Life Situations, Emotions, And Exercise Tolerance

Life Situations, Emotions, and Exercise Tolerance CHARLES H. DUNCAN, M.D., IAN P. STEVENSON, M.D., and HAROLD G. WOLFF, M.D.

O YMPTOMS of discomfort during exertion, such ^ as dyspnea and palpitations, are among the commonest complaints for which medical aid is sought. They are among the early and significant phenomena of structural heart disease. Wolf and Wolff (12) have shown that they may also arise from circulatory changes occurring as part of the reaction to stressful life situations. The distinction between these two origins of exercise intolerance is of the utmost importance in the management of any patient with this complaint. The present study was an investigation of the respective contributions of these two factors to the symptoms and signs in a group of patients who came to the hospital chiefly because of discomfort on exertion. The variations in the signs and symptoms produced by exercise were studied repeatedly during changing life situations and various emotional states. It was thereby hoped to evaluate the portion of the total impairment of function related to life stress.

Subjects and Methods Most of the subjects were patients from the clinics of the New York Hospital. They were selected because of the primacy among their complaints of such symptoms as palpitations, dyspnea, dizziness, and effort intolerance. Eleven had these complaints without evidence of structural heart disease and belonged to the group usually designated as neurocirculatory asthenia. Sixteen showed hypertension or evidence of various degrees of structural heart disease. Patients with rheumatic, arteriosclerotic, hypertensive, and congenital heart disease were included. For comparison with these groups and to extend the observations of Wolf and Wolff (12) a group of 8 healthy young hospital workers without complaints or evidence of cardiovascular disease were also studied. Of the 35 subjects, 26 were studied for from six to eighteen months and the others for shorter periods. Each of the patients was given a physical examination, a radiologic examination of the chest, an From the Departments of Medicine and Psychiatry of the Cornell Medical College and the New York Hospital, New York, N.Y. Received for publication, January 23, 1950.

electrocardiographic examination, and other indicated laboratory studies necessary to elucidate the physical state. As the patients were followed in the clinic a detailed psychiatric history was obtained from them in a series of interviews covering up to thirty hours. Inquiry was made at frequent intervals into the symptoms of the patient at rest and upon exertion, and these were related to the emotional state of the patient as judged by his own statements and the observations of the physicians. From time to time during their course in the clinic certain measurements of circulatory function were made on the patients before and after exercise. In most instances the following were measured: blood pressure, heart rate, and cardiac output. In a few instances heart rate only was measured. Blood pressure was taken by the auscultatory method. Cardiac output was measured on a low frequency, critically-damped ballistocardiograph (6) and stroke volume calculated by the formula of Nickerson (7). The cardiac output was referred to the body surface area for comparisons of one subject with another. The cardiac index thus obtained is the cardiac output in liters per minute per square meter. Mean blood pressure was obtained by adding one third of the pulse pressure to the diastolic pressure. Peripheral resistance was derived by dividing the cardiac index into the mean blood pressure. The exercise was in most instances the "two-step" test devised by Master (5), in which the subject ascends and descends two 9-inch steps for one and one-half minutes, the number of trips being adjusted to the age, sex, and weight of the subject. Most of the tests were done in the morning under basal conditions but a few were performed at other times of the day, not less than two hours after the last meal. Before the resting values were obtained the subjects rested in a reclining position for approximately twenty minutes. At the time of the test inquiry was made into the feeling states of the subjects and the occurrence of symptoms before and after the exercise. In addition to the observations made on different days, exercise tolerance was tested on several occasions before and after a rapid change in the emotional state occurring in a controlled, experimental setting. VOL. XIII, NO. 1

DUNCAN, ET AL. Standards of Reference of Cardiac Output and Exercise Tolerance. This study is primarily concerned with variations in the same individual at different times, rather than with the delineation of absolute normal and abnormal values. Because of a rather wide variation in basal cardiac outputs of healthy subjects found in this and other studies using the same method (8, 10), more importance is to be attached to variations in one individual from time to time than to deviations of that individual from the mean of a group. Thirty healthy young subjects tested under basal conditions were found to have a mean cardiac index of 3.1 with extremes of 1.7 and 4.7. Eighty per cent of the subjects gave values between 2.0 and 3.5. A significant difference was found in the cardiac indices of subjects who were completely relaxed compared to those who were poorly relaxed or under some slight psychic tension, the mean indices for these two groups being respectively 2.6 and 3.7 (11). Following the standard exercise the circulations of relaxed subjects rapidly returned to their resting states. The average heart rates of 18 relaxed subjects were 64 before and 65 two minutes after the exercise. The avearge stroke volume was 76 cc. before and 95 cc. two minutes after the exercise. The average cardiac index was 2.6 before and 3.4 two minutes after the exercise. In many cases at five minutes and in all cases at ten minutes the stroke volume had returned to the resting value ( n ) . There was a moderately wide range of values in this group. Therefore "impaired exercise tolerance" was defined as failure of the heart rate to return to within ten beats per minute of the resting value within two minutes, or, failure of the cardiac index to return to within 2.0 (liters/min/m 2 ) of the resting value within two minutes. As with the resting values more importance is to be attached to variations in the performance in one individual than to his deviation from the average of a group.

Results Although some variations were observed in the cardiac index and exercise tolerance during apparently comparable emotional states, these were of small degree. In every subject studied significant changes in the exercise tolerance were related to changes in the emotional state of the subject. A. Observations on Healthy Subjects Without Cardiovascular Symptoms The 8 normal subjects studied showed in general fewer emotional changes and less variation in exerJANUARY-FEBRUARY, 1951

37 cise tolerance than did the patients. In all, however, changes in exercise tolerance were found related to changes in the emotional state. On the days of impaired exercise tolerance the subjects were aware of mild psychic tensions and preoccupations which hindered complete relaxation. On such days the resting cardiac indices were higher than on the days of complete relaxation. The higher outputs were derived chiefly from increases in stroke volume rather than in heart rate, and in 4 subjects the resting heart rate was not higher on the day of poor relaxation than on the day of optimal relaxation. In general the subjects found the exercise more difficult on the days of poor relaxation than when they were optimally relaxed. The following 2 cases illustrate the changes observed. Case 1: The subject was a 21-year-old student and laboratory assistant who was studied seven times over a period of six months. He was a quiet, sensitive individual of linear habitus, not given to strenuous athletics but preferring a sedentary life. His chief satisfactions were obtained from reading, music, and good food. At the time of observation he had broken off his studies, but was making efforts to resume them and encountering considerable opposition to his plans. Blood pressure, heart rate, stroke volume, and cardiac index before and two minutes after standard exercise are shown in Fig. 1. On December 1, 1948, and February 28, 1949, the subject was aware of depression related to the protracted frustrations he was encountering in

II II II II II II II II llII ll II l l lII ll .1 II II l II II II II l l, 1 II

• •

II

T9

""<,_/

F E D CHEERPUL

PREOCCUPIED

Fig. 1.—Exercise Tolerance During Different Emotional States (Case 1). The measurements at rest (S) and after (2') the exercise are given. On the first and second tests when the subject was depressed cardiac output was low compared with the values on the fourth test when there was anxiety.

