PTSD Takes a Heavy Toll on Mind and Behavior

aaRenoir_NiniAuJardinPosttraumatic Stress Disorder (PTSD), regardless of its cause, takes a heavier toll than it is widely known on the mind and behavior of its victims. PTSD sufferers feel, think and behave as in a state of prolonged, and for some even unending, stress reaction. This disorder of the mind strikes after a traumatic event has disrupted a person’s life. Immediately following an experience such as combat, rape, assault, physical abuse or violence, a natural disaster or a terrorist act, most people react with acute stress. They may persistently re-experience the trauma in recurring images, thoughts, dreams, illusions, flashbacks, some form of dissociation or derealization, and in the inability to recall details of the event. Significant anxiety is also felt, with poor concentration, difficulty sleeping, irritability, hypervigilance, startle response and restlessness. For a minimum of two days and up to four weeks after the event, Acute Stress Disorder is the natural and expected reaction to the magnitude and seriousness of the psychological impact of the trauma. Even though the disturbance can cause impairment of functioning and significant distress during this time, many of these symptoms generally subside and even disappear within three to four weeks of the event. Except when they don’t.

The Many Forms of PTSD

In PTSD, all these symptoms, often in more severe form, persist well beyond the 4-week span of acute stress. In many cases, as in Acute PTSD, the symptoms last up to three months. In Chronic PTSD, they can continue indefinitely, especially if the disorder remains unacknowledged or is inadequately treated. In some cases, after the acute stress phase is over and life seemingly has returned to normal, PTSD can suddenly appear six months or longer after the trauma has occurred (PTSD with Delayed Onset).

This disorder causes great anxiety and a disruption of life’s activities that can have serious financial and social consequences. It also takes a heavy toll on the mind of its victims and affects their behavior in multiple ways, by inhibiting certain actions, modifying others, and removing barriers to self-injurious acts, including suicide.

The Heavy Toll on the Mind

Many survivors of severe trauma who suffer from PTSD develop self-focused beliefs that have a victim theme. They may see themselves as being continually and particularly vulnerable to physical danger. In the wake of the 9/11 terrorist attacks on New York City and Washington D.C., many people continue to experience pain, fear, threat and a heightened sense of vulnerability. They may also perceive themselves as being mentally defeated.

"Ball four… take your base."  Those were the sympathetic words of the umpire during my little league baseball pitching debut – after I had walked the 11th batter in a row, thus… run number seven.  My coach finally started to come out to relieve me, and I was glad to be taken out of the game.  Feeling mentally defeated and miserable, as he approached the mound, I desperately needed a little comfort and compassion from the adult leader of the team. Unfortunately, I was met with criticism and a few choice words that confirmed my perceived inadequacy as a baseball player. –-Dwayne K. Smith

It is not unusual for PTSD sufferers to continuously dwell on the negative implications of their traumatic experiences. Although they may protest that their trauma safely belongs in the past and no longer bothers them, they remain preoccupied with their own view of themselves and with others’ views of their behavior under fire, their inability to fend off their attacker, their shattered self-esteem. Lastly, a persistent imagining and a continuous ruminating about what might have happened (a “wishing the past could have been different”) blocks progress toward real healing and forgiveness. The experience continues to rerun on the horror channel, and is seldom if ever safely archived in the history channel.

Depressed-Soldier-02Alongside with bothersome thoughts and negative self-assessments, the constellation of symptoms also induces the development of negative beliefs about the world and the future. Most common are the belief that the trauma consequences are permanent and unchangeable; that the world has become unsafe, unpredictable, untrustworthy; that the future will be negative; and that life has lost its meaning. In the most severe cases of PTSD, these beliefs can lead to deep feelings of hopelessness and despair and culminate in suicide. According to recent US Army data, there are an average of 950 suicide attempts each month by veterans who are receiving some type of treatment from the Veterans Affairs Department. Seven percent of the attempts are successful, i.e. 18 veterans commit suicide each day, and 11 percent of those who don’t succeed on the first attempt try again within nine months.

How PTSD Negatively Affects Behavior

PTSD wreaks havoc on the individual’s behavior patterns, by inhibiting certain protective actions and inducing others that can be harmful or at the very least do not promote recovery. Among the actions that are most often induced by PTSD are behaviors associated with a continuous state of hypervigilance, such as barricading doors and windows, sleeping with a weapon nearby, frequently checking behind one’s back and scanning the environment for threats. In the same vein, the individual may also intentionally avoid any reminders of the traumatic events, dissociate, engage in “undoing” behaviors that more properly belong to compulsive disorders, withdraw from social contact, abandon normal and previously pleasurable routines, and engage in unsafe behaviors such as gambling or drug and alcohol abuse.

