How hyper-stimulation of the hypothalamus relates to Chronic pain

This week in pathophysiology we are studying endocrine functions. More specifically, we are focusing upon which structures secrete particular hormones, what triggers the release, and how the hormone affects bodily function. With some hormones, a releasing hormone from the hypothalamus is necessary for their secretion to begin. These hormones travel through the blood stream to initiate the action of their target cells (structures).

These hormones regulate changes/challenges called stress responses. When exposed to repeated stress, these response mechanisms become depleted and reach levels of diminishing return, therefore rather than the restoration of normal function, damage results. The ways in which these organ systems can be affected are by way of: the Immune defense system, Cancer (tumor growth cells), Cardiovascular disorders, Metabolic disorders, GI disorders, Reproductive and sexual disorders, Respiratory disorders, Musculoskeletal disorders, Pain, and Sleep patterns.

A friend of mine has chronic pain associated with rheumatoid arthritis. Acute pain is considered adaptive and in response to specific trauma or tissue injury, whereas chronic pain lasts beyond 6 months, and is no longer just adaptive, and can influence other functioning. The cycle of stress, inflammatory response, and pain are evident. Her painful episodes trigger the hypothalamus to release epinephrine and norepinephrine via the sympathetic nervous system, which in turn initiates the secretion of releasing hormones that reach the pituitary and the pituitary gland secretes other hormones that travel to the inflamed tissues. Although each time we respond to stress or pain we don't normally think about the body's endocrine responses, its helpful to look back and take the time to consider the complexity of our mind and body connection.

Chronic stress and biologic responses

In the blog I posted yesterday reference was made to the first two stages of the general adaptation syndrome. The first being: Alarm (response of the body to stress--epinephrine release) and the second Resistance (adaptive responses to the stressor--appraisal and coping).

In instances where the stress is prolonged the body reaches the third stage of Exhaustion. Exhaustion refers to the inability of the body to maintain the adaptive responses needed to maintain functional equilibrium. Any condition of change or challenge that places tension/strain is considered stress, and when this interferes with normal functioning, illness and disease can result.

Recently I was able to interview a patient who had an autoimmune disease. That patient, when exposed to prolonged stress would exhibit signs of being in the exhaustion stage and would suffer inflammatory responses/flare ups as a result. The patient was able to effectively maintain optimal health when careful consideration was given to diet, sleep, and compliance to medications.

Stages of General adaptation syndrome

As noted on page 112 of our test, Hans Selye was among the first researchers to present the notion that the body's response to stress, which are healthy, when endured for extended periods of time can cause homeostatic imbalance and lead to illness and disease. Stress defined as a condition of change, strain, or disequilibrium has been found to affect both the body and mind through various interacting domains such as genetic or biologic response, behavior (coping), cognition, sociocultural values, and life events (environmental).

Theory suggests that the disequilibrium in any of the above mentioned domains will affect the other in some interconnected way. When chronic stress affects an individual to the point that they can not return to a normal individual range of balance between their five domains, it is likely that the body will naturally respond to maintain this equilibrium. An example of the biological response domain would be a direct surge of incoming sensory information.

One day this week it snowed, and the back roads I drive to class are often covered by shade. Several icy patches were left, even after the sun melted most of the snow. During my drive I was very cautious when I spotted icy patches ahead. A small truck that was directly in front of me hydroplaned on one of the patches and I had to compensate by carefully pumping my breaks. Aware of the epinephrine that my nervous system secreted rapidly and the surge of hormones secreted by my endocrine glands, I recognized this as the flight or fight response (biologic and cognitive). It was brief and necessary stress needed to adapt to the situation. Since it was brief, my body quickly adapted. It is understandable how continued responses without return to homeostasis could lead to chronic stress and illness.

Interpersonal verses Impersonal thoughts about death and dying

In this blog I'll continue to focus on the text reading from this week. In particular the section about the role of the health care provider in the process of their patients who may be facing death. Often patients and their families express discouragement and disappointment in the way their health care provider has notified them of terminal illnesses, their treatment during the progression of the disease, and even the actual transition to death itself.

There is a necessary balance that health care providers should maintain so that they are able to express to their patients and patents' families that they are connected to them personally, yet not so personally connected that their professional judgement is altered in any way. It is important to keep the focus on the needs of the patient and their family, so that they don't feel responsible for consoling the health care provider.

This concept is presented in the text as intrapersonal death over impersonal death. Impersonal death would be when a health care provider simply goes through the motions of reading a chart, making rounds, or visiting with the patient routinely without expressing or showing any degree of understanding or connection to the person as a whole. Often this is a coping mechanism, yet it is not best for those going through the stages of dying: denial, anger, bargaining, depression, acceptance. As noted on page 82, it is the truly gifted practitioners who is able to attain intrapersonal and impersonal balance when conveying emotional connection without compromising the needs of the patient or his/her own personal judgement.

