It is not uncommon for people to experience some stress and anxiety following a diagnosis of TTS, and some of this may be due to lack of information about the condition and uncertainty about what to expect.
Some practical actions that you can take include:
The information on this page has been developed by Caron Curragh.
Following your Takotsubo incident, which may have been caused by either emotional or physical stress or no known cause, it is important that you understand what stress is, why it happens and what we can do to control or manage it. This web page is split into sections as listed below. You can click on any of these sections if you want to move to a particular section.
This section will help you understand what stress and the stress response are and their effects on the body, the concept of the stress curve and why it is important to decrease stress after heart failure by looking at what triggers stress.
This section will help you change from a stress response to a de-stress response by looking at different techniques that you can perform on your own such as breathing and relaxation techniques, exercise and mindfulness. It will also help you understand how the brain functions, STRESS 101, and the importance of support.
This is a listing of the articles and journals referred to in this area of the website to enable you to read the research behind these ideas.
The concept of stress is not always clearly determined and is frequently used to depict both the “stimulus” or causation of stress i.e. the stressors, and the “response” to the stressors both psychological and physiological. It is important, therefore, to distinguish between the challenging exposure (the stressor) and the physiological distress response. “Stress” can be thought of as any pressure or accumulation of pressures – physical or psychological – that is too great for a person to cope with adequately when demands exceed resources. The body’s response to some form of threat, fear, worry or anxiety, be it real or imagined, is called the “stress response”. This is a physiologic response of the body through information transduction of neurochemical changes and electrical impulses in the brain. Even though it is impossible to totally eliminate the “stressors” from our life (e.g. work, people, financial concerns, illness etc), we can learn to change our reaction to them and regulate our state of mind.
Whether the trigger for TTS was emotional, physical or had no obvious causation, the stress response would have been activated. To date, the pathophysiology of TTS is not understood but one of the hypotheses is that a high circulation of catecholamines (neurotransmitters and hormones produced by the adrenal glands as a reaction to stress) may play a central role. In fact, some TTS cases have been noted following the administration of epinephrine or dobutamine, thereby supporting this hypothesis.
It is well known that anxiety, worry and distress are common emotions after experiencing some form of heart failure or diagnosis of a heart issue. There may also be feelings of guilt, anger, sadness or confusion so it is important to remind yourself that these feelings are all normal and will likely ease with time. This common phenomenon has been well cited in clinical research, so understanding and gaining some insight into the mechanics of the stress response and how to employ stress circuit breakers will lead to improved psychological health, self-management and control leading to a healthier life.
Something important to be aware of is that not all stress is bad – it is a part of life. For success in our evolution as a species, the stress response was and remains a big part of our survival instinct. In pre-historic times, we needed to react instantly if a tiger thundered out of the undergrowth. If we had hung around wondering if this tiger was a Bengali tiger or a Sabre-tooth, we would have been dinner! To survive we had to react instantly and switch on the stress response which is also known as the sympathetic nervous system - the fight/flight or freeze mode. However, the problem with modern day life is that this system can remain switched on for too long.
In life, we need a certain amount of stress to get things achieved; it is a call for energy. Too low levels of stress lead to inactivity and boredom but equally too high levels lead to exhaustion, stress overload and, if maintained over longer periods of time, illness.
How we deal with stress as an individual is subjective and will therefore vary from person to person. For example, two people can be in the same car accident and both are uninjured. Person “A“ may just be shaken up for a few days whilst person ”B” goes on to cultivate long term stress from the incident. Some people may also have less physiological resilience to stress (e.g. from learned behaviour patterns) or there may be a physical factor present where the body is unable to cope with larger amounts of stress hormones. It is the same after TTS or any other illness, different people will react and cope in different ways.
We have evolved over the millennia to cope with acute stress and our stress levels rise because our brain is primarily about safety – the survival instinct. However, once the stressful incident has passed, we need to switch off this response and allow the stress hormones to return to a normal level to re-establish allostasis (the process of achieving equilibrium through fluctuating neuroendocrine responses to physical and psychological stress) and homeostasis (the synthesis of bodily functions that keeps the bodies internal environment stable).
