Stress / Emotional Health Q & A

By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.

*Q: My wife had a triple bypass last year, and she’s doing fine. It’s me I’m worried about. I can’t talk to her because she might get upset. My chest is always tight nowadays, and I can’t get to sleep. I worry all the time. What should I do?

Your situation is very common. In fact, whenever I start to treat a new patient, I remind myself that I am treating two people: the patient and his or her spouse. You see, people who share the same habits also share the same risks, and you may not be aware that if you live with someone with heart disease, you have doubled the risk for developing the illness yourself. This is because the spouse and patient share the same diet, habits and stress.

Although you didn’t have the trauma of major surgery you may be exhausted by the caretaking you’ve had to give your spouse. Even if you’re not taking care of your wife’s every need, you are probably busy monitoring her medication and supplements, exercise requirements, encouraging her to follow a new diet and struggling to protect her from stress.

I counsel couples to recognize the four dangerous emotional issues that may surface after a cardiac event:

  • Vigilance – living in dread that something traumatic will happen.
  • Fear – living with continuous terror of losing your partner.
  • Loss of control – the friction that arises when your spouse cannot do some of the things he or she wants to do (either for him/herself or for you).
  • Anger – when your partner isn’t direct with you or refuses to change self-destructive habits that may have led to his or her heart disease.

Any of these situations or emotions, if not expressed, will fester and can be very unhealthy for both of you in the long run. I’ve treated many of my patients’ spouses for chest pain, insomnia, backache and arthritis, which were a direct result of their bottled-up emotions.

If possible, try to communicate honestly with your spouse in order to let go of any feelings of anger or fear or misunderstanding about control issues. I highly recommend a couples’ support group, targeted workshop or cardiac rehab, because listening to others, who are going through similar situations, helps people to realize they are not alone. We often “see ourselves” in others in group experiences. Hearing other couples share their struggles often gives partners insight about their spouses’ concerns as well as the courage to speak the truth.

*Q: Since my heart attack, I’ve become preoccupied with dying. I can’t get it off my mind. I’m scared a lot of the time. Sometimes I even feel panicky. How can I return to the way I was before I had a heart attack?

A preoccupation with death is very common after a heart attack. This may feel like an obsession to you at the moment, but hopefully time will diminish your current fixation.

However, I believe it’s important to come to terms with or mortality. In our culture, we rarely prepare for our own death, unless we know we are dying. Ram Dass, a protégé of great Buddhist teachers, reminds us that death is merely the completion of our life on Earth. As part of this completion, then, we need to make the necessary physical and spiritual preparations for our death. That means, among other things, having a living will and the legal documents to settle our estates. But many of us, even if we have a will, fail to put it where others can easily find it. This may, in fact, reflect our resistance to death.

However, if 6 to 12 months have passed since your heart attack and you still feel preoccupied with a fear of death, I would recommend that you seek guidance from clergy or a psychotherapist to explore the possibility of a deeper issue that has surfaced in response to the stress of your heart attack.

*Q: I’ve read that depression could lead to sudden death. Is this true?

Absolutely. Not only do depressed patients suffer more heart attacks, they have a higher incidence of sudden death. A recent study, in fact, suggests that the rate of sudden death rises 50%, as does the risk of a second heart attack or episode, if severe depression goes untreated.

We don’t know exactly how melancholy can lead to heart disease, but we do know that depression affects the central nervous system, causing an increase in heart rate and blood pressure, which results in wear and tear on our cardiovascular system. We also know that people who suffer from depression are more likely to engage in self-destructive behaviors such as overeating and cigarette smoking.

If you have coronary artery disease, the key is to be aware of the symptoms of depression so that you can get treatment. They include fatigue, lack of motivation, sleep disorders, loss of appetite or overeating, weight loss or gain, lack of pleasure in life, disinterest in hobbies and feelings of worthlessness or excessive guilt.

