The American Medical Association estimates 90% of all illnesses are provoked by stress. Neurologically stress is strongly related to pain disorders including spine and head. Also autoimmune diseases that provoke neuropathies stress are a major cause of insulin resistance and Diabetes, Hypertension, all causes of Stroke, Heart Attack and especially Alzheimer's.

Dr. Vincent Fortanasce trained in Psychiatry at the Institute of Living, a Yale affiliate hospital. The staff includes Dr. Blake and Dr. Hartell, a marriage and family therapist, and biofeedback by a registered therapist is available.

All patients of the Fortanasce-Barton Neurology Center fill out stress questionnaires.

Why are we so interested in your stress? Stress treatment often decreases symptoms of pain by increasing your pain threshold. Also stress treatments prevent anxiety, panic attack and help you gain control.

Ask about our classes on stress reduction and biofeedback. More can be learned about stress reduction in The Anti-Alzheimer's Prescription. Also CD or DVD tapes are available in the Alzheimer's series - ask for Stress & Sleep.

Table of Contents

Introduction
Stressed Out + Sleeplessness = Double Damage
Stress and Your Brain
Stress and Coping Skills: Why We Respond Differently
Acute Stress Gives You Energy
Chronic Stress Destroys the Brain
How Stress Shortens Your Life
The Signs and Symptoms of Chronic Stress
Why Sleep is Important
Poor Sleep Increases Appetite and Weight
Poor Sleep Reduces Levels of Human Growth Hormone
Obstructive Sleep Apnea and Alzheimer's Disease
A Self-Fulfilling Prophecy
All Stressed Out and Sleep Deprived
Hormonal Balance and Psychological Responses
Preventing Alzheimer's with Rest and Recovery: Finding Your Circle of Quiet
Strategies to Increase Rest and Recovery

Introduction

My colleague, Dr. Marks, chair of the hospital ethics committee, never walked down the hospital corridor, he marched. In fact, the sudden disappearance of every nurse on the floor was the preeminent alarm that always preceded Dr. Marks' presence. He was a perfectionist and demanded it from every person in the hospital.

One day a number of years back, I received a phone call from Dr. Marks' nurse requesting that I meet him at his office at 5:30 pm sharp for the annual USC ethics lecture.

Dutifully, I waited for the older doctor in the corridor outside his office when he came walking out (not storming out as usual). Dr. Marks seemed surprised to see me waiting for him. Uncharacteristically He asked me to drive and remained silent during the 30 minutes trip to the University.

At the lecture, as was his custom, Dr. Marks asked a poignant question on double-effect in ethics, which he read from a scrawled note in his pocket. It was unusual for such a brilliant doctor to keep notes. Driving him home, I observed that Dr. Marks' had at least 10 folded notes stuffed in his shirt pocket.

More concerned than curious, I asked, 'Did you think Professor Aaron's response to your question was adequate?'

Dr. Marks did not respond. However, when he did speak, it became apparent that there was a problem. He did not remember the question he'd asked, much less Dr. Aaron's response. This forgetfulness combined with his demeanor, pocketful of handwritten notes, and outward ambiguity in a normally precise and perfectionistic man was diagnostic.

Within weeks, Dr. Marks became my patient and the origin of his problem was apparent. At age 62, he was overwhelmed with enormous stress with a schedule that a roomful of interns could not do. After doing a physical exam, patient history, and laboratory tests, I diagnosed him with type 2 diabetes, hypertension, and the early stages of dementia. He also had extremely high levels of C-reative protein and homocysteine. Though you might find it unusual he had not seen a physician for himself in20 years.

His wife had called me and commented on his snoring and moments when his breathing stops during sleep, which she said had worsened in the past few years. She mentioned that he rarely slept for more than six hours at night and had not taken a real vacation since their honeymoon right before medical school.

In taking his family history, Dr. Marks had no genetic predisposition for dementia. In fact, his parents lived well into their 80s with no sign of mental decline. Unequivocally, I determined that Dr. Marks caused his own mental decline, meaning his dementia was lifestyle induced. He had the two sentinel risk factors, stress and sleeplessness and a clear case of obstructive sleep apnea. Dr. Marks lifrstyle was a recipe for disaster , a recipe for Alzheimer's. A type 'triple A' personality with the key traits uncontrolled stress a sleepless workaholic and a solitary personality, who took no time for reflection or social activities.

All stressed up but no place to go? Hasn't everyone felt that way? Sure there are times when we can all identify with running in circles, trying to juggle myriad commitments in our lives with kids, careers, and other commitments. When you add caregiving to aging parents-especially to those with Alzheimer's disease-you have a guaranteed recipe for disaster...or as Dr. Marks experienced, a recipe for early dementia.

Stressed Out + Sleeplessness = Double Damage

In this 4th and last step of the D.E.A.R. program (part of my Anti-Alzheimer's Prescription), I want to delve into the 'double damage' of stress combined with sleeplessness, and how this increases the chances of Alzheimer's disease. I will discuss how chronic stress keeps the hormone cortisol at extraordinary high levels in the body, which results in a catastrophe with hormonal imbalance, inflammation, and neurotransmitter dysfunction in the brain. I'll introduce new findings on sleep deprivation and how it increases pro-inflammatory markers in the body and may be to blame for the epidemic rise in obesity, type 2 diabetes, and Alzheimer's disease. I will then explain how inflammation and obesity are both linked to serious sleep disorders such as obstructive sleep apnea (OSA), a problem in which the person literally stops breathing (periods called apneas) many times throughout the night. OSA is increasingly common with aging, and is a risk factor for Alzheimer's disease. Finally, I want you to feel relaxed and get better sleep so you can enjoy social activities. Having a strong social network and developing religious or spiritual practices with 'A Purpose Driven Life' are important ways to decrease the chance of Alzheimer's. I'll also show you how to optimize the neurotransmitters and receptor sites in your brain to keep your cortisol levels from wreaking havoc in the body and mind so you can maximize your ability to succeed under stress and reduce the risk of Alzheimer's.

