discu 4
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discu4.docxLecture: Stress and Physical and Mental Health
This week we are looking at various topics: the relationship between illness and psychological factors and the role of stress, the adjustment disorders and post-traumatic stress disorder. I have copy part of the changes in the new DSM5 compared to the DSM-IV.
http://www.apa.org/helpcenter/stress.asp
Stress and Illness.
The authors of your textbook make a good argument regarding the harmful effects of stress in our lives. Most of us are aware of these effects due to the prevalence of information in the media and medical sources. We paid good lip service to these warnings, but as a society as well as individuals we rarely heed the warnings.
We can’t avoid stress, but we can certainly try at minimizing its impact on our lives. Each day there is more and more evidence that stress will seriously hurt us physically, emotionally, and socially. The link between stress and illness is by now well established, both in the short term as well as down the road in our lives. Chronic stress will deplete and weaken our immune response and will make us vulnerable to a host of different and serious health conditions. In fact, the great killers of our times are not anymore the infectious disease but the so called “life-style” diseases: cardiac illness, strokes, hypertension, diabetes and certain forms of cancers. Western societies are characterized by environments that place a heavy burden on time and effort from all of us. We seem to be in a rush to go somewhere, which leads to nowhere. Yet, we engage in this crazy race. A quick look around us will show insanely busy lives, and the most common complaints one hears is “I do not have time”. We have adapted our personalities to the demands and now we are seeing the infamous Type A personalities with its link to heart disease or the Type D personalities with depressive, anxious expectations. There is a general malaise I have seen for years in my practice; a sense of despair, of not knowing what’s the purpose of all of this, and even if life is worth this much effort. Correspondingly, we have seen an increase of mental illnesses and suicide, even among those who “have it all”. The most prescribed drugs are pain killers, anti-cholesterol meds (statins), anti-hypertensives, anti-diabetics, and not far down the list we have the psychiatric drugs with Xanax and Zoloft leading the pack. As a society we eat too much and too much, we don’t exercise enough, we don’t play enough, we don’t love enough, we use too many chemicals legal or otherwise, we don’t sleep enough and our relationships tend to be shallow and temporary; not a promising picture. Those are the bad news.
However, it does not have to be like that for each individual. We do have a choice of how we want to lead our lives, and the kind of future we want for ourselves. Yet it requires self-awareness, and determination. You need a life-plan and a commitment to that plan. I want to cut to the chase and tell you that it requires a life-sustaining change, a new life-style if you will. The answer is not to throw us back to the Stone Age, or to have “a list” of stress-management techniques to combat stress. Have the courage and the vision to transform your life so you “will have time”, and since we all have the 24 hours per day, the key is how you want to prioritize the “stuff” in your life. But that prioritizing needs to stem from a dedicated personal philosophy you can put in practice and live it. Here is an interesting short article from the British Newspaper the Guardian regarding the top 5 things people regret at the end of their lives:
OK I hope this reflection is useful to you all. The greatest gift you all have is that you are starting your Journey. I ask you “What kind of life you want to have”?
Adjustment Disorders
First, I want you to understand the Adjustment Disorders and now a Bona Fide “stand-alone” disorders and not a residual category like in the DSM-IV. The folks working on the DSM5 have argued that people experiencing difficulties, traumas (not necessarily “traumatic”) may develop significant psychological symptoms that may not rise to the category of other (major) disorder. For example, a person dealing with financial issues, or conflict on a primary relationship (stressor) may develop symptoms of depression without meeting diagnosis for Major Depression. Here from the DSM5 folks:
In DSM-5, adjustment disorders are reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event, rather than as a residual category for individuals who exhibit clinically significant distress without meeting criteria for a more discrete disorder (as in DSM-IV ). DSM-IV subtypes marked by depressed mood, anxious symptoms, or disturbances in conduct have been retained, unchanged.
Posttraumatic Stress Disorder
The changes on PTSD have also been significant, eliminating the requirement of a “direct exposure to traumatic event” and the provision that the person facing or experiencing the traumatic event feels a sense of terror or horror. Another important change in the diagnostic criteria is the recognition of persistent “negative alterations in cognition and mood” as well as the important role of anger and aggressive behavior. See for yourselves:
DSM-5 criteria for posttraumatic stress disorder differ significantly from those in DSM-IV. As described previously for acute stress disorder, the stressor criterion (Criterion A) is more explicit with regard to how an individual experienced “traumatic” events. Also, Criterion A2 (subjective reaction) has been eliminated. Whereas there were three major symptom clusters in DSM-IV—reexperiencing, avoidance/numbing, and arousal—there are now four symptom clusters in DSM-5, because the avoidance/numbing cluster is divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable or aggressive behavior and reckless or self-destructive behavior. Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.