Since the 1990’s there have been exciting advances in the development of supplemental and herbal treatments for mild depression. I’m comfortable recommending amino acids like L-tyrosine, a precursor to the neurotransmitters that support your central nervous system (take two grams daily on an empty stomach), and herbs such as St. John’s wort (one to three tablets daily for mild depression), and ginkgo biloba (120 mg daily in three divided doses with meals), which may improve circulation while reducing depression. If you still feel depressed despite nutritional support and lifestyle changes, you must seek a medical consultation. See your physician on a regular basis to see if further pharmaceutical medication is necessary.

*Q: I’ve done everything “right.” I stopped smoking, changed my diet, added supplements, started an exercise program, lost weight and reduced my stress level at work. Why isn’t my heart disease getting any better?

I hear this frustration all the time, and my heart goes out to patients who ask me this question. Often, I discover that they have neglected their emotional needs. I’m thinking of my patient Bob, who asked me this question after one of my Stress and Illness workshops. When I told him he looked sad, he began to cry. Somehow, my observation had triggered Bob’s realization that he had been harboring a lifetime of buried feelings. Bob vowed to work on addressing his feelings through psychotherapy; for Bob, this was the first step in uncovering the emotional cause of his coronary disease.

I can’t emphasize enough the importance of addressing not only the physiological aspects of heart disease, but the psychological and emotional factors as well. That’s because, until we begin to understand the emotional roots of our physical disease, we cannot begin to heal. Any illness can be a combination of emotional, physical and spiritual factors. Unfortunately, many of us live in denial about the effects of our emotional life on our health. If you are interested in exploring your emotions further, I suggest you read my book, Heartbreak and Heart Disease.

*Q: I was shocked to hear that the strong, silent type might be at risk for heart disease. How is this so? I’ve always thought that angry, impatient screamers ended up with heart trouble. I’m not someone who emotes, so does my personality place me at risk?

It is now widely accepted that people who are consistently hostile, impatient, angry, cynical and negative (the classic Type A) are at risk for coronary heart disease (CHD). However, a study published in The Lancet in April 1996, identified a new group at risk for CHD. The researchers labeled as Type D behavior, self-contained loners who avoid social contact. I was gratified to see this breakthrough in a major research journal because it confirmed the work my colleagues and I published 15 years ago on how dangerous it is for the heart if people consistently withhold and deny their emotions.

My work involved collecting urine samples to measure the level of cortisol (the worry hormone that soars during anxiety or stress) for people who were susceptible to heart disease. The highest elevations of cortisol were in men who had heart disease, had difficulty expressing their emotions and frequently masked their true feelings. Conversely, most of the women in the group (who had higher levels of self-expression and strong social support) had much lower levels of the hormone and, I might add, no documented heart disease.

I have consistently observed that patients who are negative and sad, unable to cry or express anger and who are socially isolated, are definitely at risk for CHD. The good news is that there are ways to help the “closed” personality open up. Bioenergetics, for example, can help you get in touch with and release pent-up emotions that place your heart at risk. Bioenergetic therapy (BT) is a body-oriented form of psychotherapy that focuses on muscle tension triggered by emotional conflict. As a trained bioenergetic psychotherapist, I have seen how it improves the flow of energy in the body. That’s good news for many CHD patients (or people at risk for developing heart disease) who need to release restricted heart energy that is blocked in the chest wall and diaphragm.

If you want more information on bioenergetics, my book Heartbreak and Heart Disease is a good resource.

*Q: I tend to be the type of individual who believes the glass is half full rather than half empty. Does this kind of positive mental attitude make a difference if you have heart disease?

Yes, you are well ahead of the game. When a patient believes that improving their health is possible, they are more likely to actively participate in their treatment options, which is the strongest element in healing. Sadly, if patients tend to think pessimistically, they are likely to obstruct their recovery by becoming stuck, fearful, confused, angry and even despairing. These negative states may depress the immune system and have an effect on the nervous system, which can lead to disturbances in digestion, circulation and other internal functions.

I have observed that when a patient views their illness as a misfortune that they don’t deserve, they are unable to change or get better. Feeling like helpless victims, they remain convinced that their heart disease was an unlucky accident with no relationship to their attitude, emotions or lifestyle. Sadly, as a result of their negative attitudes, they invariably give up and become progressively sicker.