Among the behaviors that PTSD may inhibit are change behaviors that could help treat the disorder, such as psychotherapy, counseling or medication; communication behaviors that could help share one’s trauma story with others, including openly acknowledging the symptoms that are being experienced. The individual may also dismiss the notion that anything positive could result from trauma experience, and not read, watch or listen to information that would disconfirm their negative beliefs. Perhaps most harmful, PTSD also inhibits the seeking of social support from close relatives and friends, and the utilization of available means of coping (such as faith and religious practices).

Treatment Options for PTSD

Empirically-validated treatment options for PTSD that have been proven as effective include:

  • Cognitive-behavioral psychotherapy. This type of talk therapy is effective in desensitizing the individual by a gradual and guided exposure to negative and irrational thoughts, images, situations and feelings that are reminders of the traumatic event, in a safe environment. The treatment may last for a minimum of three months and up to one year of weekly session.
  • Family counseling. Family therapy is especially effective in treating not only the individual who is directly affected by PTSD, but also spouses, children and extended family that may also be affected by the symptoms. Family therapy promotes understanding, facilitates communication and helps address the relationship problems that almost always accompany a case of PTSD.
  • Medication. Psychotropic medication, most often fluoxetine (Prozac) or sertraline (Zoloft), is prescribed in PTSD to relieve severe symptoms of depression or anxiety. These medications have an effect on the symptoms, but they do not treat the causes of PTSD.
  • EMDR (Eye Movement Desensitization and Reprocessing). This treatment consists of cognitive-behavioral therapy combined with guided eye movements, hand taps or sounds. In EMDR, the bilateral stimulation of the brain works by reprocessing highly charged fragments of memory and emotion and integrates them into safer and less emotion-laden memories.

Can Psychological Stress Increase Cancer Risk?

FaggioBurcinaThe continuous circulation of white immune cells throughout the body is our defense against disease caused by bacteria, viruses, harmful chemicals, as well as our built-in, 24×7 surveillance system against the development of cancer. A healthy body sees between 4,000 and 11,000 white cells per microliter of circulating blood, but this concentration increases in response to a threat. Psychological stress has an immuno-suppressive effect by reducing the white cell count and thus the body’s ability to fight diseases ranging from the common cold to cancer.

How Stress Affects the Immune System

The direct communication between the sympathetic nervous system (SNS) and the immune system consists of adrenergic projections and sympathetic nerve terminals that are found in many organs of the body, such as the spleen. An acute SNS activation by a stressor causes the immediate release of catecholamines from nerve endings, initiating the automatic arousal that takes place during the stress reaction. This neuroendocrine response to stressors also increases the levels of glucocorticoids (primarily cortisol) in circulation, which are steroid hormones that in addition to rapidly mobilizing the body against the threat also have an effect on the immune system.

Acute vs. Chronic Stress

Stressors, depending on their nature and duration, modulate the functions of the immune system by influencing the number of white cells circulating in the bloodstream. The effects of a brief, acute stressor (e.g., a sudden noise) on white cell circulation are short-lived and subside when the stressor passes. There are longer lasting effects on white cell circulation when the stressor is prolonged and severe (e.g., a relationship problem), as in chronic stress.

Regardless of its origin, psychological stress always leads to a change in white cell count at varying degrees depending on the type and duration of the stressor. Current research shows that longer-lasting stressors cause a reduction of immune function and increase our vulnerability to disease. Numerous studies document the immune system suppression caused by severe stressors such as marital strife, bereavement, long-term caregiving, living in unfavorable conditions, and by the psychological reaction to environmental disasters such as floods, earthquakes, fires, and hurricanes.

Stress, Immune System and Cancer

According to the National Cancer Institute’s current information on the possible association between stress and cancer, at least three areas of investigation are being explored: stress effects on virus-related cancer, stress effects on cell processes, and stress effects on tumor growth and spread.

Virus-related Tumors. An indirect relationship between certain types of virus-related tumors (Kaposi sarcoma, Burkitt lymphoma, cancer of the liver) and stress has been established. The indirectness results from the fact that some cancers are triggered by a process that involves certain precursor infections (such as herpes and hepatitis) that are known to be exacerbated by stress and a weakened immune system.

Cell Processes. The body’s natural neuroendocrine response has been shown to alter important cell processes that protect against the formation of cancer, such as DNA repair and the regulation of cell growth. Age-related deficits in protein synthesis and the responsiveness of cells to stress, decreased cell-cell communication, and inefficient signal transduction may render old cells less able to withstand stress (genotoxic stress).