38

EXERCISE TOLERANCE

efforts to resume his studies. On these days the cardiac index (2.4 and 2.0 respectively) was low in the resting state but the exercise tolerance was normal. The day before the third test the subject made a deliberate effort to shield himself from persons or circumstances which might be disturbing to him. He spent most of the day in pleasurable and relaxing activities, slept well, and appeared in the laboratory the next morning (March 16, 1949) in good spirits. He felt that his objective had been accomplished and there was no depression. The resting cardiac index (2.7) was higher than on the preceding days. A little later the question of his return to college came to the fore and he was to have a decisive interview on this matter. The subject was studied again on April 1, 1949, four days before this interview when he was aware of tension and anxiety about the outcome. The resting cardiac index was 3.1 and CAROIAC^ INDEX after the exercise there was a delay in the return of stroke volume and cardiac output to the resting level. After the interview—which was unsatisfactory—the subject returned to some degree of depression with a 9/16/48 2/28/49 3/11/49,. 4/6/49 — 4/29/49 component of resentment, but no anxiety. The resting / \ RELAXED AND cardiac index was somewhat lower under these condiDEPRESSED RESENTFUL CHEERFUL tions (April 8, 1949). On the sixth test a week later Fig. 2.—Exercise Tolerance During Different Emotional (April 15, 1949) the subject felt more cheerful and States (Case 2). On the first day the subject was depressed there was less depression, but some preoccupation with and the cardiac outputs at rest (fl) and after exercise (2') his problems and difficulty in relaxing. He stated that were low compared with those on the second test which the exercise was more tiring than it had been on the was made during a period of resentment. Impairment of previous test. On the day of the seventh test (May 5, exercise tolerance on the second test was indicated by pro1949) the subject came to the laboratory feeling tired longed elevation of the stroke volume with normal return and somewhat tense. He had been out to dinner the of the heart rate to the resting value. night before and the evening had not gone well, for which he blamed himself and ruminated the events with whom he had once been close but from whom he with feelings of guilt and tension. Although the resting had recently felt alienated. The resting cardiac index cardiac index (2.2) was not as high as on some previous was 2.3 on this day. Several months later the subject occasions the heart rate was higher than usual and the entered a period in which, although working hard, he exercise tolerance was impaired in comparison to his thought that he was not making satisfactory progress. usual performance. He said he had difficulty relaxing He felt over-extended and in conflict over the demands after the exercise and that the exercise was more dif- of the two aspects of his work, neither of which lent itself to reduction at die time. On the morning of ficult than it had been on any other day. February 28, 1949, he awoke feeling somewhat irritable Case2: The subject was a 29-year-old physician. He and was aware of preoccupation with this problem. He was quiet and reserved in manner, but energetic and decided to reduce the amount of his work. On the way ambitious. Outwardly he was equable and displayed to the laboratory he encountered a member of his little emotion. He was absorbed in medical research department who informed him of a large number of work and also in the treatment of patients. He often items of work which he was expected to do that found himself in conflict over these responsibilities. morning. The subject felt that this person had no Apart from chronic bronchitis he enjoyed good health awareness of the load he was carrying and proceeded and was free of cardiovascular complaints. The cardiac to the laboratory in a mood of resentment where he index of this subject was measured seventeen times mulled over this problem arid relaxed poorly during throughout a year. The mean value of the cardiac the preliminary rest period. On this occasion the restindex was 3.1 and most of the values obtained were ing cardiac index was 3.9 and there was impairment within ± 0.4 of this figure. The two extreme values of exercise tolerance with delay in the return of the occurred on two days on which occurred emotional stroke volume to resting levels, although the heart rate states outside the usual range of this subject's feelings. had returned to the resting level at the end of two The circulatory dynamics before and after exercise on minutes. Two weeks later on March n , the subject these two days and on three others are given in Fig 2. came to the laboratory after sleeping poorly. He felt tired and relaxed fully while resting. He was in good On September 16, 1948, the subject was aware of spirits. The cardiac index (2.7) was somewhat low depression related to a disagreement with a friend VOL. XIII, NO. 1

ll II

.1

I ll

ll

• • l l .1 l l I I

DUNCAN, ET AL. although not as low as on September 16. On April 6 the subject was tested again. On this occasion there were no disturbing, circumstances or feeling states. The cardiac index was 3.2 (close to the average of the whole series which was 3.1) and the exercise tolerance was normal. On April 29, 1949, another test was made the day before the subject was to give a paper at a professional convention. Although the subject was aware of mild tension connected widi this event, life was going well with him at this time, he felt satisfied with the work he was to present and had no anxiety or feelings of frustration similar to those of February 28. Comment: All of the values of the cardiac index at rest in these two subjects (as in the others of this group) were within the range of normal values. Nevertheless a change in cardiac function was apparent in the variations of the cardiac index in each subject. In these variations a correlation was found between attitudes, feeling states, and the direction of the functional change. Situations evoking feelings of anxiety or anger with an attitude of preparedness were associated with increase in cardiac output. Less frequently observed were states of discouragement or despair in which cardiac output was depressed below the usual values for the particular subject. B. Observations on Subjects with Cardiovascular Complaints The observations of the preceding section confirm those of Wolf and Wolff (12) by demonstrating the occurrence of cardiovascular hyperactivity and inefficiency during stress associated with anxiety or resentment in healthy subjects. Circulatory inefficiency of this origin was observed in every one of the patients studied. In all of them marked fluctuations in the signs and symptoms accompanying exertion were related to changing life situations. In most of the patients the effort intolerance of which they complained was attributable not to the structural state of the heart (even when it was structurally diseased) but to chronic or repetitive psychic disturbances. Personality Patterns of Subjects Exhibiting Chronic Effort Intolerance Certain recurrent features of personality observed in these subjects were relevant to the occurrence of chronic cardiovascular mobilization. They gave evidence of long-standing anxiety, usually to be easily identified in childhood. Such anxiety was closely related to parental loss or rejection which occurred in one form or another in all of the subjects. Thus most had parents who were unusually JANUARY-FEBRUARY, 1951