The key to getting well is to transform a negative situation, like illness, by focusing on some positive aspect of the circumstance. For example, my successful patients have used their heart disease as a powerful opportunity to change not only their lifestyle, but in many cases their mindset about personal conflicts that have upset them for years. As they surrendered to their illness, they eventually came to believe that their heart disease was a gift that motivated them to finally live in a positive, health-affirming manner. Ironically, the calm, positive acceptance of their illness as a blessing or opportunity has allowed them to move beyond sickness and make spectacular progress in many aspects of their lives. I am always overjoyed when I see my patients who, having experienced such exciting personal growth, begin to live fulfilled and happy lives.

*Q: I have tried lifestyle changes and many natural therapies to reduce my high blood pressure, and it’s still soaring out of control. What should I do?

Of course diet, weight reduction, exercise and nutritional supplements are key components to helping you control your blood pressure. I also recommend beta-blockers, diuretics or ACE inhibitors if you can’t bring your pressure down with natural methods.

But there’s something else you should be aware of – your emotions, specifically anger. That’s because anger can trigger high blood pressure and heart disease. Poorly handled and repressed anger can lead to a number of debilitating physical and emotional symptoms and diseases, including high blood pressure.

One of the best ways to cope with anger is to get it out. Your body should not be a warehouse for it. There are a number of was to do this. Use your voice! Scream, yell or cry alone in a parked car or another place of solitude. Talk to a friend. Or try twisting towels, hitting tennis balls, kicking a mattress or punching pillows or even a punching bag. If your anger continues to be toxic and you find yourself slamming doors or “kicking the cat” you should see a therapist.

*Q: I recently heard on the news that elderly heart patients are much less likely to die following surgery if they are socially active and find strength in their religious faith. If this is really true, I won’t be so worried about my grandmother’s upcoming bypass operation.

The findings from a study by Dartmouth Medical School are very encouraging. My first hand observations over 20 years, in addition to scientific data about prayer and healing, have convinced me that spirituality fosters healing. And according to Herbert Benson, M.D., author of The Relaxation Response, there is scientific evidence that faith, religion and/or belief in God reduces mortality and promotes health by reducing anxiety, depression, anger and blood pressure.

In the Dartmouth study, medical researchers analyzed the variables that led to survival for 232 patients 55 years or older who elected heart surgery. They found that the most consistent indicator of survival was the amount of strength or comfort the patient felt they received from their religious faith. And the more religious, the greater the protective effect as shown by the following statistics for mortality six months following surgery:

  • 88% survival for those who rarely or never attended services.
  • 95% survival for those who attended religious services.
  • 100% survival for those who described themselves as deeply religious.

The researchers also concluded, “It appears that there is something unique and life-protective about participating in an organized, regular social activity.” Six months after surgery, only 4% of those who engaged in organized groups such as senior centers, historical societies, etc. died. Fourteen percent of the group who had no social activities died.

The study concluded that patients who actively engaged in religious activity and belonged to organized social groups were 14 times more likely to survive than those who did neither. Hopefully, these findings will help to reduce your anxiety about your grandmother’s recovery from surgery.

If you would like to participate in your grandmother’s healing – and also reduce your own worries – try praying for her recovery. Double-blind studies worldwide confirm that people who are prayed for by others have higher survival rates and fewer complications after heart surgery. Though we still do not know why, positive intentions by others, even strangers, can make a difference. Positive intention sets up vibrational energies that improve healing.

*Q: I would greatly appreciate any information you could give to help me with my anxiety. I take vitamins, exercise, have a healthy diet and am never sick; so why do I feel upset and stressed out much of the time?

Your question strikes me as a call for help. And I commend you for your awareness. Of course everyone has some degree of stress in their lives, which can become severe at times. However, when stress becomes distress- prolonged stress with no chance for resolution or escape – your body is flooded with adrenalin (the fight-or-flight hormone) and cortisol (the worry hormone). If these hormonal secretions continue unchecked, your body is vulnerable to a variety of physical problems, ranging from insomnia to acute illness and even heart attack and stroke.

