USA in In one study, for example, skin blisters were induced on the forearm. Subjects who reported higher levels of stress produced lower levels of immune proteins necessary for wound healing Glaser et al. Have you ever wondered why people who are stressed often seem to have a haggard look about them?

A pioneering study from suggests that the reason is because stress can actually accelerate the cell biology of aging. Stress, it seems, can shorten telomeres, which are segments of DNA that protect the ends of chromosomes. Shortened telomeres can inhibit or block cell division, which includes growth and proliferation of new cells, thereby leading to more rapid aging Sapolsky, In the study, researchers compared telomere lengths in the white blood cells in mothers of chronically ill children to those of mothers of healthy children Epel et al.

Mothers of chronically ill children would be expected to experience more stress than would mothers of healthy children. These researchers also found that the average telomere length of the most stressed mothers, compared to the least stressed, was similar to what you would find in people who were 9—17 years older than they were on average.

Some studies have even demonstrated that stress can begin to erode telomeres in childhood and perhaps even before children are born. For example, childhood exposure to violence e. Another study reported that young adults whose mothers had experienced severe stress during their pregnancy had shorter telomeres than did those whose mothers had stress-free and uneventful pregnancies Entringer et al.

Further, the corrosive effects of childhood stress on telomeres can extend into young adulthood. In an investigation of over 4, U. Efforts to dissect the precise cellular and physiological mechanisms linking short telomeres to stress and disease are currently underway. The cardiovascular system is composed of the heart and blood circulation system. Heart disease is one such condition. Each year, heart disease causes approximately one in three deaths in the United States, and it is the leading cause of death in the developed world Centers for Disease Control and Prevention [CDC], ; Shapiro, The pain often feels like the chest is being pressed or squeezed; burning sensations in the chest and shortness of breath are also commonly reported.

Such pain and discomfort can spread to the arms, neck, jaws, stomach as nausea , and back American Heart Association [AHA], a [link]. A major risk factor for heart disease is hypertension , which is high blood pressure. If left unchecked, hypertension can lead to a heart attack, stroke, or heart failure; it can also lead to kidney failure and blindness.

Hypertension is a serious cardiovascular disorder, and it is sometimes called the silent killer because it has no symptoms—one who has high blood pressure may not even be aware of it AHA, b.

Many risk factors contributing to cardiovascular disorders have been identified. These risk factors include social determinants such as aging, income, education, and employment status, as well as behavioral risk factors that include unhealthy diet, tobacco use, physical inactivity, and excessive alcohol consumption; obesity and diabetes are additional risk factors World Health Organization [WHO], Perceived discrimination appears to be associated with hypertension among African Americans Sims et al.

Sometimes research ideas and theories emerge from seemingly trivial observations. In the s, cardiologist Meyer Friedman was looking over his waiting room furniture, which consisted of upholstered chairs with armrests. Friedman decided to have these chairs reupholstered.

When the man doing the reupholstering came to the office to do the work, he commented on how the chairs were worn in a unique manner—the front edges of the cushions were worn down, as were the front tips of the arm rests. Were cardiology patients somehow different than other types of patients? If so, how? After researching this matter, Friedman and his colleague, Ray Rosenman, came to understand that people who are prone to heart disease tend to think, feel, and act differently than those who are not.

These individuals tend to be intensively driven workaholics who are preoccupied with deadlines and always seem to be in a rush. According to Friedman and Rosenman, these individuals exhibit Type A behavior pattern; those who are more relaxed and laid-back were characterized as Type B [link]. An example of a person who exhibits Type A behavior pattern is Jeffrey. Even as a child, Jeffrey was intense and driven. He excelled at school, was captain of the swim team, and graduated with honors from an Ivy League college.

Jeffrey never seems able to relax; he is always working on something, even on the weekends. However, Jeffrey always seems to feel as though there are not enough hours in the day to accomplish all he feels he should. He volunteers to take on extra tasks at work and often brings his work home with him; he often goes to bed angry late at night because he feels that he has not done enough.

Jeffrey is quick tempered with his coworkers; he often becomes noticeably agitated when dealing with those coworkers he feels work too slowly or whose work does not meet his standards. He typically reacts with hostility when interrupted at work. He has experienced problems in his marriage over his lack of time spent with family.

When caught in traffic during his commute to and from work, Jeffrey incessantly pounds on his horn and swears loudly at other drivers. When Jeffrey was 52, he suffered his first heart attack. By the s, a majority of practicing cardiologists believed that Type A behavior pattern was a significant risk factor for heart disease Friedman, Indeed, a number of early longitudinal investigations demonstrated a link between Type A behavior pattern and later development of heart disease Rosenman et al.

Subsequent research examining the association between Type A and heart disease, however, failed to replicate these earlier findings Glassman, ; Myrtek, Because Type A theory did not pan out as well as they had hoped, researchers shifted their attention toward determining if any of the specific elements of Type A predict heart disease. This relationship was initially described in the Haynes et al. Also, one investigation followed over 1, male medical students from 32 to 48 years.

At the beginning of the study, these men completed a questionnaire assessing how they react to pressure; some indicated that they respond with high levels of anger , whereas others indicated that they respond with less anger.

Decades later, researchers found that those who earlier had indicated the highest levels of anger were over 6 times more likely than those who indicated less anger to have had a heart attack by age 55, and they were 3.

From a health standpoint, it clearly does not pay to be an angry young person. After reviewing and statistically summarizing 35 studies from to , Chida and Steptoe concluded that the bulk of the evidence suggests that anger and hostility constitute serious long-term risk factors for adverse cardiovascular outcomes among both healthy individuals and those already suffering from heart disease.

One reason angry and hostile moods might contribute to cardiovascular diseases is that such moods can create social strain, mainly in the form of antagonistic social encounters with others.