39 and overtly hostile to them and in the remaining few one or both parents died when the patients were children. Most of the patients were strongly dependent with a deep need to please others—their parents, spouses, bosses, physicians, or others appointed by them to the role of protector. Hostility was prominent in most of them, but their dependency needs required the suppression of hostility. They experienced extreme difficulty in the expression of any feelings which might have been interpreted as aggressive or hostile. They were susceptible to slights, disfavors, or frustrations and exhibited strong retention of such incidents. A habit of ruminating these with inward accumulation of tension was observed in most of them. In all the dominant personality feature was a strong sensitivity to phychic stress. Their world was an insecure one full of emergencies. The psychic tension was paralleled by cardiovascular mobilization which, when'sufficently great, produced symptoms. The following patient illustrates these features which may also be found in the other illustrative case. Case j : A twenty-four year old housewife came to the New York Hospital with the complaint of palpitations which she had had for a year. Other symptoms were tightness in the throat, pain in the left chest, difficulty in breathing, and light-headedness. The symptoms came on more often when the patient was sitting than when she was active. Palpitations were particularly distressing after meals and during any stressful event or disturbing conversation. On Sundays when she was at home and relaxed she was much better. The patient was the youngest of three children in an immigrant Polish Jewish family. Her father was a butcher and her mother busied herself in his shop and spent little time with her children. The patient's older brother, eleven years her senior, largely took the place of her father of whom she saw little. Her brother was a driving, successful young man who by his example, and to some extent by direct expression, imposed high standards of performance on the patient. When her elder sister married, a large share of the housework fell to her lot and she did this under the direction of her brother. The patient became, like her brother, efficient and ambitious, but preoccupied with neatness and efficiency and disturbed by changes in her routine. She was sensitive to the opinions of others about her performance. At 18 she married a man who was amiable but intellectually inferior to her and lacking in initiative. She earned more money than he did. When she was 19 her father died of coronary disease. When she was 22 her mother, who had been unable to live harmoniously with her elder daughter, came to live with the patient. Her mother had diabetes and frequently neglected the care of herself, being in

EXERCISE TOLERANCE

4o

addition rather rigid in her habits and usually untidy. The patient found her mother's behavior increasingly irritating. However, she was deeply dependent on her mother and prided herself on tolerating her mother when her sister had been unable to do so. She was unable either to chastise or modify her mother. In this setting of conflict and anxiety palpitations began and continued until the patient came to the hospital one year later. Examination showed sinus tachycardia (heart rate 90) and warm moist palms. There was no evidence of structural heart disease. The electrocardiogram was normal as was the basal metabolism (minus 4 per cent). The patient's eyes were prominent and the lids widely opened. She expressed her feelings haltingly and with evident uneasiness about an entirely new experience. Her sensitivity was demonstrated by her statement that even the discussion of someone else's illness evoked palpitations in her. She complained of palpitations in the subway, but these were chiefly troublesome in the morning on the way to work, rarely in the evening after work.

B.2

B 2*

T

t1

SYMPTOMS SEVERE

DEATH OF MOTHER

B 2' A

BETTER

which her symptoms had given added anxiety. In the three months following the death of her mother the patient gradually improved and became free of symptoms. Exercise tolerance was then normal. The patient remained completely well for another seven months. At this time she arranged for her husband to obtain a job at her factory, intending to resign from her own job and have a baby. Her boss, who had obliged by giving her husband a job, hinted that he would discharge her husband if she left the company. The patient felt frustrated and tense, but was unable either to express her feelings to the boss or leave her job. In this setting she had a return of the former symptoms in milder degree. Although her resting pulse rate was only slightly higher than it had been, exercise tolerance was impaired and continued so for some months thereafter. Comment: It is apparent that during the relapse of this patient the resting heart rate offered no indication of the impaired cardiac function since it was little elevated from the previous rate. This

B 2'

f

GOOD DAY

B 2' A B 2' PRESSURE AT WORKNO I RETURN OF SYMPTOMS SYMPTOMS

¥'

Fig. 3.—Variations in Exercise Tolerance During Different Emotional States in Neurocirculatory Asthenia (Case 3). The measurements of the heart rate before (B) and after (2') a standard exercise test are given. Note that the resting heart rate was not significantly increased when exercise tolerance was impaired during the relapse.

At her first visit exercise tolerance (Fig. 3) was considerably impaired. As the patient was followed in the clinic successive tests of exercise tolerance were made. The second test was made a few days after the sudden death of the patient's mother to which she reacted with considerable guilt and depression. Although the resting heart rate was lower on this day the exercise tolerance was impaired more than on the previous day. During the interviews which followed the patient was able to talk more freely about her relations with her parents and brother. She gained some understanding of her emotional development and in addition was reassured concerning the condition of her heart about

observation, previously made by Wolf and Wolff (12), was repeated on other patients of this series. Furthermore, there may be a normal return of the heart rate to the resting level but abnormal persistence of elevated stroke volume after exercise during emotional disturbance, as in Case 2 (Fig. 2). Fluctuations in Circulatory Efficiency with Changing Life Situations Neurocirculatory asthenia is frequently spoken of as a chronic, fixed condition. Such an impression may arise from random observations made only VOL. XIII, NO. 1

DUNCAN, ET AL.

41

adulthood the patient was casual and irresponsible, sexually promiscuous and without goals. He was generally passive and lacked initiative at work. He became a steamfitter in his early twenties, but although he stayed in this trade for over twenty years he never became a master steamfitter, insisting that he was unequal to this responsibility and could not organize the work. In his middle thirties the patient became acquainted with a Protestant girl who had already been married twice and who was separated from her second husband. As their friendship increased they drifted into a common-law marriage and when the patient was 38 a child was born. As his "wife" was still undivorced the threat of social censure was added to the burden of his new responsibilities. Nevertheless he felt unequal to the commitment of a formal marriage even when his partner finally obtained a divorce. In this setting the patient had a number of acute respiratory infections, became impotent and began to have palpitations. These continued until he came to the clinic three years later. The patient's heart rate was invariably rapid during early visits, the highest rate recorded being 128. It slowed after ventilation and reassurance when it would Case 4: A 44-year-old steamfitter's helper came to the fall to between 80 and go. The blood pressure was hospital for the treatment of repeated episodes of pal- 160/IOO at the first visit but later fell to 120/80* pitations, which he had had for the previous three Physical, electrocardiographic, and radiologic examinayears. There was usually associated anxiety and muscle tions of the heart were entirely normal. tension, but there was no dyspnea. The patient was a timid, shy person who avoided

when the subject is under some stress, as in the army. However, frequent observations over a long time, made during periods of security as well as during periods of stress, show the condition to be rather changeable. Its apparent chronicity is due to the heightened sensitivity to stress mentioned in the preceding section, rather than to any rigid physical defect. In the subjects of this study it was found that when the stress of life abated or when through modified attitudes situations appeared less stressful, circulatory function correspondingly improved. In several patients two or more cycles of changing exercise tolerance were observed to be closely related to alterations in life situation and emotional state. During periods of remission exercise tolerance was in some instances entirely normal, in others still somewhat impaired, depending upon the degree of relaxation attained by the patients. The following patient illustrates the fluctuations in this condition associated with changes in the emotional state.