Stress and Your Brain

Simply stated, stress describes the many demands physical, mental, emotional, or chemical you experience each day. It includes the stressful situation (or stressor) and the symptoms you experience under stress (stress response). Stress can be negative (distress) or positive (eustress).

No one is immune from stress. We all experience it from day to day. Perhaps just hearing the word stress makes your head turn. Whether from an argument with your spouse, a confrontation with your boss, or fighting customers, clients or traffic day after day during rush hour, stress is real, and it's here to stay.

Whereas physicians used to think that while stress made you feel uncomfortable, it wasn't really a big deal, we now know that daily stress can lead to tremendous emotional turmoil that shocks an immune system into a downward spiral, resulting in chronic or serious illness-and, yes, even increase the chance of Alzheimer's. In fact, some revealing findings indicate that the signs and symptoms of aging may be more related to our stress reactions than to our chronological age.

In research presented at the 114th Annual Convention of the American Psychological Association (APA), researchers explained evidence that biological and behavioral stress responses may be adaptive in the aftermath of stress, but can cause damage when they go on for a long time. In other words, whereas acute or short-term stress may enhance immune function and improve memory, chronic or long-term stress has the opposite effect; it can lead to cognitive impairment, as well as serious health conditions such as hypertension, depression, type 2 diabetes, and even cancer.

Stress and Coping Skills: Why We Respond Differently

What's most interesting about stress is the fact that none of us respond in the same way to stressful events. In other words, what may give you a feeling of emotional excitement might give your spouse or friend a sense of abject terror! That's because we all perceive and respond to stressors in different ways. However, it's the inappropriate responses to stress that influence your health and increase your chance of Alzheimer's disease and other illnesses.

The Austrian physiologist Hans Selye, introduced the General Adaptation Syndrome when coping with stress. This means that the biological changes that occur in response to a stressor are beneficial as they enable you to adapt to the situation. This adaptation involves drawing upon resources within the body to provide the energy and oxygen that your body needs to either fight or flee.

Try to think of this process as being like your savings account at the bank. You set funds aside for use in an emergency. When your car unexpectedly breaks down, your life is barely interrupted because you can afford to have it quickly repaired. The emergency will not severely affect your lifestyle because you have the money to deal with it.

Your body's currency is stored away as triglycerides and glycoproteins. The currency itself is glucose and other sugars. This is what fuels your brain as well as the muscles and other organ systems within the body. Without it, your body would literally shut down

Acute Stress Gives You Energy

So what happens when you find yourself in a threatening emergency? First, there's an immediate activation of the sympathetic nervous system and release of adrenaline. Then the brain sends a message to the adrenal glands. The primary mission of the adrenal glands is to produce a chemical or hormone that converts stored energy into usable energy. This chemical is the stress hormone cortisol. Without cortisol, there's no way you could survive an emergency. Cortisol literally puts energy in your personal tank in the form of blood glucose.

When you have an acute emergency, one that lasts for a short time, no permanent physical damage is usually done. (In biological terms, a short time would be a few hours, perhaps even a couple of days.) Your heart rate and blood pressure increase and the alarm neurotransmitter, adrenaline, floods your body, making your heart beat faster and changing the blood flow to muscles and intestines. This adrenaline 'rush' prepares you to fight the wild beasts (life's problems). We have a built-in mechanism called the 'fight or flight' response that causes a profound set of involuntary physiological changes that allows us to handle acute stressful events. This response is controlled by the hypothalamus in the brain. When we face fear-or even recall a stressful or frightening event from the past--the resulting hormonal changes super-charge our body to a state of high arousal to prepare us for action.

Chronic Stress Destroys the Brain

However, when stress happens for days, weeks or months, it is called chronic stress. Chronic stress occurs when we face stressors over a period of time. As an example, if you have a demanding job, financial problems, or a drawn out divorce, chances are you live with chronic stress. If you're a caregiver to an aging or ill parent, you may be experiencing chronic stress. Likewise, if you have a chronic illness like asthma, type 2 diabetes, or cancer, you may also have chronic stress.

How Stress Shortens Your Life

Chronic stress in time affects your body's genes by shortening the telomeres, the so-called tale of the gene. It has been shown in animal studies that stress decreases telomerase activity, affecting the telomere. Telomerase is an enzyme that regulates how many times a cell can divide. Telomeric sequences shorten each time the DNA replicates. When some of the telomeres get too short, the cell quits dividing and ages. This is thought to cause (or at least contribute to) age-related problems like Alzheimer's. It is not uncommon for soldiers who have been in combat for a long period of time to return looking as if they had aged 10-20 years.

When stress is chronic and the stress hormone cortisol is elevated over a period of time, it may shift fat distributions that precede many chronic diseases such as metabolic syndrome or insulin resistance syndrome. Abdominal fat or an increase in waist size also increases inflammation in the body, which is associated with an increased chance of Alzheimer's disease. Yes, that deposit around your waist is a toxic waste dump that fouls up the rest of your body!

When chronic stress lingers for weeks or months, problems arise. Because you are constantly withdrawing savings (naturally stored energy) without replacing them, you use up all of your body's resources until you reach a point where there are no more available. Instead of drawing upon naturally stored energy, your body will begin to break down muscle and other tissues to keep going. In addition, chronic stress inhibits sleep, which is the way your primary neurotransmitters including adrenaline, dopamine and serotonin regenerate. Without this regeneration, you'll feel fatigued, achy, overwhelmed anxious and depressed.

If you do not have a healthy way of responding to the chronic stress or counterbalancing the 'fight or flight' response, the constant exposure to stress hormones will eventually cause your body to become overloaded and literally burnout. When you're stressed out for a long period of time, it can result in a dramatic decline in both physical and mental health.