Chronic, high stress can have detrimental effects not only on our health but also on cognitive functions. For example, when the “stressed” brain is dominant there is a low voltage in “working memory”, the prefrontal cortex, and a high voltage in the limbic and reptilian brain, the emotive, reactive part.
It is only in the last 50 years that scientists have sought to methodically examine and analyse the associations between the heart, brain and mind. It began in the 1970s with Friedman and Rosenman’s work into type A personality and behavioural style and now there is a clear recognition across diverse disciplines that the cardiovascular system and the mind are intimately interconnected. Research is showing that this is not only in an efferent direction i.e. the brain to the heart (primarily the medulla for regulating sympathetic and parasympathetic outflow to the heart, and the hypothalamus and cortex modifying cardiac responses to emotion and stress etc) but also in an afferent direction i.e. the heart sending signals up to the brain reaching areas such as the medulla, then onto hypothalamus, amygdala and thalamus thereby inserting an influence on it. Although still in its infancy, some very promising linkages are materialising.
Psychological stress and aspects of negative emotionality may trigger adverse cardiac changes by means of hyper-reactivity of the nervous system response that could plausibly relate to cardio-vascular disease vulnerability - for example, by heightened activation of the sympathetic nervous system as well as a decrease in vagal control. Anxiety may contribute to excessive arousal of the hypothalamic- pituitary-adrenal (HPA) axis, a subsystem in your body that is our central stress response, causing the sympathetic nervous system to generate catecholamines resulting in inflammation which in turn may damage the vascular endothelium. Anxiety is also thought to increase cardiovascular reactivity to stress leading to an elevated burden on the heart as a consequence of increased resting heart rate, baroreflex dysfunction (the baroreceptors help regulate short term blood pressure) and abnormal heart rhythms amongst other findings.
If you would like to read more about the HPA axis and how the stress response CLICK HERE.
Stress is a major cause of inflammation, even when there is no antigen i.e. nothing entered the body, but it is our thoughts that “infected” our body with an inflammatory response. Inflammation is traditionally thought of as a defence response activated by injury or infection. However, inflammation can also be induced in the absence of these, for example when homeostasis is disrupted due to the over-activation of the stress response. Oxidative stress (psychological stress promotes oxidative stress leading to damage) and inflammation are inextricably linked and play major roles in the onset and development of noncommunicable diseases (e.g. neurological diseases, diabetes or cardiovascular disease). Research has also shown that chronic stress and stress that occurs because of worry about an upcoming stressor may accelerate the accumulation of oxidative damage and increase the risk for disease. Therefore, by reacting differently to life’s stressors, we have the potential to protect our genes.
Chronic stress shortens the length of our chromosomes (our genes), which has potential implications for our life span. If you would like to know more about the science of how stress affects the heart, brain-heart interaction, health, and longevity, CLICK HERE.
With the inevitable stresses and demands that life can place on us sometimes, some people seek to find ways to bring more mental and emotional balance in their lives. We cannot stop life’s stressors from occurring, but we can change our attitude towards them. There are numerous different ways we can start to transform stress and learn how to better manage ourselves, bringing the mind, the brain and the body into alignment and in turn protecting our hearts. It is a case of finding which method or methods work best for you.
Listed below are some strategies and methods that you can use on your own but sometimes we may need to be referred to a form of specialist help, like a clinical psychologist or a psychiatrist, so please take your doctor’s advice if you have ongoing concerns. There are also different genres of psychotherapists or other therapists which you can contact independently for a referral; just do your research as to their credentials and training. Certain techniques may not be suitable for all individuals.
By adapting good health behaviours, we can help to regulate aversive, internal experiences such as stress, anxiety, negative mood states and help alleviate unwanted physical sensations.