Fig. 4.—Fluctuations in the Response to Exercise in Neurodrculatory Asthenia (Case 4). The measurements of the heart rate before (B) and after (2' and f) a standard exercise are given. Several cycles of remissions and exacerbations may be seen closely related to changing life situations.

The patient was the second child of an Irish Catholic family in which there were seven siblings. In childhood and youth there was considerable rivalry between the patient and his elder brother. The patient was particularly close to his father, a fireman, who was killed accidentally when the patient was in his twenties. His mother died when he was 14. In youth and early JANUARY-FEBRUARY, 1951

the eyes of his interviewer and talked only with effort of his own feelings. Anxiety was always prominent and he was largely preoccupied with gloomy forebodings of the future. He was frightened about the condition of his heart. Expressed hostility was slight. He was dependent in his relationships with his wife and physician, on both of whom he leaned heavily in mak-

42

EXERCISE TOLERANCE

The cardiac output and other circulatory measureing decisions. Any strange situation such as an application for a new job or a temporary separation from his ments on this patient for 6 representative occasions wife threatened his security and evoked marked are given in Fig. 5. On April 7, 1948, (exercise not recorded) the patient was unusually anxious because anxiety and palpitations. This patient was studied over a period of eighteen of the presence in the room of another doctor, which months during which a series of therapeutic interviews he interpreted as a sign of the gravity of his illness. was undertaken and close attention was paid to the The cardiac index was 3.7, derived from a heart rate occurrence of symptoms and signs of effort intolerance. of 101 with a comparatively small stroke volume (70 Fig. 4 shows the variations in the heart rate before cc). On June 5, after changing jobs, the patient was cheerful and relaxed; the cardiac index (2.5) was and after a standard exercise test. Three cycles of improvement and exacerbation can be distinguished appreciably lower and exercise tolerance was normal. Three weeks later his wife announced the forthcoming with a general trend towards improvement. When the patient first visited the hospital (November vacations of herself and their daughter and the patient 12, 1947) he was still unmarried, but finally brought began to feel "jittery." On June 25 there was little himself to accept and welcome the formalization of change in cardiac output but the heart rate was higher his relationship with his common-law wife. After this and the stroke volume somewhat less than on June 5. event and the assurance of support at the hospital he Three weeks after this, on July 16, the patient's family entered a period of relative security and relaxation. had actually left and he had had a recurrence of anxiety Anxiety attacks and palpitations gradually diminished and palpitations. On this occasion the resting cardiac and exercise tolerance improved (December 5, 1947). index (4.6), stroke volume, and heart rate were all A little later he was paired with an uncongenial fellow increased and exercise tolerance was impaired. worker with whom he was unable to exchange hostilities for fear of losing his job. Symptoms of anxiety and palpitations once more increased and concomitantly exercise tolerance became impaired again (April 7, 1948). Later he obtained new work and improved once more with a complete disappearance of symptoms (June 5, 1948). Another relapse was associated with his wife's decision to go away for a vacation at a time when their daughter was also away. The patient felt rejected, insecure, and had further anxiety. Once again there was increase of the resting heart rate (June 25 and July 16) but palpitations did not return. After this the patient became unemployed again. His wife blamed him and they almost divorced. He continued to be symptom-free throughout this crisis which evoked in him more depression than anxiety. He was not studied during this critical period and when exercise tolerance was- again tested he was in a relatively relaxed state, having resumed satisfactory relations with his wife and regained employment. Although the resting heart rate '5' 0 2 5 was low on this occasion, (November 6, 1948) exercise tolerance was not normal, which result might have been due to the fact that the patient had been sedentary during unemployment or may have been associated with some anxiety about taking the test after a long Fig. 5.—Variations in Exercise Tolerance in Neurocirculainterval. Anxiety and impairment of exercise tolerance tory Asthenia (Case 4). The measurements are of cardiac recurred when he experienced further hostility from output during part of the period covered in Fig. 4. The a fellow worker (December 4, 1948). Not long after- measurements before (B) and after (2') and (5') the wards he again became unemployed, but to this again standard exercise are given. The maximal anxiety occurred reacted with more despair than anxiety. There was at the time of the first test (results after exercise not given). On this day heart rate was greater, but stroke volume less tome recurrence of palpitations but this symptom was than on the day of the fourth test when anxiety was somemild compared to its former severity, and accompanied what less. Note the depression of cardiac function during by relatively little impairment of exercise tolerance, and psychic depression at the fifth test. no complaints of palpitation on exertion. Still later Comment: The patient showed even greater exercise tolerance improved again as he became once more relaxed (March 19, 1949). The resting heart rate anxiety on April 7 than on July 16. On the former was 70, being 58 beats per minute slower than when he day the heart rate was more rapid but the stroke had first come to the hospital. volume and cardiac output actually less than on

Ill III III III ill ill

III

1 III

llll 1,11 ill ,1,11.. ill .1.1 1 ... 1

ill

1

VOL. XIII, NO. 1

DUNCAN, ET AL. July 16. A decreased stroke volume with a rapid heart rate during extreme anxiety was also observed in other patients. On December 18, the patient was unemployed, Christmas was approaching, and the prospects were gloomy. The patient had felt depressed and "down in the dumps" all week. The cardiac index before (1.6) and after exercise was lower on this occasion than on any other day. On January 26, 1949, the patient was still unemployed, but although somewhat depressed, he had no anxiety and entertained some hopes of employment. The heart rate was 67 and the increased cardiac output on this day compared to the previous one, was due to a higher stroke volume. Variations in Exercise Tolerance in Patients with Structural Heart Disease A similar close relationship between changes in exercise tolerance and in the emotional state was observed in the subjects with structural heart disease. They showed varying degrees of rheumatic, hypertensive, arteriosclerotic, or congenital heart disease. In these patients the impairment of exercise tolerance was a product of the structural damage and the emotional disturbance. When the former was great, mild degrees of the latter might precipitate symptoms or exacerbate existing ones. On the other hand, in subjects exhibiting the personality features described, impaired exercise tolerance occurred with moderate structural damage. With improvement in the life situation and emotional state of the subject exercise tolerance improved also, although some impairment—that due to the structural damage—often remained. The symptoms, however, were frequently associated solely with that layer of impairment related to life stress. The assessment of these patients was difficult because of the similarity of the symptoms and signs which they presented to those found in heart failure which might have been expected in them sooner or later. Frequently this important distinction could only be made by a careful study over a period of time during which the two components of the impaired exercise tolerance were dissected. The following two patients, for examples, both had advanced structural heart disease and symptoms of exercise intolerance which were found to be due not to the structural disease, but to cardiac hyperactivity related to life stresses. Case 5: A 32-year-old housewife of Italian extraction came to the clinic with the complaints of dyspnea, palpitations, pain in the back of the neck, and dizziness. The patient was the fifth of 6 children, the third of 3 daughters. Her delivery was difficult and she was JANUARY-FEBRUARY. 1951