It's thought that stress causes an imbalance in our hormonal system and, in doing so, imbalances our entire neurotransmitter system. The increase of cortisol, the catabolic hormone, decreases lean muscle mass and increases fat and obesity. The increase of glucose sends insulin levels soaring. Over time, increased insulin levels increase levels of amyloid protein in the brain (the toxic protein that's the underlying cause of Alzheimer's).

We need some cortisol to keep our immune systems healthy. But when cortisol is elevated as with chronic stress, it can inhibit the lymphocytes or white blood cells or our immune system. Other chemicals produced by the brain's autopilot--known as the autonomic nervous system--can similarly damage the cells that comprise the immune system. Increased cortisol from stress increases the likelihood of colds, cancer, infections and inflammation to the blood vessels and cells in the brain. Increased cortisol also increases our sympathetic nervous system and increases adrenaline and noradrenalin. After many years of being exposed to cortisol, a super charged sympathetic nervous system can result in chronic fatigue and a decrease in executive function, attention, and concentration because of the decrease in blood supply through the vital hippocampus area of the brain. Remember, the hippocampus is the part of the brain that's hit the hardest by Alzheimer's disease.

During younger years, when cortisol is stimulated because of stress, there is a feedback mechanism that occurs in the hypothalamus of the brain that causes the cortisol to shut off. Yet as we get older, this feedback loop does not work so well and hinders our ability to manage the stress response. Stress also interferes with weight loss and, most importantly, disrupts normal sleep thru interference with the sleep cycle. The stress/sleep 'double damage' connection may be the greatest of all risk factor combinations when it comes to increasing the chance of Alzheimer's.

Did You Know That . . .

• According to the American Stress Institute, stress is America's #1 health problem, costing the economy more than $300 billion annually.
• Levels of the stress hormone cortisol are at their highest early in the morning, making you more likely to overreact.
• Watching the late night news can elevate your cortisol and cause increased anxiety, making it tough to fall asleep.
• People who are anxious drink and eat more.
• Anxiety increases the chance of accidents, colds, heart attacks and Alzheimer's disease.

The Signs and Symptoms of Chronic Stress

We have discussed the long-term effects of stress, hypertension, obesity, diabetes and Alzheimer's disease. But what are the short-term signs of stress. It might be assumed that it is easy to know if one is stressed or not. The truth is it isn't. An interesting study showed that over 50% of those tested did not recognize when they were under acute stress and especially did not recognize chronic stress. This was verified by me in a series of 100 patients I did using Biofeedback. Galvonic skin resistance was used to measure sympathetic activity that is increased when under stress. The subjects generally well educated showed poor recognition of their stress in 40% of the cases.

The signs of stress differ from person to person but generally one has the following due to the immediate effect of our neurotransmitters adrenaline and noradrenaline. The signs of relaxation on the other hand are due to other neurotransmitters as serotonin and dopamine and the vagal system.

The acute signs of stress, from head to toe are dilated pupils, dry mouth, tense muscle starting with one's jaw muscles and then the trapeze or neck and shoulders muscles. Breathing feels difficult and increased rate of breathing can bring on hyperventilation followed by a panic attack characterized by shortness of breath and hands and feet going numb. There is a sense of impending doom. The hands and feet become colder. Teeth clenching, especially at night leads to worn tooth enamel. Other features of chronic stress are neck pain and tension headaches and stomach ulcers.

Paying attention to your personal signs of stress is as important as paying attention to what you eat and how much sleep you get.

Why Sleep is Important

To understand why sleep is so important, we need to go back to the concept of our hormonal symphony. Normally, we go through about six sleep cycles. There are also four stages of sleep, plus rapid eye movement (REM) sleep. The deepest stages of sleep (3 and 4) are necessary for the production of sufficient neurotransmitters, including dopamine and serotonin. REM sleep helps us organize and store our memories. Interruption of these stages is devastating to the brain and body.

Dopamine is the 'get up' or pleasure neurotransmitter that motivates and promotes good habits. It's also linked to mood, plays a role in controlling appetite. When dopamine levels fall, the brain's ability to experience happiness and well-being suffers. People with less dopamine have a greater incidence of depression, addictions, and other neurological problems. Serotonin, the 'I can do it' neurotransmitter is relaxing, calmative, and helps us to sleep well and take things in stride. Serotonin also stimulates the hormone melatonin that helps lull us to sleep at nighttime.

Poor Sleep Increases Appetite and Weight

A recent study of healthy volunteers in the medical journal Sleep found that those who slept two to four hours a night were more than 200 percent more likely to be obese than those volunteers who got seven hours of sleep. In fact, one study found, just a 16-minute loss of sleep per night also increased the risk of obesity.

These studies indicate that sleep loss lowers the level of leptin, a hormone that stimulates metabolism and decreases hunger. Sleep loss or shorter hours of sleep appear to boost the concentration of the hormone ghrelin, which increases hunger. In a controlled study, researchers have deprived healthy males of sleep and found that their levels of leptin went down, while ghrelin went up -- both changes that increase appetite.

In line with these studies, there is increasing evidence that people who sleep less than six or seven hours a night have a higher risk for diabetes. Researchers at the University of Chicago found that losing just three to four hours of sleep over a period of several days was enough to trigger metabolic changes that are consistent with a pre-diabetic state (also metabolic syndrome). They determined that when sleep was restricted to four hours for six consecutive nights, the body's ability to keep blood glucose at an even level declined significantly. This may be because sleep deficit affects the immune function of the body. In one study, scientists found that a 45 percent reduction in total sleep time resulted in a nearly 30 percent reduction in cellular immunity. Getting quality sleep is now considered a basic defense mechanism to staying healthy and preventing disease. Getting 7 to 8 hours of sleep each night is your best defense against conditions such as obesity and diabetes that increase the chance of Alzheimer's.