The relaxation response is the antithesis to the stress response. It was coined by Professor Herbert Benson, a cardiologist and founder of the Harvard Mind/Body Institute and is defined as your personal ability to encourage your body to release hormones and brain signals that regulate those of the stress response. As Benson observed “when people evoke the relaxation response, you actually change, add to and alter the genes themselves”. It is instant and changes can be made in as little as three breaths and can be done anywhere, any time.
Research continues to show the benefits of breathing exercises and how correct breathing protocols can be used as a means to bring down over-active stress levels. How an individual is breathing can affect both anxiety and stress levels, impact cognition and effect variable heart rate (VHR). Breathing is the one autonomic function that you have control over. With each inhalation, there is a slight increase in the heart rate and with each exhalation a decrease. ‘Shallow breathing’ limits good use of the diaphragm and as a result the amount of oxygen supplied to the base of the lungs is decreased. This can result in a feeling of shortness of breath and anxiousness. Superficial, fast breathing activates the sympathetic nervous system (the fight/flight response) - as does breathing in through your mouth! By taking simple steps to change your breathing, you can shift smoothly into the parasympathetic nervous system (calm/relaxation response). When the sympathetic nervous system is over-active for too long, stress hormones, e.g. cortisol, are activated, whereas deep, slow breathing stimulates the vagus nerve putting a break on anxiety, releasing the calming hormones, e.g. GABA, which calms the center of the brain down. Deep breathing also encourages good balance between the incoming oxygen and the outgoing carbon dioxide.
Listen to Caron's audio on breathing exercise below:
Some basic pointers for good breathing:
When you have stress or anxiety in your life, one of the ways the body responds is with muscle tension either within a particular muscle group or throughout the body. Becoming aware of where you are holding this and using techniques to release the tension is conducive to bringing anxiety levels down and can be achieved in many ways.
If you suffer with panic attacks this exercise can have contraindications, as the feeling of letting go may bring on a fear response of losing control thereby creating anxiety.
Progressive muscle release exercises
Addition of guided imagery
Use of guided imagery will help change and install positive emotions into the limbic region of your brain. Research has shown that there is a chemical change of over 1,200 different biochemical responses in the brain that can help shift an individual from a sense of breaking down to building strength and resilience up again.
Relax in a comfortable position. Focus on your breathing and start to let your body soften and your mind become calm and quiet. Imagine a soothing scene or place, for example, a beach, mountains, a garden, somewhere that you feel safe and calm. It can be somewhere real or imagined, just use your power of imagination (see the scene as clearly as you can, the colours, imagine the sounds around you, the smells). Or think about a happy memory, someone that you love or feel good with and focus on those emotions.
There are many good guided imagery exercises available on audio apps or YouTube - find a voice and imagery that works for you or simply use your own. Use as many modalities as you can i.e. your sense of imagery (seeing as clearly as you can, like colour and texture of the sea) and sense of hearing (e.g. sounds of the waves). Obviously if you suffer with hay fever please don’t use a garden scene or if you have vertigo stay away from mountain tops etc!
Listen to Caron's audio relaxation exercise:
Primal man didn’t have to think about exercise! They just got it by the sheer need to survive: for example, hunting for food or moving to safer ground. In our modern times, exercise is seen as some form of “extra” thing to add into our day but there are benefits to any movement which is important to remember in the early days of TTS recovery. Even gentle walking around stimulates the anti-gravity muscles sending messages stimulating whole body metabolism as it’s saying “I’m alive“ and connectivity in the system is triggered off. Over time, reduced levels of cardiac related activity, especially physical exercise is likely to result in a further reduction of physical endurance and strength. The benefits of exercise on a physical level have long been established and more recently research has shown that exercise is considered necessary for maintaining “mental fitness” and reducing stress. Exercise is very important for healthy mitochondrial function and research has shown that sedentary people have shorter telomeres. It is not just simply about how much exercise you do and how you achieve it, but also linked to how much sitting you do. An important moderate activity is brisk walking and a gentle run 3 times a week is good if appropriate for you, but always check with your physician.
