Stressed out? Here's some more bad news

First it was said to cause heart attacks. Now it's cancer. Liz Hunt looks at the making of a modern disease

The link between breast cancer and stress reported this week by a team of British doctors and psychologists has significance beyond its clinical conclusion. Previous studies have hinted that major traumas such as bereavement, redundancy or divorce are associated with the disease but the latest evidence, published in the British Medical Journal today, is the most compelling to date.

This study obliges us to place stress at the core of mainstream medicine as a cause of ill-health. And it begs the question that if stress really does cause disease, what can doctors do about it?

Doctors do not like stress because it is difficult to treat. They prefer magic-bullet medicine, where a drug or operation will cure the disease or alleviate the symptoms. This has been a barrier for more than 50 years to their acceptance of stress as a potential trigger for a range of illnesses. Their patients, however, have recognised stress and its associated risks more readily.

Everyone has felt "stressed out" at sometime or other; it was the classic Eighties' disease. And when people are under stress they know, almost intuitively, that they are more vulnerable to coughs, colds, and other infections.

This may sound like common sense, but it is only with scientific evaluation that stress will be taken seriously. Cary Cooper, professor of organisational psychology at the University of Manchester Institute of Science and Technology, says: "Studies like the BMJ study can only help. What we have needed is a scientific approach to evaluating stress and, until recently, few doctors and psychologists have worked together on this."

An Austrian physiologist, Hans Selye, working in Montreal in the Thirties, is widely regarded as the father of modern stress research. He noted that adverse stress - physical or emotional stimuli including internal conflicts, significant life events or physical violence - were risk factors for a range of illnesses in certain patients. Dr Selye hypothesised in medical journals and lectures that these forms of stress disturbed the production of certain vital hormones in the body, resulting in pathological changes to some tissues.

His work attracted some attention from fellow doctors but it was not until the changes in working practice brought about by the Second World War that stress became more widely recognised as a subject worthy of research. Long hours and extra night shifts in munitions factories and the aircraft industry took their toll on people's health, reflected in absenteeism and behavioural changes such as increased drinking and smoking.

In the Fifties and Sixties, the rise in heart disease among men was identified and since they then made up the bulk of the workforce, it was suggested that stress - possibly related to new technologies in the office and modernisation of manufacturing industries - might be a contributory factor. "It was a gradual dawning that something was going on here and that stress could play a part," Professor Cooper says.

The real springboard for the emergence of stress as a modern disease was the work of two cardiologists in the late Sixties in San Francisco. Dr Meyer Friedman and Dr Ray Rosenman showed a direct relationship between what they termed "type A" behaviour (ambition, aggressiveness, competitiveness, hostility, restlessness etc) and heart disease. Their eight-year study of more than 3,000 men in California concluded that those who showed type A behaviour ran twice the normal risk of developing coronary heart disease. This was comparable to the risks associated with smoking and drinking.

Their study remains controversial, since several attempts to confirm the findings have failed to do so. However, it remains a landmark in stress research, and funding for further work by the growing number of interested psychologists and scientists was forthcoming as a result.

They set out to discover if stress played a role in the development of other diseases. They had their answer when, in the Seventies, scientists at Ohio State University showed that the immune system of animals subjected to stress was compromised, and that production of white blood cells, the T-cells, which fight disease, fell.

Since then a variety of studies - some good, some dubious - have linked stress to a series of major and minor illness: cancer, mouth ulcers, infertility, and post-viral fatigue syndrome. Dr Selye's hypothesis is now the accepted view: that when coping with stress the body responds by increased production of certain hormones such as adrenaline and cortisol, which affect heart rate, blood pressure and metabolism. However, at a certain level and under continued exposure to stress, these physiological changes affect a person's ability to cope, and possibly cause damage to vital organs. In some susceptible individuals, this may trigger disease.

Dr Tony David, a medical psychologist at the Institute of Psychiatry in London and one of the researchers involved in the new BMJ study, has postulated that treatments which directly affect the immune system, protecting it from the effects of stress, are a therapeutic option in stress-related illness. But this is many years away; hormonal treatments are another possibility, but again, too little is known about their role in disease development.

Preventive action against the bad effects of stress is, then, largely up to the individual, by learning how to reduce or manage their stress levels. GPs can help by referring patients to counsellors or therapists, but those who do are the exception rather than the rule.

Alternatively, Professor Cooper sees a growing role for employers in reducing stress. Changes in the workplace throughout the Eighties and Nineties have disrupted the lives of millions. The job for life has disappeared, replaced by insecurity and short-term contracts. In the short-term at least, occupational stress will be a growing problem, reflected in poor health and absenteeism. By reducing stress levels at work or helping people cope through access to counselling, employers will be getting more out of their employees while enabling them to manage stressful events outside work more effectively. The way forward may be through the workplace rather than the surgery.