Poor Sleep Reduces Levels of Human Growth Hormonei

According to the National Institute on Aging, 1 out of 8 individuals in their twenties has chronic insomnia, while 1 out of 5 people ages fifty to sixty-four and 1 in 4 people over age sixty-five experience this sleep disorder. Findings indicate that millions of women suffer with disordered sleep, especially insomnia. With age, the prevalence of insomnia increases as sleep time decreases, even though the time spent in bed might increase. An old adage women will attest is 'when menopause begins a good night sleep ends.'

The problem with poor sleep is that it deprives the body of human growth hormone (HGH). Declining sleep quality begins between the ages of 25 and 45, according to a study reported in the Journal of the American Medical Association. In this study, researchers evaluated sleep study data from 149 healthy men, ages 16 to 83, and found that sleep deteriorates at two points in a person's life-between the ages of 16 and 25 and again between the ages of 35 and 50. Results showed that the time spent in deep sleep dropped from 20 percent (men under 25) to less than 5 percent (men over 35). Recent studies from the University of Pittsburg using functional MRI indicate some with chronic sleep disturbance have activity in central sleep and alerting areas of the brain that should be shut down as they attempted to sleep but were not. Instead, in these individuals with long-term sleep disturbances, the areas were activated by attempting to fall asleep. Identifying these patients is important to correct this particular sleep disorder.

Obstructive Sleep Apnea and Alzheimer's Disease

While snoring is caused by the vibration of the soft parts of the throat while breathing in and out during sleep, obstructive sleep apnea (OSA) involves periods of breath holding while snoring. The periods of stopping breathing (called apneas) are caused by obstruction of the upper airway. Apneas may be interrupted by a brief arousal that does not awaken you completely-you often do not even realize that your sleep was disturbed. Yet if your sleep was measured in a sleep disorders laboratory, technicians would record changes in the brain waves that are characteristic of the arousals.

The most brain damaging effect of OSA is that it interrupts sleep stages 3 and 4 and REM sleep. In fact, in severe OSA, a person may never reach stages 3 and 4 at all during the night. I first realized that I had OSA when my transcriber told me I had fallen asleep during the dictation. When she played back the tape, you could hear me talking for 10 minutes, and then nothing but my snoring and breathing interruptions. That was a wake-up call for me! I diagnosed at least 2 patient's a month for 10 years before I recognized I had it.

Obstructive sleep apnea results in low oxygen levels, which result when the blockages prevent air from getting to the lungs. The low oxygen levels also affect brain and heart function. OSA is more common than asthma in adults and up to two-thirds of those with OSA are overweight. Those with more than 20 apneas (complete obstructions) per hour of sleep may have a greater risk of dying from cardiac rhythm and rate disturbances and complications of high blood pressure such as stroke and heart attacks than people with fewer apneas.

Treatment of OSA involves weight loss and sometimes using CPAP, a device that creates positive airway pressure. Studies show that treating sleep apnea properly with positive airway pressure leads to lower blood levels of C-reactive protein and levels of two markers of platelet activation.

If you wonder if you have OSA, ask your spouse if you snore, or tape record yourself while sleeping. If you are 50, over-weight, male and snorer, chances are you have OSA. Women are not immune to this disorder either. Please don't delay. Talk to your Doctor about OSA, as it is a parasite that robs the vitality of your body and brain.

A Self-Fulfilling Prophecy

When we cheat ourselves of ample sleep - and the normal cycles of sleep - a self-fulfilling prophecy occurs. Less dopamine is secreted, which causes our willpower to wane. Less dopamine leads to:

• a bigger appetite and binge eating or drinking;
• a decrease in leptin (a special hormone that makes you feel full);
• an increase in grelin (a hormone that stimulates hunger and appetite); and
• an increased tendency for depression.

Less sleep also results in decreased amounts of serotonin. Having less serotonin alters your body's biorhythms, increasing your sensitivity to pain, and resulting in early morning awakening with feelings of dread, alarm, and panic. Less serotonin also increases the appetite, especially for simple carbohydrates (chips, cookies, cakes, candy, white bread and pasta), which I believe is the direct root of the obesity epidemic in the United States today. (On a lighter note, my practice dietitian reminded me that 'stressed' is 'desserts' spelled backwards!)

With less serotonin, we require more drugs to fall asleep, and these chemicals interfere with our own biorhythms and hormonal balance. With the decrease in dopamine, our executive functioning decreases, as does our ability to follow through with plans and commitments. In addition, because of decreased dopamine, our self-control markedly diminishes. I've done myriad informal studies on hundreds of my patients through the years, and I've found that those individuals who suffer with addiction problems -whether alcohol, drugs, sex, or food -- also have very low dopamine receptors in their frontal lobes and other important places in the brain.

All Stressed Out and Sleep Deprived

After months of poor sleep and chronic stress, you feel exhausted with low mood and no energy. You probably binge on simple carbohydrates (chips, candy, desserts) to satisfy the dramatic decline in dopamine and serotonin. The increased carbs cause insulin, your symphony conductor, to go wild, with its levels soaring upward. When insulin soars, your limbic (emotional) brain takes control, and your neocortex thinking brain takes a backseat. Your limbic system then tries to jumpstart your body by doing the following:

1. Binging on carbohydrates;
2. Getting high or numb with sleeping medication and alcohol;
3. Drinking tons of coffee for a jolt; and
4. Adding salt to food.

All of these are abusive! If you continue this 'body/mind abuse' regularly, it becomes a destructive habit. Over a period of months, the destructive habit becomes a full-blown addiction. Common addictions include nicotine, alcohol, and sleeping pills, both over-the-counter and prescribed. Less significant addictions include caffeine and salt. Thus, the key reason I call 'stress and sleeplessness' the 'double damage' that increases your risk of Alzheimer's is because the loss of dopamine and serotonin cause key hormonal changes that result in a direct inability to cope with life's stressors. With the 'double damage,' your hormonal symphony is definitely imbalanced and out of key.