These two changes are important primarily on the recognition that challenges in the person’s environment (life) can bring about serious psychological consequences that are not automatically “linked” to the idea of a “Mental Illness”. So, a person who loses his job develops a depression and this depression does not need to be diagnosed as “Major Depression” (Implying an “illness” although to be clear, the DSM does not make causal assumptions) and instead is diagnosed as an Adjustment Disorder with depressed mood; that I think, it is a step on the right direction. As far as PTSD, it is becoming diluted more and more with the addition of not having to experience the trauma personally, but vicariously. On the other hand, the addition of having “persistent emotional estates (ie; anger, depression) was an important inclusion in the diagnosis as those presentations are very common in modern forms of PTSD. This is also consistent with what happens in current cases of PTSD.
Well, I hope you enjoy this chapter.
Just one More Thing
Working with this couple in marital therapy had been a significant challenge. They were very different from each other. He was an engineer by training and at the time, he was working at a prestigious multinational company. In all his dealings, demeanor and expression of emotion, he tended to be matter-of-fact, calculating, exacting and generally unemotional. She was his opposite. She was a school teacher, an artist and highly emotional. They had a beautiful family with five children, but their relationship had been deteriorating for many years now. By the time I began to work with them, it was clear that one fundamental issue was their very different characters and world-view. But they loved each other and above all, they loved their children and the life they had built for themselves.
Therapy with them was based in helping them understand their fundamental differences, and work from there. They could not change each other, but could try to understand each other and certainly, they could improve their communication. I used to joke with them saying that if I was in a plane I would feel comfortable knowing someone like him was flying it; on the other hand, if I wanted to go to a party and have fun, I would rather hang out with her. After a period of time, they seemed to be doing better, their fights were diminished and both felt they had come to the point where they could continue to work on their own. On the last day of our therapy, after finishing the session and saying our goodbyes, Ruth asked her husband to wait a couple of minutes for her and asked me if I could find the time to see her for a couple of sessions individually to discuss something “personal”. Since I had the space in my work-load and she had been so compliant and effective in marital therapy, I agreed.
The following week, Ruth came to session and after the initial small talk she began to tell me her story. I was not prepared to hear the kind of story she shared with me. This woman who just a week ago was pleasant, apparently happy and verbally engaging, was transformed into a rather anxious, tearful and unarticulated person. She proceeded to tell me about two years prior, she had gone to a get-away weekend to a resort in the eastern coast of the USA. Walking one late evening on the beach on an isolated part of this resort, she had been attacked by this man, who yielding a knife proceeded to rape her. She barely remembered the details, but she recalled her horrible fear, and her expectations she was not going to leave that place alive. This man after abusing her, left her there, ashamed, horrified and in severe shock. It took a long time for her to gather her strength to get up and return to her hotel room where she shower for a long time trying to erase the filth and guilt she felt. She was not able to sleep on her bed, but recalled cuddling in a corner of her room, wrapped on a blanket, crying throughout the night. She thought for a long time about what to do next, but by the morning, she had decided to do nothing; her husband would never understand and perhaps blame her, and she felt too ashamed to report the crime.
However, the following months after this event became unbearable to her. She turned incredible anxious, could not stand the dark, developed panic attacks and became increasingly depressed. Her relationship with her husband deteriorated, as she was having significant difficulties receiving and expressing affection, and she could not be intimate with him. This eventually led her to seeking marriage therapy, but never came out in our sessions.
When she finished her story, she was crying and asking me to help her. I told her I was going to do everything in my power to help her overcome this problem, but it was going to take a while to address it successfully. I shared with her she was experiencing the symptoms associated with chronic stress post-trauma known as PTSD. I also told her that the only way we can overcome our fears and terrible memories is to face them. We however, were going to do this at her own pace, but the process was going to be difficult. She agreed and we began our treatment.