43 described as blue and stuporous for two days. Her father was drunk at the time and when told of her birth said that he wanted a boy. Her childhood was passed in circumstances of poverty made worse by the frequent quarrels between her mother and father. Her mother was a hard-working, kindly, and rather timid person. She was completely dominated by her husband, who was strict, abusive, and often drunk. In childhood the patient had many illnesses. She was timid and backward socially at school. In her late teens she had her first date and a friendship developed rapidly until her father expressed his disapproval of her boy friend and she was obliged to drop him. A little later she became friendly with another man but this time met the opposition of his family. After a lengthy courtship she finally married this man only to find that he closely resembled her father. In addition her husband was dominated by his mother who remained cool towards the patient. Sexual relations were unsatisfactory. The patient became pregnant two years after her marriage. During the pregnancy her husband became neglectful" of her and her father became ill and finally an invalid. At prenatal physical examination the patient was found to have definite evidence of mitral stenosis and insufficiency. She was examined frequently and advised againt excessive exertion. At this time she first noted palpitations and dyspnea on exertion. Delivery was uneventful but the symptoms persisted as her marriage gradually deteriorated. Her husband stayed out late' at night and showed little interest in the patient, but insisted on her making ritualistic visits to his family. He spent little time with their boy but freely offered strict injunctions about his upbringing. The child became restless and anxious and soon was a serious disciplinary problem. She was quite unable to protest against her husband's behavior. Resentment against her father for siding with her husband accumulated and culminated in her wishing him dead. Not long after this her father did die and, as it happened, shordy after the patient had seen him without speaking to him. On the day of the funeral the patient had an acute anxiety attack with severe palpitations and dyspnea. She continued to have these symptoms episodically and they were joined by dizziness, pain in the left chest, and in the back of the neck. Palpitations and dyspnea were exacerbated by exertion but occurred, with the other symptoms, also at rest. She also had fears of dying and of insanity. The symptoms continued and became worse during the eight months following her father's death and finally brought her to the clinic. Physical examination revealed an enlarged heart with characteristic mumurs of mitral stenosis and insufficiency. The rhythm was regular and the blood pressure was 118/70. There was no evidence of congestive failure, or other physical abnormalities. An x-ray film of the chest confirmed the enlargement of the heart. The electrocardiogram was normal. The patient exhibited marked anxiety with dry mouth, cracked voice, many tense, restless movements',

EXERCISE TOLERANCE

44 and difficulty in expression of her feelings. She hesitated, stammered, and often blocked completely. Hostile feelings were largely hidden and rarely verbalized. The patient was troubled by a number of obsessive ideas, such as need to memorize license plates, and to read a newspaper completely; and by compulsive behavior, chiefly with respect to attendance at church and performance of house work. Upon the occasion of her first visit (November 3, 1948) exercise tolerance was tested. The test itself frightened her despite attempts at reassurance. She said afterwards she was afraid someone was going to anaesthetize her suddenly. At rest the heart rate was 100 and the cardiac index 4.6 (Fig. 6). Response to the 120

BL Sl ' 0 0

0 S 0 U D R E

80

60

II1 III ill III

100

III ill 1 1 si ° 1 Jl 1ill it: 1 ill ill 1 H

B

E

A

A T T

? eo

„

III

E

60

s v "°

9

:

c

E

70

1

7

8 2'J 1

FRIGHTENEO

B2'3'

MORE

Fig. 6.—Variations in Exercise Tolerance with Changes in Emotional State in Rheumatic Heart Disease. (Mitral Stenosis) (Case 5). The measurements before (£) and after (2') and ( / ) the standard exercise are given. The principal change accompanying relaxation was a decrease in the heart rate. Note some residual (asymptomatic) impairment of exercise tolerance during relaxation.

exercise was grossly abnormal. Three months later (February 9, 1949) she was again tested, having in the meantime visited the clinic once a week and there ventilated her feelings and discussed her problems. On this occasion the patient was more relaxed and had fewer symptoms. The resting heart rate was 90 and the cardiac index 3.8. Exercise tolerance was less impaired. Some weeks later the patient had a partial relapse and exacerbation of symptoms after a quarrel with her husband who had refused to take her out. When the patient was tested three days after this incident while still in this relapse (March 2, 1949) her

resting heart rate was 82, but there was an increase in stroke volume and the cardiac index was 3.9. Exercise tolerance was impaired compared to the previous test. Still later after further interviews the patient's symptoms left her completely, despite unchanged conditions at home. On April 27, 1949, the heart rate before exercise was 75 and the cardiac index 3.4. The patient performed the exercise with only slight dyspnea and there was further improvement in exercise tolerance. The remaining impairment was presumably that due to rheumatic heart disease. Case 6: A 24-year-old secretary of Italian extraction came to the clinic with the chief complaints of palpitations, dyspnea, and weakness which occurred at rest but more severely upon exertion. At times she felt pains in her left chest and in her legs. The symptoms had been present for two and a half years, had recently become worse and had resulted in a diminution in her physical activities. The patient's father was a humble butcher who worked hard but made little money. He was strict although devoted to his family. He was described as "very emotional" and was frequently in tears. Her mother was also kindly, but was a driving, perfectionistic, and hard-working woman and worked at a job herself to supplement the family income. The patient was the youngest of 5 siblings. When the patient was a few weeks old a heart murmur was discovered. Her mother reacted to this information by becoming overprotective to the patient. She frequently listened to the patient's heart by putting her ear to the chest wall. She restricted the patient's activities, telling her not to rollerskate or skip rope and giving other precautious advice. In childhood the patient was easily frightened and had some enuresis. On one occasion when she was 11 she stayed out late playing, was the object of a neighborhood hunt, and when found felt extremely guilty for the trouble she had caused. That night while feeling tense she masturbated for the first time. She continued to do this for some years thereafter but always with intense guilt and anxiety afterwards. She received no information on sexual activities from her parents. At school she did exceptionally well and graduated from high school at 15. Her first serious acquaintanceship with a boy ended in his jilting her; after this she was depressed and lonely for a year and withdrew from social activities. She went to college for two years and at first did well, but as her depression lifted and she increased her social activities, she neglected her studies. Realizing this too late, she began to study long hours and became unusually tired. At this time she became introspective about her heart, began to count her pulse, and wondered if she would die suddenly. In this setting her physical symptoms began. As they continued, she left college and rested at home. After some months of this program she felt better and returned to work. Then she underwent another disVOL. XIII, NO. 1