The limbic brain eventually leads you into a disharmonious life filled with bad health habits, eating disorders, addictions, obesity, metabolic syndrome, type 2 diabetes, and eventually Alzheimer's disease. Continue to keep in mind that 70 percent of the time, Alzheimer's is not genetically programmed-you control your destiny, and following the 4-steps in the D.E.A.R. program will let you stay Alzheimer's free. In the other 30 percent-those cases that are genetically linked-- we can still delay the onset of Alzheimer's by more than 10 to 15 years by watching our diet and lifestyle habits, including controlling stress and getting quality sleep. It is never too late-or too early--to control your stress response and increase your quality of sleep.

Granted, the older we get, the harder it is to sleep. Older adults have less deep sleep time, more arousals and disruptions during sleep, and less efficient sleep. When missing a few hours of sleep over a week continues for several weeks or months, the damage to your body is cumulative, as it results in markedly increased inflammatory cytokines, which increase systemic inflammation. So how do we stop the cycle?

Hormonal Balance and Psychological Responses

To reduce the chance of Alzheimer's disease, you must seek hormonal balance. Unbelievably, the stress hormone cortisol actually helps you to achieve that balance. Because cortisol is intimately regulated by the limbic (emotional) brain, emotional stress can, through cortisol, have a profound impact upon anabolic and catabolic hormones.

During stress there are many hormones produced by the body, including some, such as growth hormones, that actually augment the immune system. Whether the immune system will be affected when you're stressed is determined in large part not by the concentration of any one hormone, but instead by the relative amounts of several different ones. Furthermore, these hormones are profoundly influenced by your psychological response to stress. Let's look briefly at these five responses:

1. Perception.
   
   Of the four psychological responses, your perception of the stressor is absolutely paramount. Unless you think that something is going to be a dangerous, it is not going to trigger the so-called alarm phase of the General Adaptation Syndrome, the stage when you realize that there is a potential threat to your well-being.
   
   What is the difference between deleterious stress and normal, everyday concerns? A lot! Sure, we are all busy. We all have concerns and responsibilities. Nevertheless, stress occurs when you feel something is way out of your control, that it's far more than you can handle. Also, with stress, you might fear the consequences or what 'might' happen.
   
   Stress, then, is a combination of being unable to cope because of a situation we cannot control, along with the resulting fear. Is it true that there are some who imagine that they are under stress and others who actually are under stress? The answer is 'Yes.' Unfortunately, it is your perception of the stressor (and imagined consequences) that is often the determinant.
   
   Consider this scenario. As you get into the elevator on the 22nd floor of your office building, you calmly push the button to go down to the parking garage. The elevator begins to descend normally, and then suddenly it jerks, makes a loud squeaking noise, and stops. All the lights go out. In just seconds, you've gone from feeling calm and in control to feeling trapped-with no control. Your limbic emotional brain jolts into overdrive and the immediate alarm response is the outflow of adrenaline triggered by the sympathetic nervous system. Your heart races. Your muscles feel tight. Your respiration becomes rapid and deep. In simple terms, you are ready for action! At the same time, another stimulus has gone to your pituitary gland to excrete a longer-term response to this immediate threat. This stimulus causes the adrenal glands to release the stress hormone cortisol.
   
   As you frantically look for the control buttons, the elevator jerks, and the doors suddenly open. At this moment, another physiological response occurs. This time the parasympathetic nervous system calms and balances the sympathetic nervous system (your alarm system). The parasympathetic nervous system now mobilizes its internal defenses and causes a soothing excretion of hormones that relax your body and, in particular, protect the hippocampus, one of the central portions of the limbic system and source for memory transmission.
   
   Now-unbeknownst to you--there is a raging war going on between your brain's alarm system and its calming system to reach a state of balance that we call homeostasis. At this moment, the body's stimulating and tranquilizing chemical forces are clashing. The sympathetic nervous system and parasympathetic nervous system are at a tug-of-war with one another.
   
   Problem is, for some individuals, these calming chemicals never occur, and there is a constant stimulation of the alarm system. I treat many of these individuals after they lose it completely and eventually have nervous breakdowns.
   
   When the alarm system is triggered by an external event such as the sudden stopping of the elevator, the production of anabolic hormones, such as growth hormone, and reproductive hormones such as testosterone, estrogen, and progesterone is decreased. Even the immune system goes on hold and blood flow to the skin is reduced. These physical reactions are why stress leads to decreased sexual function and an increased risk of illness like asthma, allergy, hypertension, diabetes, and cardiovascular disease.
   
   In addition to these risks, when the alarm system is triggered, your blood pressure and heart rate are increased, and blood vessels are constricted because of an increase in epinephrine. The oxygen-enriched blood going to the brain increases initially because of the increased respiration and heart rate because of the 'fight or flight' reaction. Vast amounts of energy are available because the adrenals have caused a rapid release of glucose and fatty acids into your bloodstream. In addition, your senses become more acute, with your pupils dilating to give you greater peripheral vision. Your sense of smell becomes highly acute, and, initially, even your ability to think and your memory are vastly improved. You also become less sensitive to pain.
   
   The best way to turn off the body's alarm system is by physical activity. Physical activity burns up the excess glucose and adrenaline, and, in fact, helps metabolize it back to normal levels. However, if there is no physical activity, as in this case, being stuck in an elevator, the high glucose levels lead to an increase in insulin. If glucose levels are increased for a long period of time, it can decrease brain glucose, causing agitation. The high insulin levels cause a decrease in the removal of amyloid proteins from the brain-and, as I've said, increased amyloid proteins in the brain is a key sign of Alzheimer's disease.
2. Control
   
   When you feel like you have no control, emotional excitement, which is positive, turns into anxiety, which is negative. There is a very fine line between the two conditions. It is similar to the fence that separates you from a caged tiger at the zoo. The same animal 10 feet from where you are standing is simply an object of curiosity when there is a protective barrier. The moment that barrier is removed, the tiger now becomes a threat. Being in control is similar to that protective barrier. It is when the sense of control is lost, and you feel helpless, that anxiety and subsequent health problems can occur.
3. Coping Style.
   