Absence of grief

In many cultures the loss of a loved one is followed by a traditional ritual in which family members, friends, and other supportive circles recognize the death of the individual, celebrate their life, and with dignity, provide those close to the deceased with support. These rituals allow family and care givers to grieve without feeling that it is not socially acceptable or that something is pathologic if they don't immediately (within weeks) return to life as usual. Allowance of this process therefore promotes the natural progression of grieving and also through the various stages of mourning. If the process of grief is halted for whatever reason, it is possible that there will not be normal healing and return to optimal functioning. This can become pathologic if not addressed.

Just as customs vary among cultures, as do the end of life ceremonies/rituals. In the Italian/Catholic culture it is acceptable for a person to mourn the loss of a loved one by wearing black garments for one year. This is an indication to others that the person is to be respected and allowed to mourn in his/her own way without judgement from others. In addition the mourner is treated with kindness and compassion above and beyond the norm, without expectation of any return of favors such as meals, financial help, or household assistance during that entire year. It is also unlikely that the widower or widow will date or marry during that time. Mainland tradition has been altered by Americanism, however there are a number of decendents who carry on the tradition of their greatgrandparents and grandparents because they believe that the healing process is essential for optimal growth and health.

At the Hospice house a ritual is practiced with the passing of every one of their patients, which allows the family members to grieve and celebrate their loved one's life. Respect and dignity for the patient is of utmost importance. It begins when the lights of the entire living area are dimmed. All of the staff members; administrative, chaplain, and medical alike, accompany the lost person and their family members to the hurst with a candle lighting their journey. After their loved one is taken from the home, the staff presents them with a hand made prayer shawl and rosemary tied in a ribbon. The prayer shawls are knitted or crochetted by surviving cancer patients, family members of those lost to terminal disease, or others who want to contribute in some way. During the time of the knitting or crochette process the craftperson prays for the family members who might receive the prayer shawl. My sister is one such person. Last week I talked with her about the ritual and she has already begun a shawl and is going to continue making them in memory of our mom. Contributing to others who are experiencing grief or who are mourning will hopefully give back, in some way, what others did for us during our time of loss and will give them freedom to mourn and eventually regain joy again.

Grief and Mourning

The most recent focus of our reading covered the subjects of dying, death, and grief. In conjunction with my recent volunteer training at Hospice and the reading for this week, the focus of this blog will be the areas of grief and mourning. As the authors, Wedding and Stuber state, grief and mourning are natural emotional healing mechanisms (p. 85) that promote a return to normal living after a person experiences the loss of a loved one.

This section was of particular interest because I have just completed 11-1/2 hours of Hospice training for helping terminally ill patients and their families deal with the process of grief and mourning. Last night there were five volunteers who have each worked for Hospice for 20-35 years. Hoppice offers bereavement counseling to the care givers and families of their patients.Their accounts and memories of the patients that have touched them and who in turn they were blessed to have known, was moving beyond explanation with words. In line with our text the processes they described were the initial or acute grief and intense emotional distress, followed by the three stages of mourning that take place after the acute grief. The three stages of mourning as described by John Bowlby are: protest, despair and finally detachment.

The initial phase of protest is a normal, expected, and spontaneous reaction of disbelief. The second phase of despair is the realization that their loved one is indeed gone, which may lead to floating anxiety and depression. It is believed that this step is necessary for the stage that will lead to resolution of their loss. The final stage of mourning is a time when the mourner reorients his/her focus from the lost loved one to other people and activities until they reach a point of acceptance of the loss and resume normal function. Bowlby summarizes that the process usually takes from three to 12 months. As the experienced volunteers pointed out last night, this varies from person to person taking into account different situations. An example mentioned was one patient who lost her husband and son within a few hours of one another. When the families are able to witness and accept death as a normal part of life and the patient is treated with dignity and respect during their transition from life to death, the progression of grief and mourning can be very healthy, so much so that many have described it as a time of intense spirituality and closness with the patient and with God.

Middle years are not marked by illness

In a study done by Verbrugge (1986), the symptoms requiring rest, work absences, self-medication, M.D. office visits, or hospitalization were not higher when compared to the same variables in younger people. This finding is contrary to what many would expect (Wedding & Stuber, p. 54).

It is common for many people who are are approaching middle age or who are in the midst of these years to experience worry and concern due to the physical changes and possibility of physical decline they witness in themselves. The realization of eminent mortality faces this age group. As a provider it is necessary to understand and sympathize with patients who may be overly concerned or preoccupied with the changes in their appearance, bodily functions, and sensations. These concerns are normal and valid; a supportive and sympathetic provider can make a tremendous contribution to the progress their middle aged patients might make when they begin lifestyle modification programs to improve their newly diagnosed health problems.

Chronic illness often presents during this cycle of life, yet if it is managed successfully the middle aged person will better cope, tolerate, and accept the illness and undertake the adaptations necessary to maintain their self-image and satisfaction with life. This period is also a time of evaluation of personal worth, values, and new goals (career, relationships, and lifestyle change). The above mentioned study found that 78% of middle -aged women and 79% of middle-aged men noted their overall health as good or excellent.