Virtually any form of exercise from the types we think of as typically cardiovascular (e.g. brisk walking, running and swimming) to yoga, Pilates and gentle walking when done with intention will act as a stress reducer. Endorphins – which are “the brain’s “feel-good” neurotransmitters - are produced; your overall health and sense of well-being are increased, and sleep is improved. It is important to choose something that you enjoy, something that inspires you so whether it be walking in a forest, swimming or playing golf, if you fully immerse yourself in the activity it focuses the mind and enables you to forget the irritations causing the anxiety. Choose what YOU want to do – if exercise is arbitrarily imposed by others it may prove dull, boring and even stressful! Even a little exercise can go a long way to reducing stress. After heart failure, it is extremely important to build up exercise levels in a careful and gradual manner of resuming physical activity as this will help recovery. For example, any activity in the home where you use your muscles and expend energy is important and there are endless possibilities where to start…….walking around the home, climbing stairs, light cleaning. Ideally you will be offered a cardiac rehabilitation program which will take into account a full medical assessment, offer a suitable graduated exercise program, education as well as psychological support.
*Whichever exercise genre you choose always set realistic goals. Consult with your doctor prior to commencing especially if you haven’t exercised for a while.
Much research is taking place on mindfulness and its efficacy on stress reduction and there have recently been a number of specific studies on mindfulness techniques and the cardiac population. There is mounting scientific evidence that mindfulness practice not only reduces stress but also builds an inner strength which is conducive to increasing resilience. You are better able to focus which helps quiet a “busy mind’ that may be prone to over-rumination or catastrophising about events real or imagined. By training your mind to become present in the moment, you learn not to get lost in past regrets or in worries about the future. It teaches the sympathetic nervous system to let go rather than running on fight/flight/freeze mode and this deep, internal relaxation of the nervous system fosters healing. Through functional magnetic resonance imaging (fMRI), scientists have verified that neural pathways in the brain are able to change through mindfulness meditation practice and the longer-term the practice, the more positive changes in the physical structure of the brain are observed.
Hypnosis is perhaps the oldest Western conception of psychotherapy and it is now incorporating some of the most recent understanding of the neuroscience of the brain. fMRI has mapped specific areas in the brain involved in hypnosis and a great deal has been learned about the neurophysiological underpinnings of hypnosis. When practiced, it can increase our ability to decrease anxiety, lower pain levels, improve mood and build up self-control, among other benefits. For example, when someone notices an increased heart rate or are over-worrying about something that in turn can trigger an even bigger stress response leading to a vicious cycle like a “snowball effect”. Research has shown that as well as clinical hypnosis and hypnotherapy, delivered by a practitioner, being useful methods of helping to reduce stress levels and increase better overall health, self-hypnosis has also been proven to be a salient treatment as it gives an enhanced control of the mind and in turn control over the body. The process of hypnosis involves firstly entering into a deep state of relaxation then by staying in a highly focused state of attention (like a telephoto lens zooming in) whilst dissociating from competing thoughts, one makes positive suggestions for the unconscious mind to accept. There are some possible risks with self-hypnosis, particularly if you have a history of dissociation,bipolar disorder or schizophrenia.
With both mindfulness and hypnosis, if you wish to use either on a more clinical level (e.g. for chronic pain reduction, depression, excessive anxiety levels), it is important to undertake instruction from a fully qualified practitioner preferably with the equivalent of post-graduate study in the discipline. Mindfulness especially, has become huge in the media and some individuals may set themselves up as teachers with little or no training.
Both mindfulness and hypnosis train you to be in control of your mind so that your mind doesn’t control you. All the above need regular practise - these small nudges help to make positive changes in the brain. Think of the brain changes occurring in micro-ways, even a few seconds of practise is rewiring and developing a more flexible vagal system.
