Stress Response Areas

Even 20 years ago, when my interest in psychosomatic disorders began to develop, I was disappointed by the lack of rationale and consensus on

1 =

hypophysis

2 =

hypothalamus

3 =

reticular formation

4 =

limbic system

5 =

thalamus

6 =

frontal lobe

7 =

vestibular projections of the cortex

8 =

auditory projections of the cortex

9 =

visual projections of the cortex

10 =

motor projections of the cortex

11 =

somatovisceral projections of the cortex

12 =

the main sympathetic ganglia: from superior

cervical ganglion (a) to lumbar ganglia (e)

Fig. 5.16 Representation of the CNS according to Durinyan. The thick dotted line circumscribes a very large functional area related to the pituitary-hypothalamic system and the reticular formation.

many of the above-reported points/areas. In particular, with a few exceptions, I could not find points which could be clearly defined as having an anxiolytic or antidepressant effect. I became aware, however, when systematically using a pressure-probe to examine patients with symptoms of possible psychosomatic origin, that the auricle presented a more or less constant sensitivity in some specific areas. I started therefore to study the auricular 'stress response' of those patients who associated the onset of symptoms such as tachycardia, dyspepsia and IBS with some particular stressful life events that had occurred in the previous months. Applying tools such as the Paykel scale24 for life events I was able to measure the number of stressful events that had occurred in the previous 6 months and their objective impact using a five-point scale. I added a distress scale, Kellner's Symptom Rating Test (SRT),25 which is a combination of sub-scales scoring anxiety, depression, somatization and inadequacy.

A group of 50 patients with one or more of the functional symptoms mentioned above, for which all possible investigation had been negative, were compared to 20 volunteers without any of those symptoms.26

The first group, which I called the 'stress group', showed an average of 2.2 life events compared to 0.9 in members of the control group (P<0.001); measuring the number of events scoring a higher objective impact (3-5), as proposed by several studies, I obtained an average of 1.8 events compared to 0.8 in the control group (P<0.001). All 70 subjects were submitted to 4 weekly sessions of ear acupuncture and to a control after 6 weeks. The stress group had on average 5.3 tender points compared to 2.4 of the control group; the higher sensitization of the first group was significantly different (P<0.001). At the baseline the total score of the SRT was, as expected, higher in the stress group; but the treatment reduced the SRT score significantly at each session from the first to the third. In the control group, however, it was reduced significantly only after the first session.

The first information I obtained from this study, published several years before those of Wang,27,28 was that ear acupuncture may have a rapidly balancing effect on parameters such as anxiety, depression and somatization. This positive effect is more pronounced in patients with stress-related symptoms, but also measurable in apparently symptom-free subjects.

As one of the characteristic aspects of ear acupuncture during a therapeutic course is the progressive, sometimes very fast drop in the number of tender points, I expected the same effect to occur in the subjects in my stress group. I was surprised to find that the reduction of points was slow and became significant only after the third session. In my opinion this slow fall of sensitization could be related to the time necessary for the body to come out of the stress response and regulate its negative effects on the endocrinal and immune systems.

This hypothesis may be supported by the fact that stress response seems to sensitize the auricles on recurrent areas and some of them have a significantly higher number of points. I identified in 50 subjects with stress response at least nine areas with a variable concentration of points (Fig. 5.17): the first ranked area (number 5, summing 44.9% of the total in the stress group) may be associated with both Triple Energy (CO17 sanjao) and the neighboring endocrinal area (CO18 neifenmi) of the standardized map. This area corresponds to the representation of the hypophysis for Durinyan and the representation of the hypothalamus for Bourdiol (Fig. 5.18). In second place I identified area number 4 (16.3% of the total) on the tragus, which may be associated with the adrenal gland shenshangxian or Nogier's adrenocorticotropic hormone (ACTH) point on the internal wall of the tra-gus. Next came area number 6 (8.8% of the total), which is rather a broad one overlapping with both the heart (CO15 xin) and spleen (CO13 pi) zones, corresponding on Bourdiol's map to the upper cervical sympathetic ganglia (see Fig. 5.14). In decreasing order came the other zones on the

Romoli.

Sensory thalamic group

Pulvinar Posterior

Sensory thalamic group

Pulvinar Posterior

Dorsal Columns Somatotopy
Fig. 5.18 Representation of the pituitary-hypothalamic system on the intertragal incisure according to Bourdiol (with permission).

anterior part of the ear lobe, on the Shen men area, etc. (Table 5.2).

The conclusions of my study were as follows:

The stress response seems to activate certain areas of the outer ear most of which are innervated by the vagus nerve. According to some anatomists, this nerve's field does not limit itself to the cavum and cymba conchae but includes also the tragus and triangular fossa. This sensitization of a para-sympathetic territory seems to be in contradiction to the supposed liberation of catecholamines on tissue receptors under stress. But if we consider acupuncture a 'regulation therapy' there is no real sympathetic-parasympathetic contradiction here. The areas of higher density of points are located on the cavum conchae and particularly on the Sanjiao area. We do not know why this area has the name of a meridian whose points are indicated for treatment of dysfunctions of the digestive and the genitourinary systems. It is interesting to note that Sanjiao area borders on other important points such as the 'adrenal gland' and 'endocrine'. Its role, despite its name, seems therefore related to neuroendocrine structures of the brain. Its sensitization during a stress reaction could therefore be consonant with the commonly accepted theoretical and experimental model of stress in which the hypothala-mus-hypophysis-adrenal cortex axis is activated.

Table 5.2 Distribution of the total tender points identified in the stress group during 4 consecutive weekly sessions of ear acupuncture and in the follow-up 6 weeks later

Stress group (50 subjects)

Location

No. points right ear

No. points left ear

Total points

%

Area 1

36

53

89

6.6%

Area 2

10

14

24

1.8%

Area 3

17

47

64

4.8%

Area 4

77

142

219

16.3%

Area 5

189

415

604

44.9%

Area 6

53

65

118

8.8%

Area 7

69

24

93

6.9%

Area 8

32

21

53

3.9%

Area 9

9

5

14

1.0%

Other

30

38

68

5.0%

Total

522

824

1346

100

For information on the asymmetrical distribution of points with a higher significant concentration on the left, especially for areas 5 and 6, the reader should look at the section entitled 'The symmetrical/asymmetrical distribution of the points on the auricles' in Chapter 9.

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