I told her that one essential part of our work together was to be focused on discussing her memory of the event in as much detail as possible; it was necessary to face those memories, process the feelings associated with the memories, and put those memories on a different context for her. She was also going to take care of self on other ways, she was to practice regular relaxation exercises, keep good nutrition and continue with her regular visits to the GYM. I told her that as she began to improve, her other symptoms will also improve. But therapy was difficult. Relating the events over and over again in session was painful to her. Initially she progressed little and I was wondering if anything at all was being accomplished. Nevertheless, we proceed it and slowly her narrative became more coherent, less painful and amazingly, she began to remember parts of the story she had apparently forgotten. After several weeks of intensive sessions, she had a complete memory of the event, with the exception of the face of the perpetrator. She had done amazing work, and by her own report as well as per clinical presentation, she was much improved. She was sleeping better and was less anxious and less depressed. I was not sure if we had done everything we could do.
Then, one Sunday night she called me crying hysterically. She had stopped at a convenience store to buy milk on her way home and as she was getting ready to get in her car she noticed this man looking at her lasciviously. She became very frightened and barely was able to get the key in the ignition when suddenly the face of the perpetrator came to her mind flooding her with powerful emotions. We talked for a few minutes over the phone and after making sure she was fine, I told her to see me next day.
As usual, she was on time and ready to work and this was probably the best session we had had in several weeks. For the first time she was able to put the whole story together and felt she had accomplished something really important. This was a very powerful cathartic session and she felt exhausted by the end. When she got t to leave my office, she looked different and graced me with a grateful smile. We then agreed to meet once more to put it all together.
In what was going to be our last session, she looked radiant and for the first time, appeared really happy. She sat down and started to talk.
Ruth - Dr Fernandez, I feel I have done very well, but I think I need one more thing. I also need your support as this is going to be very difficult.
Dr F- Ehm, I think I know what you are going to tell me. You want to tell your husband.
She looked at me surprised and said- NO, I am not going to tell my husband, he will never understand!
DrF-Then what? I said
Ruth - I have thought hard and long over this issue and I want to go back to the place where the rape took place. I want to actually go to the same spot, I want to “fight” that bastard and I want to yell at him and I want to tell him that I am now free…I need to do this doc. I know you have told me this was not my fault, and the best thing I did that day was that I survived, but many times I felt I could have done something different…and there is something else. I want to go to the police department and make a police report of the incident!
I was stunned and did not know what to say. While it was clear to me she needed to do this, I was not sure how she would do or react once she was back to the place where the traumatic event had taken place. I feared all the progress she had made was at risk of being lost and perhaps she would actually worsen. I shared my concerns with her, but she was determined and in a very gentle but firm manner she told me she had made the travel arrangements already and she was going. She asked me if I could be available to her while she was gone via phone just in case she needed to speak to me. I told her she could count on that and I would be anxiously awaiting for her return.
It was not only a long weekend, but one of the longest weekends I ever waited, until I finally heard from her. She sounded very happy and told me everything had been a great success. She did exactly what she had planned to do and felt truly free. Her most difficult moment was going to the police department and making a report, but the police officer was kind and helpful and helped her through this process.
This turned to be our last session. I felt very happy and satisfied with the results, but more than anything else, I felt a deep admiration for this woman who was a warrior, and never for one second, once the path became clear to her, doubted or faltered.
Trauma has as many faces as our reactions to it. Our modern conceptualization of trauma, goes back to the seventies and the invention of the term “Post-Traumatic Stress Disorder”. This effort, well documented in other sources (for example Ben Sheppard’s “A War of Nerves”), was mostly a political movement to validate the suffering of returning Vietnam Vets as well as to exemplify anti-war ideology. The contrived diagnostic criteria limited, and for decades now, imposed a vision of trauma which is not faithful to the range of experience or reactions suffered by those confronted with it. The term has evolved so much, that the latest iteration of the Diagnostic manual (DSM5) does not require the patient to have witnessed the traumatic event. The requirement for exposure to trauma can be now met by having someone close to the person tell the story of the trauma; in other words, you get traumatized by association! This in my view, trivializes a deeply disturbing and life-altering experience and completely obscures the real meaning of suffering and despair. Trauma shatters our assumptions of living in a safe, predictable, loving and ultimately benevolent universe. It goes at the core of our delusions of safety and presents us with a different reality, much darker and painful. But trauma also offers us the opportunity to rework our assumptions and find a new purpose and meaning, which could enrich our lives in ways not otherwise imaginable or even possible.
In the many years I have practiced, I have treated many soldiers with PTSD but never have I found the courage, the determination and the perseverance I saw in this woman. As we said our goodbyes I asked her one more time if she would ever tell her husband; she smiled and said- Who knows Doc?
I heard one more time from her several months later. She was doing very well and she was content with her life… her marriage could be a bit better, she said, but she had learned to live with this man and was moving ahead with her life projects.