Tumor Growth and Spread. The precise biological mechanisms underlying the influence of stress on the growth and spread of cancer are not yet well understood, but a link between the effects of stress on the immune system and the growth of some tumors has been documented. A recent study at the University of Texas Anderson Cancer Center in Houston indicates that stress hormones, especially norepinephrine and epinephrine, can contribute to tumor progression in patients with ovarian cancer.

Other Factors in the Effects of Stress on the Immune System

There are many factors that can exacerbate the negative influence of stress on the immune system. Age, nutrition, gender, ethnicity, and psychosocial characteristics of the individual can affect white cell circulation in response to stressors. Depression, lack of social support, or a hostile personality can cause altered immune cell responses to acute stress. Among the protective factors, physical fitness appears to be a very important positive mediator of white cell activity in the presence of psychological stressors.

A Peaceful Christmas Everyone!

I heard the bells on Christmas Day
Their old, familiar carols play,
And wild and sweet
The words repeat
Of peace on earth, good-will to men!
And thought how, as the day had come,
The belfries of all Christendom
Had rolled along
The unbroken song
Of peace on earth, good-will to men!
Till, ringing, singing on its way
The world revolved from night to day,
A voice, a chime,
A chant sublime
Of peace on earth, good-will to men!
Then from each black, accursed mouth
The cannon thundered in the South,
And with the sound
The Carols drowned
Of peace on earth, good-will to men!
And in despair I bowed my head;
‘There is no peace on earth,’ I said;
‘For hate is strong,
And mocks the song
Of peace on earth, good-will to men!’
Then pealed the bells more loud and deep:
‘God is not dead; nor doth he sleep!
The Wrong shall fail,
The Right prevail,
With peace on earth, good-will to men!’

Christmas Bells: A poem by Henry Wadsworth Longfellow

How To Deal With 6 Personalities Under Stress

Pisa%20-%20Piazza%20dei%20Miracoli%20-%202How does each personality style tend to handle a significant stressor? And, if we happen to be the spouse, significant other, sibling or friend of any of these, what is the best way to interact with them while they are under severe stress? To answer these questions, it is necessary to understand their most relevant characteristics, the most likely meaning of the stressor to each style, the most likely feelings or responses evoked among other people that interact with them, and tips on the management of this interaction.

The Dependent Personality Style

Relevant Characteristics Under Stress: May become needy, demanding, clingy. May be unable to reassure self and will seek reassurance from others.
Meaning Attributed to the Stressor: Threat of being abandoned and left all alone. 
Feelings Evoked: May make others feel powerful and needed. May also make them feel overwhelmed and annoyed.
Management Tips: Reassure within limits, mobilize other supports, reward personal efforts toward independence, avoid the temptation to withhold all help.

The Obsessive Personality Style

Relevant Characteristics Under Stress: Meticulous, orderly; likes to feel in control; very concerned with right/wrong approach.
Meaning Attributed to the Stressor: Dangerous loss of control over body, emotions, impulses.
Feelings Evoked: May elicit admiration for their attention to detail; may also provoke anger—a “battle of wills” due to their perfectionistic approach.
Management Tips: Provide choices to increase their sense of control, provide detailed information, focus on a collaborative approach that avoids the battle of wills.

The Histrionic Personality Style

Relevant Characteristics Under Stress: Entertaining, melodramatic.
Meaning Attributed to the Stressor: May fear loss of love or loss of attractiveness.
Feelings Evoked: May make others feel anxiety, impatience, off-putting dramatic gestures.
Management Tips: Try to strike a balance between warmth and formality, maintain clear boundaries, encourage them to discuss fears, avoid confronting them head-on.

The Masochistic Personality Style

Relevant Characteristics Under Stress: “Perpetual victim,” self-sacrificing martyr, may expect negative outcomes.
Meaning Attributed to the Stressor: May view the stressor as conscious or unconscious punishment.
Feelings Evoked: May provoke anger, hate, frustration, helplessness, self-doubt.
Management Tips: Avoid excessive encouragement, share their pessimism (albeit without agreeing).

The Paranoid Personality Style

Relevant Characteristics Under Stress: Guarded, distrustful, quick to blame or counterattack, sensitive to slights.
Meaning Attributed to the Stressor: Proof that the world is against them.
Feelings Evoked: Anger, feeling attacked or accused, defensiveness. 
Management Tips: Avoid assuming a defensive stance, acknowledge their feelings without disputing them, maintain interpersonal distance, do not confront irrational fears.

