Soc. Sci. Med. Vol. 15E, pp. 3 to 42 0271-5384/81/0201-0003502.00/0 Pergamon Press Ltd 1981. Printed in Great Brilain BIOLOGICAL BASIS OF STRESS-RELATED MORTALITY PETER STERLING and JOE EYER University of Pennsylvania, Philadelphia Abstract--lt is believed in primitive society that physical health depends on harmonious social relations and that sickness follows social disruption. The mortality patterns of adults in modern society support this view, but its biological basis is not widely appreciated. This essay reviews the mechanisms by which chronic psychological arousal produces chronic physiological arousal and, in turn, specific biological pathology. The brain sets for the body a broad pattern of physiological and metabolic activity and enforces it by control over the autonomic and endocrine systems. Under conditions of arousal the brain sets a pattern of catabolism, mobilizing all the mechanisms that produce energy for "coping" and suppressing the mechanisms that store energy or use it for growth, repair, and surveillance against pathogens. As part of this adaptive response the brain mobilizes cardiac, vascular, and renal mechanisms to raise blood pressure. When arousal is chronic, the high pressure causes damage which, in interaction with a variety of arousal-induced chemical changes, leads to endstage diseases such as coronary heart disease, stroke, and kidney disease. The biological causes of cancer and diabetes are not fully known but seem to be powerfully influenced by arousal-induced endocrine patterns. Treatment of arousal pathology at the end stages has been highly technological, of limited success, and very expensive. The leading alternative has been an attempt to prevent endstage disease by treating mild hypertension on a mass scale (23~0 million patients in U.S.) with potent drugs. As drugs block peripheral pressor mechanisms, the brain drives them to compensate and to require blocking by ad- ditional drugs. Over the decades of prophylaxis for which drugs are intended, their cumulative iatrogenic effects are likely to be serious. Psychosocial treatments for mild hypertension (including placebo, relax- ation techniques, and social support) appear to be quite effective. These treatments appear to work by reducing chronic arousal, and tend not to evoke compensatory or iatrogenic responses. The extraordi- nary sensitivity of the brain and the neuro-endocrine system to psychosocial intervention suggests that in modern, as in primitive society, these are the treatments that will prove safest and most effective. INTRODUCTION The Iroquois Indians were, in 17th Century America, a society of agriculturists and warriors. The men were brave, self-reliant, and uncomplaining even when sub- jected to physical torture. Although it was not permit- ted among them to express openly any weakness or dependence, the Iroquois did dream. Their dreams were of rage--often directed against the French, and of pleasure---of feasting, of being cared for by friends, of orgiastic sex. Such dreams were entirely acceptable, and, as one account puts it, "without shame they received the fruits of their dreams and their souls were satisfied" [1, 2]. It was understood by the Iroquois centuries before Freud that dreams are expressions of unconscious wishes. These were not, as the Victorians believed, statements of infantile conflict, but rather expressions of pressing adult needs. The dreams were publicly dis- cussed and interpreted, and it was for the community to fulfill the demands of the dream. The Iroquois believed that failure to respond to the dream and frus- tration of its expressed wishes would result in serious illness and death. "The community rallied round the dreamer with gifts and ritual. The dreamer was fed, he was danced over, he was rubbed with ashes, he was sung to, he was given valuable presents..." [2]. When someone had a hostile dream, he was helped by the community to act out the hostility---either in reality, if the hos- tility was directed outside the community---or sym- bolically if the object of anger was within the com- munity. When a sick person dreamed about another person, it was understood that he wanted a friend. In such cases therapy included giving a friend in a special ceremony, following which the two treated each other as kin in a life-long relationship. In short, the Iro- quois believed that disease could be prevented or cured by encouraging fierce warriors to be dependent, by helping members of the community to act out their fantasies, and by providing lonely people with friends. This view of disease as primarily a social phenom- enon, the result of an unfulfilled social or psychologi- cal need, is a very general one in primitive societies. It is also usual in such societies that an important part of therapy for existing disease involves restructuring social relationships to fulfill unmet needs. This may involve a relation between a "patient" and shaman or may, as in the Iroquois example, involve the whole community [3]. Only traces of this conception of disease and ther- apy as related to social interaction remain in modem society. It is acknowledged, of course, in the many forms of psychotherapy, and in the potent social in- teraction known as the "placebo effect". A placebo (L. "I shall please") is a pharmacologically inactive sub- stance that is frequently almost as effective therapeuti- cally as a pharmacologically active one. For example, a pl/~cebo relieves post-operative pain in 50~o of patients while a standard dose of morphine, one of