To know that we can alter the way we think about and react to life’s stressors and to recognise that we don’t have to be stuck in negative thought patterns gives us a tremendous power and hope for the future. This rewiring of the brain is called neuroplasticity (see later) and takes place in the brain but is triggered by the mind. Psychologists have known for a long time that negative thought patterns travel the same neuronal pathway in the brain and over a period of time become stronger in their connectivity and faster with their transmission (i.e. the more we think about or ruminate on a negative thought, the more entrenched it become). Dr. Donald Hebb, neuropsychologist, coined a phrase “neurons that fire together, wire together“ (and of course, this goes for positive thoughts too!) So, we need to increase the neural network to be form pathways for the things we want to be in life, rather than those we don’t; concentrate on the positives rather than the negatives thereby creating new ways of behaviour. An example is the brain’s ability to create new patterns of learning in order to to reorganise itself. So, regular practise of all the above stimulates the brain to achieve the neuroplasticity.
You may like to watch the short video explaining about neuroplasticity and learning.
Neuroplasticity and learning explained
Connectivision - Digital technology teacher tips
Published on Feb 14, 2018
Having an awareness of what part of the brain you are utilising, can be beneficial for some people in understanding and turning around negative thought patterns, emotions and behaviours. A simplistic way of looking at the brain is having three interconnected levels.
The first level is the so called “reptilian or lizard brain”. This is our built-in safety system for survival – our fight/flight/freeze. It is hard-wired and controls the body’s vital functions without us even having to think about it e.g. regulating heartbeat, breathing and other vital organs.
The second level is the so-called “mammalian brain“ or limbic system which is responsible for generating our feelings. It records memories of behaviours that produced agreeable and disagreeable experiences and works with arousal - this is where the amygdala and hypothalamus are housed. It is sometimes referred to as the emotional brain.
The third and final level is the neo-cortex, our “smart brain” which is the CEO responsible for all higher-order conscious activity e.g. complex reasoning, language, organisation and regulating attention. It gives us the ability to pause before acting on impulse and can calm down the irritable limbic or brain stem areas. One thing to note is that even though the neo-cortex is more sophisticated than the limbic system, it can be easily be overridden as it is slower in its processing. Therefore, having an over-reactive amygdala can hijack the prefrontal cortex and be deleterious to good thinking patterns
Noting which part of the brain you are using can be helpful in a stressful situation:
Having good social relationships are known to have powerful effects on improving physical and mental health. If we feel socially isolated, we don’t feel safe; fear sets in and we don’t feel protected. After diagnosis of any medical condition, social support is known to play an important role in both recovery and future well-being - it provides both a protective effect and can help to buffer the negative effects of stress. Research has shown that cardiac patients who have social support generally have a better prognosis than patients who are lacking in social support. Studies have shown also that the availability of social support can help buffer the negative effects of a major stressful event (such as heart failure) and other life stressors that may be present. Research is proving how peer support groups have been shown to improve health outcomes, the mechanisms which explain this are multiple and in turn can make the individual more resilient to new stressors or coping with historical ones. Even just talking to others, who have been in a similar situation, sharing your experience and talking through any concerns, has been shown to bring stress levels down as you know you are not alone in what you have had and are experiencing. Evidence also shows that taking time to help others, to care about others or even a simple gesture of kindness is beneficial to improving one’s own health and mental well-being. It gives one a sense of purpose and satisfaction, helps to keep things in perspective, reduces stress, helps get rid of negative feelings and releases the neurochemicals of happiness: the pleasure hormones e.g. oxytocin, serotonin, GABA and dopamine.
Can you look at some of the stressors in your life with a different mind-set? Your belief systems, your expectations and inner dialogue all provoke the inner world - how you think is how you act. Learn to spot and understand unclear, unhelpful thinking. For example:
Imagine you are walking down a street and see a friend or colleague on the other side. You wave but your friend doesn’t respond and keeps on walking. What would you think? Would your internal dialogue be “oh well she/he probably didn’t see me”, or “I wonder if I have done something to upset them?” or “I hope they are ok, I will phone later to check“ or “Have I said something that may have offended them?“ or “they are avoiding me for some reason?” How you respond can have an immediate impact on your mood and, if you have a negative interpretation of the event, it can start a spiral of anxiety and worry when a moment earlier you may have felt fine.