The Narcissistic Personality Style

Relevant Characteristics Under Stress: Arrogant, devaluing, vain, demanding.
Meaning Attributed to the Stressor: May view it as a threat to self-concept of perfection and invulnerability; may be shame evoking.
Feelings Evoked: May cause others to feel anger, a desire to counterattack, activate feelings of inferiority.
Management Tips: Resist the desire to challenge their sense of entitlement, provide opportunities for them to show off, offer appropriate advice if requested.

The Ultimate Stressor: Being Mark Madoff

MarkMadoffThe sudden, sad news of Mark Madoff’s suicide at the age of 46 while embroiled in as many as nine lawsuits against him and his family was not entirely unexpected and also somewhat unsurprising. From a clinical point of view, Mr. Madoff was at moderate to high risk for suicide or self-inflicted injury, but also benefited from several “protective factors” that could have made his choice of suicide less likely.

Nonetheless, the barrage of news that portrayed him as under investigation for being his father’s accomplice (without any indictment), his having become virtually unemployable, the shame of being a Madoff in a world where the surname has become a synonym for a crime of epic proportions eventually proved too much to bear. Mr. Madoff’s options progressively narrowed to one single choice which he exercised alone in his Manhattan apartment in the early hours of a Saturday morning: death by suffocation.

The pressure of the last two years weighed on him enormously… He was deeply, deeply angry at what his father had done to him — to everybody. That anger just seemed to feed on itself… That’s why I never believed he knew about the fraud. He was always a nervous wreck. He could never have stood it — keeping a secret like that would have torn him apart. –- Statements by Mark Madoff’s friends to the New York Times

Was the last straw his wife Stephanie’s application to the courts to have her last name and that of her two children changed to “Morgan”? Was there an early sign in his October 2009 disappearance, when he was eventually located at the Soho Grand Hotel, in a single room, alone with his thoughts and, some say, a weapon nearby?

By all current standards of risk for self-injury or suicide, Mr. Madoff was a danger to himself. The risk factors for suicide, according to the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention are:

  • A family history of suicide
  • A family history of child maltreatment
  • Previous suicide attempt(s)—was the Soho Hotel episode a precursor?
  • A personal history of mental disorders, particularly clinical depression—Mr. Madoff was reportedly prone to depressive mood swings and physical ailments, including stomach troubles; also, Mr. Madoff had always seemed sensitive to criticism and tended to take his grievances too much to heart
  • Alcohol and substance abuse
  • Feelings of hopelessness—unsurprising given the relentless drumbeat of negative news, the literal and figurative loss of identity that had beset Mr. Madoff for the last several years
  • Isolation, a feeling of being cut off from other people
  • Impulsive or aggressive tendencies—Mr. Madoff was said to be deeply, deeply angry at his father and at everyone else
  • Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
  • A local epidemic of suicide
  • Barriers to accessing mental health treatment
  • Loss (relational, social, work, or financial)—Mr. Madoff had lost his job, the only one he had ever had, when his father’s firm was shut down and had no prospect to find employment
  • Physical illness
  • Easy access to lethal methods—Mr. Madoff first tried the vacuum cleaner cord, which broke, then his dog’s leash, which proved to be sufficiently strong
  • Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

On the other hand, the protective factors that can make suicide a less likely choice are:

  • Effective clinical care for mental, physical, and substance abuse disorders
  • Easy access to a variety of clinical interventions and support for help seeking—after the Soho Hotel episode Mr. Madoff had obtained counseling, which seemed to have steadied him
  • Family and community support (connectedness)—Mr. Madoff was happily married and had two small children, in addition to two children from a previous marriage, and was well-connected with a network of childhood, school and business friends
  • Support from ongoing medical and mental health care relationships
  • Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
  • Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

Clearly, a diagnosis of Mr. Madoff’s true mental state and whether he benefited from any of these protective factors and to what extent he may have been at risk is impossible to make by reading news reports and at a distance. His death makes a specific statement that trumps all other assertions of low risk or protective factors. As well-connected and potentially as well-supported as Mr. Madoff was, ultimately he found himself literally alone to face the only choice that to him seemed to offer an escape from a life that had lost its meaning and its anchoring points of identity and hope for the future.

Christmas Stress Survival Kit

aaMantegna_1500_AdorazioneMagiThe holiday season is upon us — the cash tills are ringing — the car parks are chocka — the shops are heaving — and stress levels are rising. For all the perfectionists out there this time of year can be a real nightmare as The Need To Do Things Perfectly swings into overdrive.  Advertising induces huge pressure to roll out the perfect Christmas:  perfect gifts — perfect parties — how to cook the perfect turkey …   and so on. We put impossibly high expectations on ourselves and end up being unable to enjoy the celebrations.