   Coping style is another psychological variable that can influence your health. For example, I know several emergency room doctors who spend hours each day dealing with horrific tragedies and making life-death decisions for people they've never even met before. Yet, in the midst of that incredibly stressful environment, they function admirably and are in excellent mental and physical health. The stress does not get them down. I also have dear friends who've made their fortune, retired early, and have nothing more to do each day than to sit in a chair and wonder 'if and when' their children will come to visit them. Ironically, these people have the most difficulty coping with life's stressors.
   
   Animal studies have clearly shown that some people can actually develop coping mechanisms that can function even when they feel they have no control. An example of one such study used rats in a cage. When the rats were shocked, their cortisol levels increased and continued to remain high as long as the rats perceived they had no control. However, once the rats were given a lever to push that would prevent the shock, their cortisol levels returned to normal or diminished.
   
   This study showed that even when the lever was no longer preventing the shocks, the rats 'thought' that they were being protected, and so the cortisol levels did not elevate as much as they had initially. The researchers concluded that the same outcome might be true with human beings.
4. Personality Type
   
   Finally, personality types can have a profound impact upon susceptibility to illness. I mentioned that Dr. Marks was a Type 'Triple A' personality. You have probably heard of the Type A personality where individuals are quite literally slaves to the clock. They are always in a hurry and seldom take time out to enjoy life. They are time-oriented and frequently speak with a very rapid rate of speech, finishing the sentences of those they are speaking to, as they grow impatient. This is in marked contrast to the Type B personality who is quite simply a non-Type A. The latter individual gets the work done, but they also take time out to enjoy the journey of life.
   
   While this is a useful way to categorize people, it might be more accurate to think of 'personalities' as coping styles that enable people to deal with problems in their immediate environment. These are just a few of the many factors that can affect both hormonal balance and the immune system, especially the way that they respond to stressors.
5. Life Balance
   
   Another way I have patients manage stress is to evaluate their life balance. In other words is your life stable or lopsided? An unbalanced life is a major cause of stress for most baby boomers. I give my patients the life balance test. I ask them to consider 8 catagories and rate them from 1 to 10. One being they are very deficient, 10 being they feel very good about that category, 5 being they believe it is adequate. A life balance rating of 5 to 10 is considered a good rating; less than 5 is a deficiency.

I ask how do you feel about your . . .

1. Diet
2. Exercise
3. Spiritual Life
4. Sex Life
5. Social Life
6. Job or Occupation
7. Marriage or significant other
8. Sleep

After they have rated these 1-10, I ask how much time do you devote to each. This is often a reality check when some find that 90% of their time is spent at work and there is no time for anything else, I advise anything under 5 needs work. A perfect 10 on everything is a sure sign of an unrealistic person with a problem, like Dr. Marks. A patient who scores less than 5 on four or more of the life balance signs is in danger of chronic stress.

Preventing Alzheimer's with Rest and Recovery: Finding Your Circle of Quiet

Both rest and recovery are crucial to balancing the body's hormonal symphony. By rest, I mean getting quality sleep every night. Making an effort to relax your body and to get in bed early enough to get 7 to 8 hours of sleep. By recovery, I mean the ability to place the body in a state where the adrenaline sympathetic nervous system is lowered and the vagal, or relaxation, nervous system is increased.

There are many tools you can use for recovery, including the relaxation response, deep abdominal breathing, listening to music, mediation, prayer, yoga, and saying the Rosary, using prayer beads, among others. In each of these relaxation remedies, you stimulate the frontal inferior temporal gyrus, the 'optimistic' center of the brain. During recovery, your blood pressure and pulse decrease, your skin warms, and your muscles relax. Using relaxation techniques frequently throughout the day for recovery helps to increase dopamine and serotonin levels, which, in turn, enable you to sleep deeper and longer. We've seen the results of relaxation techniques repeatedly in the Buddhist monks who can stay alert for 24 hours at a time and continue to function normally.

In one important meditation study performed at the University of Wisconsin, researchers were able to show changes in the brain using a functional MRI (FMRI) when different groups of people meditated. For instance, when the veteran Monks meditated, the FMRI showed a large area of the frontal temporal optimistic lobe light up. Laboratory results indicated that dopamine and serotonin levels were also high at this time. When the novice Monks meditated, they did not have the same level of the brain light up; however, the FMRI indicated there was more activity than normal in this brain area. When normal college students meditated, the FMRI showed small areas light up on the scan. Researchers determined that by constant reinforcement (continuing to meditate frequently every day), the pathways for this optimistic center of the brain are increased to all areas of the frontal lobe and they can be turned on more easily. With meditation, the pessimistic center of the brain is suppressed, so negative thoughts are diminished.

I believe this is also why those individuals who pray or meditate daily have the lowest incidence of Alzheimer's disease and also increased cardiovascular health-as they have less anxiety uncontrolled stress and consequently lower levels of cortisol and insulin in the body and brain. With higher levels of dopamine and serotonin in the body, we don't procrastinate and resolve inner self-conflicts, which controls our alarm reaction. Because we feel good and in control, we can rest calmly and get deeper sleep. We do not escape to addictive food, carb cravings, or binge on alcohol or drugs that artificially calm us or stimulate dopamine pathways and lead us to deplete the supplies of serotonin and dopamine.

Strategies to Increase Rest and Recovery

Let the following suggestions help you find your circle of quiet as you increase rest and recovery and regain control of your emotional state.

1. Identify and Eliminate Stressors
   
   To reduce stressors, you must identify the major stressors in your life such as problems with money and relationships, grief, and deadlines. If you can't resolve these stressors alone, get professional help for problems that seem too difficult to handle.
   