DUNCAN., ET AL. appointment with a man and had a return of symptoms which gradually increased in severity until her first visit to the clinic. In addition she became aware of feelings of anxiety and irritability. She found her home more crowded than it had been, although there had been little change in the membership. Her work became increasingly tedious. Physical examination of the patient showed a thin, active girl of less than average stature. The heart was found to be markedly enlarged to the left at the base. There was a forcible systolic thrust of the heart over all the precordium and a systolic thrill in the pulmonic area. Over the entire precordium there was a loud (Grade IV) systolic murmur and in the pulmonic area there was a somewhat less loud diastolic murmur. Both pulmonic sounds were much louder than the aortic sounds. The heart rate was 106 with a regular sinus rhythm. The blood pressure was 114/84. The palms were wet and the patient wore the facial aspect of anxiety. In other respects the physical examination revealed no abnormalities. The electrocardiogram showed right axis deviation with abnormally large P 2 and P 3 waves. X-ray of the chest and fluoroscopy showed enlargement of the pulmonary artery and angiocardiography revealed a patent ductus arteriosus without other abnormalities. The patient's anxiety permitted her to give her history only with great effort. She tried to unburden herself but was afraid of her own feelings, releasing them tentatively and slowly. She rarely expressed hostility. Exercise tolerance studies on this patient are given graphically in Fig. 7. The first test, in February, performed at the patient's first visit to the clinic, during marked anxiety showed a resting heart rate of 99 and cardiac index of 8.r. The response to exercise was so impaired that the values are not given for any period before seven minutes after exercise, which was the earliest that satisfactory measurements could be made. Throughout the next four months the patient came to the clinic on four other occasions and was tested on two of these. During this period she gradually became more relaxed as she discussed her emotional development, unburdened herself of guilt-laden thoughts such as those concerning masturbation, and received reassurance and explanations about her condition including the relative importance of congenital heart disease and emotional stress in producing her symptoms. She showed decreasing anxiety and symptoms and increased both her social and physical activities. In April, two months after her first test, the resting heart rate was 95 and the cardiac index 6.3. Two months later (June) the resting heart rate was 91 and the cardiac index again 6.3, and there was improvement in exercise tolerance. The patient then left the clinic, but returned for a follow-up visit six months later (December) and was tested again. At this time she was free of all symptoms except mild dyspnea on exertion; she could, however, climb two flights of stairs without discomfort. JANUARY-FEBRUARY, 1951

45 She was relaxed and cheerful and considered herself entirely well.• The resting heart rate was 88 and the cardiac index only 4.0. The exercise test was performed with noticeably less discomfort to her than on any pervious test. There was considerable further improvement, although some residual impairment, in exercise tolerance.

ll .1 .1

J

Jil •1 PROGRESSIVE

DECREASE

Fig. 7.—Variations in Exercise Tolerance with Changes in Emotional State in Congenital Heart Disease (Case 6). The subject had a patent ductus arteriosus. Values before (B) and after (7') the standard exercise are given. Note some residual (asymptomatic) impairment of exercise tolerance during relaxation.

Comment: In this patient and the preceding one (Case 5) some impairment of exercise tolerance persisted when the patients were relatively relaxed. This fraction of the original impairment of exercise tolerance might be ascribed to the structural heart disease. However, the disappearance of symptoms concomitantly with the achievement of a more equable emotional state indicates that the symptoms arose from that portion due to life stress. Rapid Variations in Exercise Tolerance The data of the preceding sections permit the inference of a relationship between certain emotional disturbances and changes in exercise tolerance. In order to validate this conclusion exercise tolerance was tested in a number of subjects before and after rapid changes in emotional state. These

46

EXERCISE TOLERANCE

changes were induced by offering the patient sug- The patient became pregnant and a son was born but gestions of relaxation, encouraging ventilation of was immediately rejected by her husband who found affect-laden material, or engaging the patient in a the confusion produced by the baby in the home updiscussion of his life situation. During these pro- setting to his routine of life. The patient felt the rejection cedures, which rarely lasted more than half an extended to her and in this setting symptoms first hour, the patient continued to lie on the ballisto- occurred. They continued intermittently during further cardiograph table. In five instances the procedure harassments from her husband who did little for their induced relaxation and abolished or diminished child, but frequently critized the patient's management of him. Through all diis the patient remained dependanxiety and these changes were associated with an ent upon her husband and sought to appease him by improvement in exercise tolerance. conforming to his inordinate demands. She said, "I The following patient exhibited the described per- would stand on my head to please that man." Yet she sonality features of this group. Her symptoms was unable to verbalize her resentment and said she occurred in a setting of anxiety and suppressed re- "bottled up" her feelings. sentment, which relationship was demonstrated by a Examination of die patient at her first visit revealed rapid, marked improvement in exercise tolerance sinus tachycardia widi a heart rate of 120. The blood following ventilation of resentment and relief from pressure was 140/84. She showed irregular blotches of flushing and dermographia. Her tense voice, jerky anxiety. speech, and resdess movements confirmed the extent Case 7: A 32-year-old housewife came to the clinic of the anxiety she expressed. with complaints of dizziness, palpitations, dyspnea, On her second visit she was taken to the laboratory and a tight sensation in her chest. These had been pres- and exercise tolerance was tested during marked ent for seven years but had recendy become worse. anxiety (Fig. 8). After recovery from the exercise the They came on in attacks which the patient could usually patient was engaged in a discussion of her relations relate to emotional disturbances. with her husband and a physician listened sympathetiThe patient's mother had died when she was an cally while she described his unkindness to her. infant and her only sibling, a brother, also died when Throughout this period her heart rate gradually deshe was young, so that she was raised alone by her creased as she became increasingly relaxed. At the end father towards whom she developed a strong attach- of the interview, tfiree quarters of an hour later, the ment and dependence. He died when she was 13 after patient was considerably more relaxed and the exercise which she lived with a grandfather and an aunt. From repeated. The heart rate and cardiac index after exerall these people she received attention and affection. cise were less, but the stroke volume greater than on In school and at work she maintained the high stand- the previous test. ards which she had set for herself. She married a man Comment: The observation of a greater stroke who appeared strong and supportive. Instead he turned out to be aggressive and preoccupied with material volume during relaxation than during anxiety was security. He was rigid in his habits and severely critical not uncommon among the entire group of patients of any lapses in the patient's routine of housekeeping. studied. Although stroke volume is usually aug-

Fig. 8—Rapid Variation in Exercise Tolerance in Neurocirculatory Asthenia (Case 7). Measurements before (B) and after (_j') the standard exercise are given. Following ventilation of resentment and ensuing relaxation, exercise tolerance markedly improved. Further improvement in exercise tolerance was shown some mondis later after further diminution in anxiety.

ll

ll

ll 1L1I B

3'

RELAXE0 INTERVIEW

/ENTILATIO AND

VOL. XIII, NO. 1

DUNCAN, ET AL. mented in anxiety the principal change is an, excessive tachycardia; at times the stroke volume during anxiety may be normal or even reduced. Relaxation is then associated with a reversal of this relationship and consequent improvement in cardiac efficiency. The patient continued to attend the clinic over the next six months and through discussions of her emotional development and present attitudes and feelings was enabled to become less dependent upon her husband and to assume more strength in the family. She began to take the initiative in decisions and her husband correspondingly began to need her more. Concomitantly anxiety diminished and symptoms lessened. When studied again four months after the first two tests she showed only slight anxiety. The exercise tolerance had improved still further. Shortly after this the patient's symptoms entirely disappeared and she was discharged.