So here are a few ideas to help ease the stress and allow you some space to enjoy the festive season.

► DELEGATE/ASK FOR HELP: If the majority of the work falls on your shoulders please don’t suffer alone.  If you do you’ll have an exhausting Christmas and probably end up feeling resentful.  Ask for help from those around you — partner, children, family, friends.  Preparing food or writing cards together feels very festive and will significantly ease the burden on you.

► BEWARE “SHOULDS”: Christmas is full of ‘shoulds’.  Be aware of the number of times you use this word.  It usually implies that you’re about to embark on something you don’t really want to do — but feel you ought to.  In other words, the impetus is stemming from external expectations.  The antidote is simply to supplant the word should with could. This instantly reintroduces the element of choice.  You DON’T have to brave the crowds to buy just one more gift … you could, but you might choose not to…

► TEMPER EXPECTATIONS … of others and, more importantly, of yourself.  Don’t sweat the small stuff. Please let go of the need to be perfect. If the turkey is a bit overcooked, or the Christmas tree lights go on the blink, or someone isn’t overjoyed with the gift you’ve bought them – how important is that in the great scheme of things?

► And finally … don’t forget to get out and do some exercise over the Christmas period.  We all eat and drink more than usual, so getting out for a walk and some fresh air always feels great and does you good.

Wishing you a happy, festive and stress-free Holiday Season.

fac_sutton_annabelThis guest post is courtesy of Annabel Sutton, a fully trained Life Coach and Author. In 2005 she was awarded the Professional Certified Coach credential. Her clients say that she inspires, energizes and motivates them towards success and she gets wonderful results. Email or visit for more information or to sign up for Annabel’s free Coaching Tips.

Making Your Marriage Last and Thrive

SH_Rcmds_smWhat makes a good marriage last? According to the best evidence provided by thousands of studies and experimental research (most prominent that of Dr. John Gottman), marriages where the spouses provide a safe haven for each other and a secure base from which to face the world together provide the best chances of success. A key skill that all good partners acquire is that of arguing in a fair manner, which respects the other’s point of view (without necessarily agreeing with it), seeks to understand the reasons underneath each respective position, and negotiates a fair compromise.

If you are a couple, you most likely have arguments. Big or small, they can ruin a day and, even worse, a relationship. Dr. Sharon Morris May says, "It’s not how similar you are or even your level of conflict that determines your marital success but how you deal with your emotions, vulnerabilities, and dragons when you argue." In her book, How To Argue So Your Spouse Will Listen: 6 Principles for Turning Arguments into Conversations, Dr. Morris May presents conflict through the lens of attachment theory, helping couples understand why they argue, how they argue, and how to unravel arguments. The book also helps spouses identify what’s really going on in their brains and in their bodies when they argue, the cycle they get stuck in, the emotions fueling the cycle, and what can help them argue in more considerate and connecting ways.

[amtap book:isbn=0849918685]

How To Argue offers six practical principles that can help turn arguments into real conversations: Establish a Safe Haven, Comfort Each Other’s Dragons, Get Inside Each Other’s Emotions, Learn How to Complain, Learn How to Apologize, and Bookend It With Good Times.

Learning how to argue so your spouse will listen and in ways which will not lead to irreparable breaches is a fundamental skill that perhaps you did not learn in your prior relationships or from our own parents. The good news is that it is a skill that can be learned at any age and virtually at any point of your marriage: this book, the Stresshacker Recommended book for this week, can teach you how.

Best Omega-3 Against Depression

aaInness_1878_AutumnOaksThe polyunsaturated fatty acid omega-3 is an important weapon in combating inflammation, the principal cause of stress-related illness. However, when it comes to helping lift depression, not all types of omega-3 fatty acids are equal. According to a study presented at the 49th Annual Meeting of the American College of Neuropsychopharmacology which took place Dec. 5-9 in Florida, only eicosapentaenoic acid (EPA) has been shown to produce significant mood improvement in patients with depression. The other type of omega-3 fatty acid, docosahexaenoic acid (DHA), has no effect on depression.

The two omega-3 fatty acids EPA and DHA are found together in food (primarily fish and nuts) in a 1:1 ratio, but man-made supplements contain either EPA or DHA or a combination of both, in a ratio that may favor one vs. the other and may vary by manufacturer. In order to take advantage of omega-3’s antidepressant effects, it is therefore important to choose supplements that have an EPA-predominant formulation.