The “over-arousal” syndrome, which I’ve just described can be caused by any of the following:

  • “People poisoning” (people exerting excessive control over your life).
  • Unacceptable time pressures.
  • Sleep deprivation.
  • Major life events such as death, divorce, financial crisis, job pressures or moving – especially when several events occur within a short time period.

What’s most important is that you’re aware that you have a problem and you’re seeking help. Living in denial is dangerous for the heart. Remember, stressful situations almost never present a real physical threat. But chronic distress creates dangerous wear and tear on the heart.

There is no single solution to manage stress, but I have several suggestions to help you achieve that goal:

  • First, it’s important that you share your feelings with individuals that you trust.
  • Consider applying stress-reduction techniques such as meditation, prayer, yoga, biofeedback, breathing techniques, positive imagery sessions, massage, dancing, stretching exercises and Tai Chi. Whatever technique you choose, the regularity of the process is more important than the length of time you spend on the activity.
  • Laughing or crying are also very good ways to release built-up tensions and diminish stress on the heart. I often tell my patient to watch comedies or very sad movies if they can’t remember when they last laughed or cried.

Try to “go with the flow” and worry about the consequences later. The most important thing you should do is ask yourself this question, “Is this worth dying for?” As trite as this sounds, just doing that may save your life. I believe it would have saved many of my patients from their heart attacks.

My book Heartbreak and Heart Disease may also give you valuable insight into how you manage your stress.

*Q: Can you tell me why meditation is useful in the treatment of heart disease? How do I know if it is working? I’ve tried it, but sometimes I wonder about the physical effects.

Your question is a good one. When meditation as a relaxation tool is practiced on a regular basis, it benefits your heart enormously. And let me underscore the fact that relaxation is much more than simply the absence of work.

In a truly relaxed state, you’re free from physical, mental and emotional tension – your body is not flooded with the fight-or-flight hormones, which, produced in excess, may injure your arteries.   Also, researchers confirm that relaxation is the vehicle with the highest potential for “opening the door to change” by connecting the body, mind and spirit.

When you meditate, you are nourishing your heart by bringing normally involuntary responses – heart rate, blood pressure, respiration, muscle tension and adrenalin secretion – under voluntary control. And, if you repeat a simple phrase from a favorite prayer or statement reflecting your spiritual beliefs, you will experience even greater physiological change as you meditate.

This simple process can be done anywhere you’re quiet and undisturbed for 12 to 20 minutes. Pick a brief phrase that’s connected to your belief system such as “Be still with God”, “The Lord is my Shepard” or “peace.” Close your eyes, breathe in through your nose and out through your mouth, saying your phrase or word as you exhale. Release the thoughts that come and go, always returning to your choice of repeated words.

Try this technique for at least 10 minutes daily. (Don’t jump up as soon as you’ve finished.) Give yourself time to consider any insights that may surface during or after your meditation. If you experience intuitive thoughts as a result of your medication, write them down. These messages, which come from the heart, may help to protect your heart.

If you would like to explore meditation in greater detail, I recommend you read either The Relaxation Response, by Herbert Benson, M.D., Director of Behavioral Medicine, New England Deaconess Hospital, or Minding the Body, Mending the Mind, by Joan Borysenko, Ph.D.

*Q: When I’m with my grandchildren, there are times I laugh so hard it brings tears to my eyes. I feel so much better after the children visit. Could having fun help my heart condition, or am I getting dotty in my old age?

Yes, your visits with your grandchildren are good for your heart, so by all means continue to be silly and uninhibited. In fact, one of the saddest things I’ve learned in my years of medical practice is that adults forget how to play. Most of my patients look at me with a blank expression when I ask them how they play, or they tell me they “play” golf or tennis.

True play is spontaneous, has no set agenda, no rules or regulations, and not even a desired outcome. When we play, we do things solely for joy and pleasure. As we play, we become absorbed in what we are doing. Time stops for us. Worries, fears, wants and needs disappear and are replaced by a sense of satisfaction and joy. When you are freed from stress and anxiety in this way, it helps your mind and heart to heal.