47 250 220 190 BLOOD PRESSURE 130

HEART 65 RATE 55

.III

ll 1

III.

1

no STROKE 100 VOLUME 90 CARDIAC 4 INDEX 3

| 1

Such rapid improvements in exercise tolerance as that observed in the previous case were not due to the slight lowering of metabolism which might 40 have occurred during the period of rest between PERIPH. the exercise tests. With three patients the attempt 30 to induce relaxation was unsuccessful and no change RESIST. 20 in exercise tolerance occurred. With two others B 2' 5' 10' B 2' 5 10' the interview was provocative of increased anxiety RESENTFUL RELAXED and resentment rather than relaxation, and the INTERVIEW> second test showed further impairment of exercise tolerance. The following case is an example of such MRS. L.H. 1/14/49 a rapid change in exercise tolerance. Fig. 9.—Rapid Variation in Exercise Tolerance with Change Case 8: A 6l-year-old woman came to the New York Hospital over a period of several years for the treatment of mild diabetes and moderate arteriosclerotic and hypertensive heart disease. She had been active in work and social activities throughout most of her life. She had also been moderately prosperous but her resources had gradually declined and she was finally obliged to go "on relief." The patient attributed her financial destitution to her illness which prevented her from working but she made efforts to work from time to time and complained much that jobs were hard to get at her age. It was apparent that it was difficult for her to accept public aid and equally difficult for her to sacrifice the relative security which this offered. A test of exercise tolerance in this patient was made (Fig. 9) after which she was engaged in a conversation about her present situation. It was suggested to her that apart from financial considerations she would herself, feel better if occupied in some light work. At this the patient became irritated and, misinterpreting the remark as criticism of her acceptance of "relief," protested that she was quite unable to do any work and was not shirking. Her blood pressure rose from 205/95 to 250/110 and the cardiac index, although increased but slightly, was now achieved by JANUARY-FEBRUARY, 1951

.11.

1

ml

Ihl 1

in Emotional State (Case 8). The values before (B) and after (2', 5', and 10') the exercise are given. During an interview the patient became resentful and her blood pressure rose; exercise was then repeated. The second test showed impaired exercise tolerance as compared to the first, with a greater increase in the cardiac index and delay in its return to the resting level. an increased heart rate and a diminished stroke volume. Exercise tolerance was then again tested and found to be impaired as compared to the first test, with a greater rise in the cardiac index and a delay in the return to the resting value. T h e patient complained that the second exercise made her more fatigued and more dyspneac than the first one had done.

Relation of Symptoms to Signs of Impaired Exercise Tolerance As in the above case, there was in general a close correlation between the complaints of palpitations, dyspnea and dizziness on exertion and the degree of impaired exercise tolerance. Among the healthy subjects without complaints and during milder life stresses in which cardiac hyperactivity was less, the symptoms were fewer and their relationship to

EXERCISE TOLERANCE objective measurements less constant. The attention focused on the body also influenced the occurrence of symptoms so that these were complained of by some patients with intense bodily preoccupation during only mild physiologic disturbances. In a few patients, of whom Case 4 was one, exercise seemed to serve as a diversion and they sometimes sought relief in exertion even at times when their performance was grossly impaired objectively. The relationship between symptoms and signs of impaired exercise tolerance is further illustrated by the following patient in whom rapid emotional change was accompanied by marked alteration in the awareness of discomfort upon exertion.

BLOOD

120 PRESSURE

III

Ill

HEART RATE

1..

1,.

ll.

.ll

ll.

.ll

I.I

ll.

STROKE VOLUME

CARDIAC INDEX

PERIPH. ( RESIST.

RELAXED <

MRS. 0 . 8 .

TENSE INTERVIEW

^

5/26/48

Fig. 10.—Rapid Variation in Symptoms During Exercise with Change in Emotional State (Case 9). The measurements before (£) and after (2 and 4) die exercise are given. During an interview the patient became anxious and there was a rise in blood pressure. Exercise was repeated and accompanied by considerably greater discomfort (palpitations and chest constriction) than previously.

Case 9: A 48-year-old woman came to the clinic with the complaint of chest pain. She was found to have hypertension and moderate arteriosclerosis, The patient had been ambitious in her youth and planned a career in medicine. Financial difficulties obliged her to give this up and she transferred her

aspirations to her husband. He turned out to be passive and mediocre and failed to rise in the world as expected. She next focused attention on her two daughters. One of them developed a severe neurosis when 7 and required prolonged psychiatric treatment. The patient was well during this period but shortly after her daughter's recovery she began to have chest pain and was found to have hypertension. The possibility of a relapse in her daughter continued to occupy her conscious thoughts and dreams. Her other daughter in the meantime developed an attraction for a man who was, in the patient's opinion, too young and unsuitable for her. The patient's pride in her daughters was diluted by a fear that they would not fulfill her expectations of them. Exercise tolerance was tested before and after an interview in which she discussed these topics (Fig. 10). Initially the patient was moderately relaxed but during the interview her blood pressure rose from 142/88 to 158/128 as she became tense and anxious and the second exercise tolerance showed a delay in the return of the stroke volume and cardiac index to the resting values. The patient stated that she found the second exercise more of an effort than thefirstone. She felt more palpitations, more dizziness and more "shaky." A sense of constriction in the chest which bothered her slightly on the first test was more disturbing on the second one.

Discussion Cannon has shown that in animals emergency situations are met by bodily mobilization for defense (1). When stressful circumstances threaten humans, similar bodily changes occur although the stimulus may be symbolic and no physical activity is intended. In this mobilization increased activity of the cardiorespiratory system delivers blood to the skeletal muscles in which activity is expected. Moreover the sensitivity of the system to activity is increased so that mild exertion is associated with cardiovascular activity suitable for a much more strenuous effort. Symptoms of this over-activity are felt by the patient and a heart which is overworking is often accused of being unable to work. This pattern may occur transiently in healthy subjects during stressful life situations which evoke defensive attitudes and feeling states of anxiety or resentment. In certain individuals the emergency is perpetuated in their own attitudes and interpretations, and the pattern of cardiovascular mobilization becomes chronic or repetitive, and is then often called neurocirculatory asthenia. Repeated observations on patients with neurocirculatory asthenia indicate that this condition is relatively labile. Its apparent chronicity is derived not from a fixed physical state but from the psychic composition VOL. XIII, NO. 1

DUNCAN, ET AL.