Being aware of what your stressors are, and by acknowledging them rather than pushing them away is helpful for the brain. When we try to avoid them, if they are simply pushed away, they keep coming back up.
If you label an emotion – i.e. I feel angry, I feel hurt, I feel vulnerable - by identifying the emotion, the activity in the brain shifts from the amygdala (reactive) to the prefrontal cortex (deliberate thought). You can learn to step back you can give yourself time to assess the situation more clearly – giving a chance to shift an incorrect perception or attitude about a thought or event giving better options for dealing with the situation.Notice what your typical reactions are: just as physical skills such as driving, riding a bicycle, swimming become automatic through repetition so do mental and emotional behaviours and attitudes. Repeatedly thinking the same thoughts hardwires the neuronal connections and it can almost be like our internal guidance system has been damaged when the reactions are unfavourable. By noting this we can start pruning those unwanted pathways and create new healthy ones.
Begin to notice if you are inadvertently picking up stress from others, even in small ways. Sometimes we compromise ourselves to please others without realising and leave ourselves then rushing around to do what we need to do for ourselves – often leaving little or no time for utilising restorative activities for yourself so perhaps you need to learn to say no?
Do you see stress as something being done to you? There is a concept in psychology known as the locus of control which refers to the extent to which people feel that they have control over the events that influence their lives and is usually divided into two categories: internal and external. People with an external locus of control are more likely to believe that they are not in control of what happens in their lives, and more likely to be anxious whereas people with an internal locus of control usually have a stronger sense of self-efficacy and are more likely to take appropriate action to turn things around.
Are you stressed about something simply because you care? That shows a positive emotion and personal value behind your stress. For example, “I’m stressed about this because I care about” ……. Realising this can help you reframe the feeling about the stress - it might not go away but changes the emotion behind it.
Mind-set is important. At the start of your day how much are you looking forward to it? What are you looking forward to or what are you worried about?
Self-talk - the narratives we have with ourselves, not only during times of difficulty but on a daily basis, are perhaps the most important ones! Narrow narratives and negative self-talk keep us down and stop up from moving on and thriving. Start listening to what you say to yourself (often you wouldn’t say those things to a friend!) See the true story and know that sometimes our thoughts are not real.
What happens around the most stressful part of your day? Notice how do you consequently react – and have certain behaviour patterns become ingrained? Do you go to the old paradigm of worry and rumination which can lead to a downward spiral? If so, you need a tool to turn this around.
Consider writing a gratitude diary. Over the last two decades, scientists have discovered that the heart has its own independent nervous system which relays information back to the brain thus creating a two-way communication system - at least 40,000 neurons! These signals can affect many different areas e.g. the amygdala (the brain’s emotional processing centre), the thalamus and the cortex (where reasoning and learning occur). Thoughts and feelings of gratitude (or love, compassion, appreciation etc.) will reduce the activity of the sympathetic nervous system and increase the activity of the parasympathetic nervous system and reduce the production of cortisol. Even the simplest of events can have a profound effect e.g. being grateful for hearing the bird song, for the food you eat, and each breath that you take; they don’t have to be big things. We humans have a genetically programmed predisposition towards something called the negativity bias so it is easier to take note of the things that go wrong rather than right, to retain an insult hurled at us decades ago rather than remember kind words so noting small positive experiences can help tip the scale towards happiness and a less stressed life!
Consider the 80/20 law - do you spend 80% of your time worrying about 20% of your life? Do you share and talk about it or bottle it up?
Hopefully this section on stress will have given you some understanding of stress and the stress response, tools on how to better navigate your stress and ways to bring stress levels down. When you have a greater understanding of stress and realise that you have a conscious choice to change reaction and behaviour patterns, things can begin to move in the right direction. It is empowering learning how to go from feeling overwhelmed and out of control to underwhelmed and in control – thereby leading to a lowering of the burden of over activity of the stress hormones and increasing the activity of the restorative, positive hormones leading to better maintenance in overall health and keeping the body in a state of homeostatic equilibrium.
CLICK HERE for a list of resources used to develop this page.