Among the many Omega-3 supplements that are rich in EPA for antidepressant effects, some of the highest rated are NutraSea Herring Oil (with a 3:1 EPA to DHA ratio), AST Bioactive Omega-3 EPA Amino Hybrid (with a 5:1 EPA to DHA ratio), and Pharmax High EPA Fish Oil.

Of Washington, Stress, and the Mind

b_800_600_16777215_0_stories_immagini_Inverno_Alba_sul_primo_piazzaleThe way we perceive a situation, and decide whether it is positive or negative, is an active, continuing process of appraisal of the risks, costs, and likely gains of our
possible responses. Three individuals may be stuck in traffic at the same time and each may perceive and appraise the situation quite differently. “OMG,” one may say, “late again, my boss will be furious!” The second may think, “I’m going to be late, but my boss will understand how unpredictable this traffic really is.” The third may settle in, turn on the radio and say, “It’s a good thing I left a little early, I can’t speed this up so I’ll just catch up on the news.”

Depending on this cognitive appraisal of a situation, the stress reaction will mobilize the body to action. The greater the anxiety generated by the situation, the higher the level of physical and psychological arousal. Sometimes, overt behavior will be produced directly by the mobilization of impulses, drives, or wishes. One specific and frequent set of behaviors is likely to occur most frequently, as a behavioral inclination to act in a certain way due to our background, beliefs and available resources. Depending on the content of our thoughts about the situation, the behavioral inclination may be a desire to withdraw (flight), attack (fight), approach, or avoid (freeze). The emotions corresponding to these inclinations are anxiety, anger, affection, and sadness, respectively. The ultimate response to a stressor can be conceptualized as a structure of the mind, where a set of beliefs about one’s self, the world, and the outcome activates and controls the behavioral inclination and the emotional response.

Life’s stressors, especially if significant to our physical, psychological and social well-being can disrupt the normal activity of the mind. In addition to almost immediate loss of the ability to concentrate, recall, reason and control impulses, a severe and unexpected stressor produces a relative increase in instinctive, more primitive, and less rational processes. Instinctive reactions are usually paired to specific stimuli. These almost mandatory reactions are characteristic to the specific sensitivity of each individual. They can give way to inappropriate or excessive behavioral reactions. For example, the need for a stiff drink, reaching for a cigarette, crying, or being unable to breathe or move can be automatic, with little insight and thus virtually unstoppable.

The wide differences between people in their specific sensitivities explains why an event that is an almost unbearable stressor for one person may be an annoying or even benign situation for another. The seasoned public speaker may still get butterflies in the stomach, but is able to carry on and deliver an excellent presentation, whereas another may be terrified at the very idea of speaking before an audience.

Core differences in one’s personality also account for the wide variations in individual
sensitivities to stressors. The independent and somewhat misanthropic personality will not be sensitive to the same stressor as the individual who craves human connection and feels dependent on it for validation. Excessive or ineffective reactions to stressors, such as hostility, anxiety, and depression, also result from specific behavioral inclinations, personality structure, and specific sensitivities.

Finally, reactions to stressors may be dictated primarily by one’s internal motivations, with no apparent connection to the events or circumstances of the outside world. For example, the belief that the only road to happiness is through total success is characteristic of achievement-oriented individuals who are therefore extremely vulnerable to excessive and ineffective reactions at the slightest doubt of failure—regardless of evidence to the contrary.

Obama & Boehner at Stresshacker.comStressful interactions with other people who may be equally as stressed, albeit for different reasons, produce a mutually reinforcing cycle of excessive and ineffective reactions. Specific psychological mechanisms, such as an egocentric approach, negative framing, and polarization, increase the level of arousal experienced by each individual and, consequently, to higher and higher levels of collectively shared stress. This cycle seems to be in evidence at this time in Washington, as the executive and legislative powers appear to be locked in a mutually reinforcing cycle of excessive and ineffective reactions to each other.

Stress Hardware Review: Anterior Cingulate

Dolomites_EN-US3033597177The anterior cingulate cortex is a region of the brain that is activated by sensation, cognition, and emotion. It appears to play an important role in autonomic, affective, and cognitive behavior. Because of its position, the anterior cingulate is anatomically and functionally well positioned to integrate information across the physical, intellectual and emotional domains. Important in the stress reaction, the anterior cingulate region is activated during self-regulation of arousal through its connections with the cholinergic basal forebrain. The whole structure, but especially area 32, produces inhibitory inputs that decrease amygdala responsiveness and are helpful in mitigating the effects of fear and in preventing or at least delaying “amygdala hijacks.”