49

of the subjects which makes them sensitive to life lar disease, patients with hypertension or various stresses. Whenever this sensitivity can be modified degrees of structural heart disease, and patients without evidence of structural heart disease but so may the physical state. Special considerations arise when individuals having complaints which place them in the group with structural cardiac defects react to stressful usually designated as neurocirculatory asthenia. life situations with cardiac hyperactivity. Com- Blood pressure, heart rate, stroke volume (balplaints of dyspnea, palpitations, weakness, or other listocardiograph) and cardiac index were deterdiscomfort on exertion in a patient with evidence mined in the resting state and at intervals of two, of structural heart disease are commonly attributed three, five, and ten minutes after a standard twosolely to the structural defect. That this conclusion step exercise (Master). is not always justified was shown in cases 5 and 6. A close correlation was found between the The respective contribution of structural disease and emotional state and the resting level of cardiac of life stress in the production of signs and symp- activity. Stressful life situations associated with toms of cardiac insufficiency can only be determined attitudes of preparedness and feelings of anxiety by the investigation of both, frequently over a or resentment were accompained by cardiac hyperperiod of time. Such an evaluation is essential in activity, with heart rate and/or cardiac index arriving at the correct prognosis and determining increased in comparison to the values found during the optimum treatment of the patient. A cardinal periods of security and relaxation. Situations evokfeature of the management of the individual with ing despair and discouragement were accompanied heart disease is the avoidance of a load greater than by cardiac hypoactivity, with heart rate and cardiac the heart can carry, and to this end some limitation index below the usual values. of physical activity is almost invariably invoked. A similar relationship was observed between the Of equal importance should be the attempt to emotional state and the circulatory response to minimize the load placed on the heart by cardio- exercise. During periods of anxiety and resentment vascular mobilization associated with anxiety and exercise usually resulted in greater and more proresentment incident to life stress. The increased longed increase in heart rate and/or cardiac index cardiac work of this origin may be not only as than did the same exercise performed during great as that imposed by the usual exertion of every- periods of security and relaxation. This objective day activity, but also much more prolonged, in evidence of exercise intolerance was commonly some individuals being habitual. accompanied by complaints of dyspnea, palpitations, The question of the long-term effects of the weakness, or other discomfort on exertion. During pattern of cardiovascular mobilization on the heart mild life stress the resting heart rate and cardiac must remain unai swered from this study. The index were sometimes unchanged but exercise toleroccurrence of delete ;ous effects is suggested by the ance impaired. frequent occurrence of arrhythmias among subjects The correlation between emotional state and showing tachycardia related to life stress and circulatory dynamics at rest and after exercise was anxiety (2, 3, 9). Such arrhythmias are found most observed in all three groups of subjects. In the frequently in subjects with hearts already structur- healthy controls the fluctuations in emotional state ally damaged but they occur in structurally normal and in circulatory dynamics were relatively small, hearts when the stress is prolonged (2, 9). Their and symptoms of effort intolerance minimal. The occurrence indicates an altered cardiac irritability, patients with neurocirculatory asthenia exhibited presumably related to the increased work of the greater variability in emotional state and in cardiac heart. That such stresses may lead eventually to activity, and the association of pronounced anxiety, irreversible damage is suggested by the higher cardiac hyperactivity at rest, and exercise intolerincidence of the later development of structural ance was frequently observed. In the subjects with heart disease in subjects with persistent tachycardia structural heart disease effort intolerance was the than in those without this sign (4). product of the fixed structural defect and the variable influence of life stress. In all patients, both with and without structural Summary and Conclusions heart disease, who presented complaints of exercise In 35 subjects the circulatory dynamics at rest intolerance a significant portion of the symptomatoland after exercise were studied during different ogy was dependent on anxiety, resentment, and emotional states. Included in the study were con- cardiac hyperactivity incident to stressful life situatrols without complaints or evidence of cardiovascu- tions. With the achievement of a state of relative JANUARY-FEBRUARY, 1951

50

EXERCISE

security a n d relaxation there was diminution in the cardiac activity at rest and improvement in exercise ,

TOLERANCE

standard tables for normal individuals. Am. J. M. Sc. 1 " :223> *9296. NICKERSON, J. L., and CURTIS, H. J.: The design of the

tolerance.

ballistocardiograph. Am. J. Physiol. 142:r, 1944. 7. NICKERSON, J. L., WARREN, J. V., and BRANNON, E. S.:

Bibliography 1. CANNON, W. B.: Bodily Changes in Pain, Hunger, Fear and Rage (ed. 2). New York, D. Appleton & Co., 1929. 2. DUNCAN, C. H., STEVENSON, I., and RIPLEY, H. S.: Life

situations, emotions, and paroxysmal auricular arrhythm w . Psychosom. Med. 12:23, 1950. 3. FRIEDMAN, M.: Studies concerning the etiology and pathogenesis of neurocirculatory asthenia. III. The cardiovascular manifestations of neurocirculatory asthenia. Am. Heart J. 30:478, 1945. 4. LEVY, R. L., WHITEJ P. D., STROUD, W. D., and HILLMAN, C. C : Transient tachycardia: Prognostic significance alone and in association with transient hypertension. J.A.M.A. 129:585, 1945. 5. MASTER, A. M., and OPPENHEIMER, E. T.: A simple exercise tolerance test for circulatory efficiency with

The cardiac output in man: Studies with the low frequency, critically-damped ballistocardiograph and the method of right atrial catheterization. J. Clin. Investigation. 26:i, 1947. 8. NICKERSON., J. L.: Personal communication.

9. STEVENSON, I., DUNCAN, C. H., WOLF, S., RIPLEY, H. S., and WOLFF, H. G.: Life situations, emotions, and extrasystoles. Psychosom. Med. 11:257, 1949. 10. STEVENSON, I., and DUNCAN, C. H.: Unpublished data. 11. STEVENSON, I., DUNCAN, C. H., and WOLFF, H. G.: Circulatory dynamics before and after exercise in subjects with and without structural heart disease during anxiety and relaxation. J. Clin. Investigation 28:1534, 194912. WOLF, G. A., and WOLFF, H. G.: Studies on the nature of certain symptoms associated with cardiovascular disorders. Psychosom. Med. 8:293, 1946.

Bronislaw Malinowski Award In the interest of encouraging workers in the various fields of applied anthropology to report on their findings, an award has been established in honor of the late Bronislaw Malinowski, an original member of the Society for Applied Anthropology, and before his death, one of its strongest supporters. The donor of the award wishes to remain anonymous. The following' prizes will be awarded to the authors of the best papers submitted during the next seven months: Class A: FIRST PRIZE: $100.00. SECOND PRIZE: $50.00 Class B: SPECIAL STUDENT PRIZE: $50.00 For further information, write Miss Elizabeth Purcell, Executive Secretary, The Society for Applied Anthropology, 61 West 55th Street, New York 19, New York.

VOL. XIII, NO. 1