   Also, never hesitate to say 'no' before you feel overextended with too many commitments. Respond instead by saying, 'Let me think about it.' Or, say, 'Let me get back to you.' Especially if you are balancing a career, along with raising kids and other volunteer commitments, you should not feel guilty about prioritizing what is humanly possible. Take time weekly to evaluate your commitments and only do those that are most important, saying 'no' to the remaining tasks. Saying no, when appropriate, can bring your stress to a manageable level and give you some control over your life.
   
   Realize that it's okay to be 'good enough.' When the pressure cooker of life begins to explode, remember that you are one person. We can do the best possible or be "good enough," but we also have to also realize our humanness and allow for this.
2. Talk It Out
   
   Talk to a friend, family member, mental health counselor, your pastor, priest or rabbi, if your stress level is too high. Getting your feelings out without being judged is crucial to good mental health. As a rule of thumb, psychological counseling can help you to develop coping skills, so life's stressors do not overwhelm you.
3. Take Time Out
   
   Before you reach your breaking point from life's unending stressors, take a time-out for solitude. Being alone does not mean feeling lonely, for we can feel lonely in the midst of a crowd or even sitting with our family and friends. Being alone can help you find your circle of quiet in life-that inner place that brings you meaning in life. Take time to nurture yourself away from the cares and responsibilities of the world and find time for inner strength and mind, body, and spiritual healing.
4. Rekindle Your Spiritual Side or Religious Beliefs
   
   There are hosts of studies showing that people who focus on spirituality or attend religious services are better able to handle life stressors and less likely to get Alzheimer's disease. Religion can give a sense of purpose and feelings of hope, even when life seems hopeless. Religious involvement also provides good social support essential for well-being, and encourages a more compassionate, forgiving world. Findings show that when we feel contented, supported, and forgiven, levels of cortisol are lowered in the body.
   
   Volunteering to help others through your religious organizations or community benevolent groups is yet another way to rekindle spirituality and feel more connected to God or a higher power as you stop dwelling on your own problems and focus on giving to others.
   
   Prayer and spirituality proclaim forgiveness, which is associated with an essential equation that is not directed by any neurotransmitter. It is a decision that helps to make us civilized; that is, the ability to help others and have compassion rather than barbarism when the strong take advantage of the weak. A study in Michigan showed a 30 percent decrease in mortality in those who learn to forgive. Physiologically, forgiving turns off the right inferior temporal lobe pessimistic center and turns on the optimistic center, triggering dopamine and serotonin, which in turn stimulate our anabolic hormones, putting our symphony in back in perfect harmony.
5. Strengthen Your Social Support
   
   Connections to a partner, family, friends, or a support group have been shown to improve mood and ability to cope and can even strengthen your immune system. Most people who are able to cope with stress have strong social support networks with family, friends, and even pets.
   
   A strong social network also has an impact on Alzheimer's. Studies have found that people with active social networks are less likely to develop the disease. In a 2006 study, researchers examined the brains of people with Alzheimer's who had recently died with the characteristic plaques and tangles of distorted protein. The researchers also had data on cognitive symptoms and how sociable the individuals had had been during their lives. Researchers concluded that even among those with extensive plaques and tangles, Alzheimer's symptoms were less severe if the people had many friends.
6. Learn to Meditate
   
   Brain scans have revealed that meditation, a highly active mental state, produces a mental condition somewhat similar to non-REM sleep (which many specialists believe is the more mentally restorative sleep phase). This is believed to occur because the many neurons of the cortex fire in harmony during meditation. Unlike sleep, consciousness is fully maintained in meditation, so there is no grogginess upon awakening. In addition, meditation has been found to surpass all forms of relaxation therapies at lowering blood pressure, as reported in the journal Hypertension.
   
   With meditation, you focus your mind on one thought, phrase or prayer for a certain period of time. You pay complete attention to what is happening in the present moment without being distracted by what has already happened or what might happen. When you do this, it leads to the relaxation response, a physiological state that helps to decrease heart rate, blood pressure, respiratory rate, and muscle tension. Meditation also decreases hormones such as cortisol and adrenaline, which are released during the 'fight or flight' response.
   
   Meditation can guide you beyond the negative thoughts and agitations of the busy mind and allow you to become "unstuck" from your fear and other disturbing emotions. Once you've learned how to meditate effectively, you can switch into this relaxation state at will-before stressors cause to be overwhelmed.
   
   How to Meditate
   
   There are two types of meditation, one passive or centering meditation, the other active or process meditation. The first clears the mind, the other controls the optimistic process.
   
   Allow 15 to 20 minutes a day to see benefits.
   1. Sit in a comfortable chair in a quiet room. Make sure there are no distractions. Close your eyes as you begin to meditate.
   2. In 'centering' meditation, you focus your attention on the repetition of a word, sound, phrase or prayer, doing this silently or whispering. An alternative is to focus on the sensation of each breath as it moves in and out of your body.
   3. Every time you notice that your attention has wandered (which will occur naturally), gently redirect it back, without judging yourself. If you continue to practice this, you will learn how to do it correctly.
   4. In 'process' meditation, you listen to an inner voice that frees them to view the good things that happened that day and let go of those experiences that were negative. Others find they are able to plan and prioritize their future by listening to an inner voice.
7. Practice Relaxation
   
   Relaxation helps to increase the body's morphine-like pain relievers -- endorphins and enkephalins -- which are associated with a happy, positive feeling. Relaxation therapy may also improve your quality of sleep. One small study of several different relaxation procedures found a 42 percent improvement in self-reported sleep complaints after one year of relaxation therapy.
   
   The relaxation response is a physical state of deep rest that changes the physical and emotional responses to stress. This physiological state is inborn in all of us and can occur at times when you are not aware of it.
   