The normal functioning of the anterior cingulate area leads to a normal response to stressful events, which is a psychophysiological arousal or increased emotionality. The normality of the brain response to traumatic stimuli also serves to inhibit feelings of fear when there is no true threat.  Any chemical or structural failure of activation in this area and/or decreased blood flow in the adjacent subcallosal gyrus can lead to an exaggerated response to stress, resulting in significantly higher emotionality and the inability to properly regulate fear. The latter condition provides the inducing cues in anxiety disorders, i.e. increased and persistent fearfulness that is not appropriate for the context.

What the Anterior Cingulate Does

BrodmanBrainAreasPhysically, stimulation of the anterior cingulate (especially in area 24) induces changes in blood pressure, heart rate, respiratory rate, pupillary dilation, skin conductance, thermoregulation, gastrointestinal motility, and changes in adrenal cortical hormone secretion (ACTH). Cognitively, the anterior cingulate cortex plays a leading role in learning new behaviors, whether as a conditioned response to predictors of painful stimuli, as an instrumental response to avoid such stimuli, or in response to reduced reward. Emotionally, the anterior cingulate (along with other structures in the limbic system) mediates emotional responses including fear, agitation, and euphoria, and verbal expression with affective content, such as sighs, cries, and screams.

Neuroimaging studies with powerful fMRI instruments show electrical activation in the rostral–ventral anterior cingulate cortex when individuals under study are asked to recall sad memories or view faces with sad expressions, when they are told to anticipate an upcoming painful electric shock, and when exposed to scenes or words with emotional content. It should come as no surprise that stress-induced activations in the amygdala and orbitofrontal cortex occur simultaneously with those in the anterior cingulate cortex.

Genes, Stress and the Anterior Cingulate

Genetic studies have conclusively demonstrated that the anterior cingulate cortex is highly sensitive to environmental stressors, either physical, psychological, or behavioral. Anoxia (lack of oxygen), maternal separation, amyloid protein expression, and drug abuse all induce hypometabolism, gliosis, and programmed cell death in the anterior cingulate cortex. After prolonged and continued exposure to stress, nerve cells in the anterior cingulate cortex are damaged and killed by excessive stimulation, a process called excitotoxicity.

When the Anterior Cingulate Malfunctions

Several psychiatric disorders are linked with abnormalities in the function of the anterior cingulate cortex. Significantly elevated neurochemical activity in this region of the brain has been observed in obsessive–compulsive disorder, tic disorder, and depression. A normal range of activity is restored with behavioral and pharmacological treatment of these disorders. Other psychiatric disorders that have been associated with abnormal functioning of the anterior cingulate cortex include attention deficit hyperactivity disorder (ADHD) and schizophrenia.

Mental Health USA: An Inconvenient Truth

aaWyeth_1946_WinterIn 2009, almost 20% of the adult population in the United States (19.9% or 45.1 million people) had a mental illness of some kind during the prior twelve months. Those with a serious mental illness were 4.8% of the adult population, or 11 million people.

These are the sobering results of the latest National Survey on Drug Use and Health (NSDUH), a report presenting estimates on the prevalence of mental disorders and mental health services utilization among adult Americans.

The results showed that adult women were more likely than men to have a mental illness of any kind (23.8 vs. 15.6%) or a serious mental illness (6.4 vs. 3.2%). An estimated 8.4 million adults, or 3.7%, had serious thoughts of suicide, 2.2 million (1%) had made suicide plans, and 1 million (0.5%) had attempted suicide within the past year.

The survey results estimate that among the over 45 million adults with any mental illness in the past year, almost 9 million had substance dependence or abuse. Among the 11 million adults with a serious mental illness, almost 26% also had substance dependence or abuse.

Only 17 million people with any mental illness received mental health services, whereas 28 million neither sought or received any treatment. Six in ten adults with a serious mental illness received mental health services, while almost 4.5 million received no treatment at all.

aaWyeth_1948_ChristinasWorldThe survey is conducted each year by the Office of Applied Studies, Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services using computerized interviewing. The 2009 results were extrapolated from screening completed at 143,565 addresses, and 68,700 completed interviews. In this survey, the category any mental illness includes the presence of a diagnosable mental, behavioral, or emotional disorder in the past year (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). The category serious mental illness includes a diagnosable mental, behavioral, or emotional disorder resulting in substantial impairment in carrying out major life activities.

You can see the complete results of the 2009 survey, published a few days ago, on the OAS-SAMHSA web site by following this link.