Laughter combined with play is doubly healing for your heart. When you laugh as you have described, with your whole heart, the depth of your breathing increases, releasing trapped energy in your chest, diaphragm and even deep down in your groin muscles.   Laughter, like its twin sister crying, promotes respiration and provides your heart with much needed oxygen. It’s free, it’s fun and it releases endorphins and DHEA, natural hormonal substances whose presence signifies health and well-being.

*Q: I would like more details on a procedure called the “relaxation response,” which a nurse mentioned in my cardiac rehab group. I’m uncomfortable with treatments that sound “way out,” but I’m determined to do everything I can to unwind and help my high blood pressure.

Think of the “relaxation response” (RR) as the opposite of the “fight-or-flight response,” which manifests itself too often in our bodies as an excessive adrenalin rush in reaction to everyday stress. The heart-healthy benefits of RR can be accessed by a number of techniques which include: biofeedback, autogenic training (a self-generated therapy that involves repeating phrases to bring about a desired physical state, i.e. a relaxing heaviness, warmth, etc.) meditation, distraction, music therapy, qi gong (an ancient Chinese practice that combines movement, meditation and breath regulation), hypnosis as well as progressive muscle relaxation and breathing techniques.

RR calms an overactive nervous system (similar to beta-blockers) and returns the body and mind to a balanced and peaceful state by:

  • Reducing oxygen consumption.
  • Reducing respiratory rate.
  • Reducing heart rate.
  • Reducing muscle tension.
  • Reducing blood pressure.
  • Increasing brain alpha waves (present in deep relaxation).

Dr. Herbert Benson, a Harvard cardiologist, has done extensive research showing the effectiveness of RR in managing blood pressure and other cardiac problems such as angina and even some high-rate arrhythmias. RR has also been effective for other medical conditions such as asthma, anxiety, pain management and recovery from surgery.

In the past, researchers believed that relaxation techniques could only be practiced in a comfortable position in quiet, low-lighted environments. However, more recent findings suggest that some of the techniques, when practiced over time, work even in crowded conditions like commuter trains. This is good news for people who have trouble finding “quiet time” of an ideal setting in which to eliminate stress.

You can also experiment with one of the following simple techniques, which are uncomplicated and can be effective anywhere:

  • Following the breath: Simply breathe… in to the count of five…hold to the count of five…and out to the count of five (feel free to adjust to the count that is most comfortable for you).
  • Open focus: Repeat a soothing word such as “one,” “peace,” “love” or “relax,” or whatever word has a calming effect for you. Continue to repeat this work slowly, over and over as you let yourself slowly relax to the repetitive rhythm. Remember to slowly inhale and exhale as you repeat your word.
  • Tension/relaxation: Progressive muscle relaxation involves starting at one end of the body and alternately tensing then relaxing specific muscle groups. For example, starting with the head, tense the muscles of the face, hold for five seconds, then relax for five seconds. Proceed to your jaw, tense and hold to the count of five, then relax to the count of five. Slowly proceed downward to your shoulders and repeat. Continue through the various muscle groups, pectorals, upper arms, lower arms, hands, abdomen, buttocks, thighs, calves and feet.

The key to successfully managing your blood pressure is to pick and stick with a relaxation technique that feels comfortable to you, and do it consistently. If you would like to explore the effect of RR in greater detail, I recommend you read either of Dr. Herbert Benson’s books, The Relaxation Response (1975), New York, William Morrow, or Beyond the Relaxation Response (1984), New York, Time Books. In addition, my book, Heartbreak and Heart Disease has a section on relaxation therapies for healing the heart.

*Q: Is stress really that harmful to the heart? What do you do to relieve stress?

There is definitely a link between stress and cardiovascular disease, and surprisingly, the American Heart Association was initially slow to accept that stress is a risk factor for the heart. The same stress hormones that can provoke arrhythmias and raise blood pressure can place chronic stress on the heart. For that reason, it’s critical to get to the source of your stress.