   How to Relax
   
   Set aside a period of about 20 minutes that you can devote to relaxation practice. Remove outside distractions that can disrupt your concentration.
   1. Lie flat on a bed or floor, or recline comfortably so that your whole body is supported, relieving as much tension in your muscles as you can.
   2. During the 20-minute period, remain as still as possible; focus your thoughts on the immediate moment, and eliminate any outside worries, which may compete for your attention.
   3. As you go through these steps, in your own way try to imagine that every muscle in your body is now becoming loose, relaxed and free of any excess tension. Picture all of the muscles in your body beginning to unwind; imagine them beginning to go loose and limp.
   4. Concentrate on making your breathing even. As you exhale, picture your muscles becoming even more relaxed, as if you somehow breathe the tension away. At the end of 20 minutes, take a few moments to study and focus on the feelings and sensations you have been able to achieve. Notice whether areas that felt tight and tense at first now feel more loose and relaxed, and whether any areas of tension or tightness remain.
   
   
   I am often asked, 'How do you know when you are successfully meditating and relaxing?' During my years at the Institute of Living (Yale affiliated hospital) we studied bio-feedback that examines the body's physiological signs during the state of relaxation, including alpha brain waves, galvanic skin resistance, and hand temperature. We found that a certain percentage of people did not know when they were truly relaxed. However, by making these people aware of bodily signs that indicated a truly relaxed bodily state, they could determine when they were, in fact, relaxed.
   
   How will you know you're relaxed?
   1. Increased moisture in the mouth
   2. Warmth to the hands and feet
   3. A feeling of heaviness to the limbs, neck and lower back
   4. A warm tingling of the skin and a feeling of well-being, even euphoria, which means dopamine is working in the body.
8. Laugh More
   
   Norman Cousins was the first to promote laugher as an antidote to disease. While serving as editor of the Saturday Review, Cousins was diagnosed with a serious connective tissue disease. Although his doctors said that it was incurable, as Cousins shares in his book, Anatomy of an Illness as Perceived by the Patient, he was determined to get well. While bedridden, he watched funny movies and used laughter to create positive chemical changes in his body, which resulted in improved health.
   
   Learning to laugh more and worry less can give you great benefit with rest and recovery. During stressful times, rent some funny videos and watch these instead of the nightly news. You'll sleep better after a good laugh, which gives your entire mind and body a healing boost. An interesting Canadian study found that even looking forward to laugher-or anticipating fun-can help boost the immune system and reduce stress. In the study, researchers tested 16 men who all agreed that a certain video was humorous. Half of these men were told three days in advance that they'd watch this video. Those who knew this in advance began to experience biological changes immediately. Than when the men actually watched the video, levels of cortisol declined by 39 percent in their bodies. Levels of adrenaline also fell by a startling 70 percent and endorphin levels (the feel good hormone) rose 27 percent. Human growth hormone levels climbed 87 percent! A practical place to start is to examine the movies you watch. Do they stir up fright, provoke conflict or make you smile, laugh and give you hope and peace?
9. Exercise Daily.
   
   If you are a chronic worrier, I urge you to get up and start exercising more often-and regularly. A chronic worrier is someone who worries about every situation in life. You can block the effect worry has on your health, by doing something positive. Not only will exercise ease your emotional anxiety and reduce dangerous levels of cortisol, it will boost serotonin and dopamine and help to boost blood flow throughout your body, resulting in optimal health and healing for your immune system. I find that going for a walk after eating a meal allows me time to sort through my thoughts and relax.
10. Let Music Soothe Your Soul
    
    Studies show that listening to soothing music lowers blood pressure and boosts immune cell count while reducing levels of stress hormones. Avoid melodies that make you tense or that cause uneasiness. Spend 10 to 20 twenty minutes a day listening to music, and try this in combination with another relaxation technique such as deep abdominal breathing or while you're walking outdoors or on a treadmill.
    
    How to do Deep Abdominal Breathing
    1. Lie on your back in a quiet room with soft music playing in the background.
    2. Place your hands on your abdomen, and take in a slow, deliberate deep breath through your nostrils. If your hands are rising and your abdomen is expanding, then you are breathing correctly. If your hands do not rise, yet you see your chest rising, you are breathing incorrectly.
    3. Inhale to a count of five, pause for three seconds, and then exhale to a count of five. Start with 10 repetitions of this exercise, and then increase to 25, twice daily.
11. Get Healing Sleep
    
    If you have difficulty sleeping because of too much stress, consider the following sleep suggestions:
    • Meditate or pray right before bedtime to calm your mind and body.
    • Sleep only as much as you need to feel refreshed, but no more.
    • Avoid daytime napping, if you have trouble sleeping at night. However, you might try a brief 20-30 minute powernap (a siesta), which many people find refreshing, especially between 2:00 and 4:00 p.m. when your sleep hormones are peaking.
    • Wake-up at the same time every day, weekday or weekend. This strengthens your circadian cycle--our daily rhythmicity--and will help to establish regular sleep patterns.
    • Use earplugs, if you are bothered by noises while sleeping. Some people find that "white noise"--a machine that produces a humming sound or turning the radio to a station that has gone off-air--helps.
    • Reduce light, especially alarm clocks and television light especially if they flicker or pulse.
    • Avoid caffeine after 12:00 noon each day.
    • Avoid alcohol, as it produces a light, fragmented sleep.
    • If these therapies do not work, talk to your doctor. Sometimes non-habit forming sleep medications may be helpful in easing you to sleep.
12. Ask Your Doctor if You Might Need Medication
    
    On a side note, I believe that antidepressants such as the selective serotonin reuptake inhibitors (SSRIs) may decrease the chance of Alzheimer's, although no studies have shown conclusive evidence. The SSRIs elevate serotonin levels in the brain while also suppressing dopaminergic pathways, thus, helping to resolve problems with stress and sleep. If you have difficulty relaxing and trouble sleeping, an SSRI may help you sleep deeper and have clarity of mind. This, in turn, allows you to make better lifestyle choices and deal with stress in a much healthier manner. Personally, I believe that antidepressants are excellent medications to help reverse the two sentential risk factors, if patients are truly anxious or depressed and need this medication. Not all antidepressants facilitate sleep. So ask your doctor which is best.