Clinical Reflections #6
Stress. Fasting. Empathy.
July 13, 2025
The other day, when I was driving my car to work, I asked myself a question:
Sometimes when we are stressed we lose our appetite and at other times we tend to eat more.
Why this contradiction? Are the two states different?
I have been intrigued by stress for sometime now. For every three patients that come to my clinic, at least one of them has the origins of their complaints in some kind of stress they are dealing with.
A married couple had visited me a few days back. This was the second time they had come. They had come to show their lab reports which I had asked for in their previous visit. The husband was a bespectacled wheatish gentleman. He was moderately built, a little on the lankier side rather. He wore a beige T-shirt on both occasions and his forehead was shiny with a thin carpet of sweat. He had an irritating habit. Every time he said something he began with a chuckle. He would interrupt when his wife said something, again with a chuckle. The corner of his lips were always on the verge of lifting up, and lift they did, with a short burst of laughter that was characteristically nervous. His chuckle was a defence mechanism disguising his anxiety neuroses. I didn't mention anything on the first visit. I let it pass. I tried to engage with the wife. The wife was a moderately built lady. She wore a salwar suit with a dupatta wrapped across her chest and shoulders. While the husband sat somewhat straight, she had a slight hunch, the hunch of weariness. The most striking part of her face were the huge dark circles around her eyes. Her face evoked the picture of melancholy. Unlike her husband’s neuroses, her demeanour was quieter. But her body language was screaming pain, a deep kind of pain that denervates a person. It was evident she was an insomniac. I have seen such people at close quarters, they have very similar striking signs.
During the second visit, as I was perusing their lab reports, they were looking eagerly at the computer. I finished noting down the reports and told them the reports were just fine. You might think they were relieved. But no, dear reader, they were not. They weren't alarmed either. They were dissatisfied that their complaints were not captured by the molecules in their blood. As I was explaining the implications, the husband continued with his interjecting kerfuffle. I was mildly peeved. I also knew that it was important to address the elephant in the room. The roots of their issues lay behind the chuckles and the dark circles. I explained in words that they could understand. Surely, quoting Freud or Jung to explain defence mechanisms would have fogged them off, so I used words that they could digest and make sense of. I think they understood. But the effect was that they became quieter. The husband was pulled down from the crest of his skittishness, while the wife was lifted from the trough of her resignation. For the first time, I had seen an expression on her pokerface.
Coming back to the question that I had asked myself in my car. When I reached my clinic, I sat down and opened ChatGPT app. I asked GPT the question that I began this essay with. After giving me a pat on my back for asking a great question (GPT probably thinks it is Pavlov and I am its dog), it promptly answered that I was confusing between two kinds of stress: acute stress and chronic stress.
While the stress of a lion chasing you or a difficult exam next day are examples of acute stress, chronic stress is a perpetual background state of emotional upheaval. During acute stress, the sympathetic nervous system is stimulated which releases a neurotransmitter called norepinephrine. Norepinephrine (a little later boosted by the hormone cortisol) dries up your mouth and gives more energy to your brain and muscles. Fight-or-flight. It drives the meter of appetite down so that you can focus on saving your ass. During chronic stress, on the other hand, the same part of the nervous system is kicked in but this time the hormone cortisol makes you eat more.
I asked GPT, why the contradiction? The system is the same, the hormones are the same, then why the opposite effect on appetite. It again congratulated me on asking a nuanced question. I salivated.
So, it educated me that during chronic stress, the cortisol levels are higher and thus it tends to affect some other aspects of the mind and body. These other aspects include the brain’s reward circuit. The reward circuit has a higher threshold for activation, hence a more prolonged and greater amount of stress is required for them to join the party.
I was satisfied to some extent, but not fully so. I switched off the app and resumed seeing patients. Later in the day when I came back home, I couldn’t reconcile the notion that GPT (based on the research articles that it was quoting) was implicating that stress was felt by the body on a likert scale. The states of acute and chronic stress have always felt qualitatively different to me, not just that chronic stress might be a pumped version of acute stress. I was reading some poetry by Iqbal and this one intrigued me.
Empathy
Perched on the branch of a tree
Was a nightingale sad and lonely
"The night has drawn near", He was thinking
I passed the day in flying around and feeding
How can I reach up to the nest
Darkness has enveloped everything?
Hearing the nightingale wailing thus
A glow-worm lurking nearby spoke thus
With my heart and soul ready to help I am
Though only an insignificant insect I am.
Never mind if the night is dark
I shall shed light if the way is dark
God has bestowed a torch on me
He has given a shining lamp to me
The good in the world only those are
Ready to be useful to others who are
It dawned on me that when we are worried about ourselves and our lack of fulfilment we tend to be in a state quite akin to chronic stress. We eat more, or at least I do. But when we are thinking about others, we lose our appetite and our state is more serene.
Perhaps this is what fasting in Islam is all about, may be in other religions too. May be the physiology underlying chronic stress has similar biological markers and pathways as in the state of inner turmoil versus during empathetic musings. Perhaps, after major events in world history like World War II, 9/11, 2008 financial crisis, etc, it is this physiology that changed in us. Our baseline appetite has changed to a higher level. Obesity and liver fat have risen with equal gusto. The incidence of diabetes, depression, dementia and several cancers (linked to obesity) have risen manifold.
Perhaps. Just one of those questions that pique my interest from time to time. I thought I would put it out there. This is an unfinished business I would like to pick up later.
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Thank you for reading.