The perception of stress differs for all of us because what is stressful to me, may be challenging or exciting for you. Typically, we associate only unpleasant or undesirable events such as losing a job with stress, but happy or joyous events such as the arrival of a baby also can be quite stressful. Properly handled, neither type of stress usually escalates into a physical problem. But unhealthy responses to chronic stressors can prolong the body’s physiological reaction to stress. Maladaptive behaviors such as drinking, overworking, overeating and suppressing anger or grief – can have serious health consequences.

I often recommend emotional healing and short-term therapy sessions to many of my cardiac patients to help them relieve anxiety, obsession, depression and unresolved feelings. Talking over a problem with someone you trust may help you to distinguish between the things that are worth fighting for and those that are less important, thereby reducing your stress level.

Group or individual psychotherapy can give you new insights into yourself and help put you on the road to healing. Many of my patients who have participated in some type of psychotherapy have learned to give up some or all of their excessive drive and struggle. After a few sessions, they often perceive their situations differently and their attitudes shift.

Some of the practices I recommend for stress reduction are prayer, meditation, biofeedback, deep breathing through relaxation techniques or even playing or laughing with a close friend or child. All of these can help you respond to life’s challenges in a more adaptable and healthy way, with the benefit of bringing normally involuntary responses – heart rate, blood pressure, respiration, muscle tension and adrenalin secretion – under voluntary control.

**Q: What will help me recover from adrenal exhaustion? I have low cortisol…

A: Adrenal exhaustion can result from being chronically stressed, whether from work, financial problems, family issues, physical disease, insomnia, nutritional deficiencies, and other sources of psycho-emotional stress (i.e. excessive worry, fear, or anger). Our bodies are designed to react to acute stressors with a surge in adrenaline (epinephrine) and cortisol, which assist the body in the “flight or fight” sympathetic nervous system response. When acute stressors become chronic stressors and cortisol levels stay elevated, this puts pressure on the adrenal glands to produce more cortisol. Over time the adrenal glands get “burned out” and are not as effective in producing cortisol.

Full recovery from adrenal exhaustion, though, will probably require integration of additional strategies such as:

1. Getting into a manageable routine- going to bed (preferably before 11pm) and waking around the same times each day, eating plenty of protein with every meal, drinking plenty of water, reducing consumption of coffee and other stimulants. Eating meals in a quite peaceful space and trying not to watch the news late at night may also help.

2.Nutraceutical support – Take a high potency multivitamin with lots of B-vitamins and Vitamin C.

3. Botanical medicine support – combination of adaptogenic botanicals including ginseng, licorice (avoid if high blood pressure), ashwagandha, rhodiola, maca root, schisandra, and holy basil. Research shows that adaptogens help people “adapt” to chronic stress. For example, licorice has been shown to extend the half life of cortisol, thus taking pressure off the adrenal glands. And rhodiola has been shown in many studies to increase exercise endurance particularly in elite athletes.

4. Stress reduction – If removing the chronic stressors from you life are not an option, engaging in some sort of meditation or stress reduction practice like tai chi, qi gong, or yoga can help counter the effects of, and help you learn to deal better with, them.

5. Grounding- Grounding, or Earthing, helps reduce stress by shifting the body into parasympathetic state, i.e. it creates a relaxation response, easing the stress on the adrenal glands. Sleeping grounded has been also shown to help normalize cortisol levels.

6. Light exercise- As heavy exercise can stress the adrenals, engaging in light exercise practices like walking in the woods or neighborhood, swimming, or gentle yoga is better for adrenal health maintenance.

Do you have a question about stress relief / mind-body health that you’d like answered on our site? E-mail us at and we’ll do our best to post an answer in this article.

*Indicates that Q&A has been reprinted or adapted from Candid Advice About Your Heart, a Heart, Health & Nutrition supplement, with permission from Healthy Directions, LLC.

**Indicates that Q&A has been posted in response to emails or comments submitted to Heart MD Institute. © 2012 Heart MD Institute. All rights reserved.

Please note that Dr. Sinatra does not provide medical advice through Heart MD Institute; any and all information found on this site is intended solely as an informational tool, and it should never replace a visit to your physician, nor be considered advice upon which you rely when making health-related decisions.

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