All the Skinny On Skin-Deep Stress

DSC_3019Sometimes the stress reaction causes unwanted problems that are only skin-deep. Good thing, you might say. Keeps issues just on the surface. Well, not quite. It turns out that skin inflammation can be one of the most bothersome (and not so rare) consequences of stress and emotion. In 1978, Harvard psychiatrist and dermatologist Robert D. Griesemer authored a comprehensive index of the effect of emotions on various skin disorders that has become a classic in the field. The Griesemer index lists 27 interactions of stress and emotion on the skin and skin disorders that are mediated by the nervous system including the autonomic nervous system, the immune system, and the hormonal system (see the index after the jump). Stress can induce or worsen skin conditions in just a few seconds after the stressor (for neurotic excoriations and pruritus, for example) or up to two to three weeks later, as in the case of nail dystrophy, cysts and vitiligo.

That a direct relationship exists between skin problems and stress is easily demonstrated by the fact that taking medications which reduce anxiety or depression, such as benzodiazepines or selective serotonin reuptake inhibitors (SSRIs) usually results in a complete clearing up of the skin condition, whereas applying topical ointments or creams can have little to no effect. Moreover, nonpharmacologic treatments such as heart rate variability biofeedback, cognitive-behavioral therapy, hypnosis, meditation, relaxation or yoga that counteract the effects of stress and emotion also have a significant beneficial effect on stress-related skin problems.

What are the most important psychological disorders that have a direct effect on the skin? Anxiety tops the charts, followed by delusions, depression, and obsessive-compulsive disorder. Let’s take a look at each one.

Psychological Disorders Affecting the Skin

Acute or chronic anxiety induces or significantly worsens most skin conditions. When anxiety is left untreated, the skin problems it can cause stubbornly refuse to clear up and can become resistant to even the most aggressive dermatological treatment. It is only when anxiety subsides that the skin has a chance to heal.

ZebraStressSpecific monomaniacal delusions of parasitosis, bromhidrosis, or fibers (Morgellons) are particularly resistant to treatment. If the individual believes that his or her skin is affected by one of these conditions, even though from a clinical point of view it isn’t, the only effective treatments have proven to be antipsychotic medications.

One of the most frequent consequences of severe depression is the involuntary (and sometimes unstoppable) scratching, picking, digging, burning, cutting, pulling, or tearing of the skin, hair, or nails. Recent studies have shown that up to 1/3 of patients receiving treatment in a dermatology clinic actually suffer from depression. Once again, treating the psychological condition with antidepressants results in a definitive improvement of the skin condition and puts a stop to the self-harming behavior.

Psychogenic physical symptoms that have no identifiable organic cause are common in dermatology. Similar in etiology to irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and interstitial cystitis, stress-related dermatological diseases include pruritus, urticaria or angioedema, self-induced dermatoses such as dermatitis artifacta and trichotillomania associated with dissociative states. A somewhat more psychological psychosomatic condition is body dysmorphic disorder, which is an excessive and often unfounded preoccupation with one’s skin or hair. Not unlike other stress-related disorders, these psychosomatic manifestations respond well to exercise and psychotherapy and not so well to medical procedures and injections.

Stress-related problems with the management of impulse can prevent individuals from being able to avoid or stop picking at their skin or twisting and pulling on their hair, thus causing acne excoriée, neurodermatitis, and trichotillomania. Cognitive behavioral psychotherapy, hypnosis and self-hypnosis appear to work well in resolving skin conditions by focusing the treatment on the underlying psychological problem of impulse control.

Finally, obsessive-compulsive disorder is often the aggravating factor of many skin diseases such as acne, atopic dermatitis, and psoriasis. For skin complications aggravated by OCD, the combination of cognitive behavioral therapy and the prescription of SSRI antidepressants appear to produce the most long-lasting results.

And you thought that skin-deep stress was just a superficial problem.

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Fake It ’til You Make It: Posture Lowers Stress

Is it possible, by deliberately assuming a simple two-minute high-power pose, to instantly become more powerful? In a study conducted conjointly at Harvard and Columbia universities, researchers have shown that humans and animals can increase the beneficial effects of power by deliberately assuming open, expansive postures for as little as two minutes, and suffer the effects of powerlessness by deliberately assuming closed, constrictive postures. The study results revealed that assuming certain postures almost immediately produces neuroendocrine and behavioral changes. High-power postures (widespread limbs, enlargement of occupied space, and spreading out) trigger a rise in testosterone, a decrease in cortisol, a perception of power and a willingness to take more risks. Assuming low-power postures (limbs touching the torso, minimizing occupied space, and collapsed inwardly) produces the opposite effects.


By simply changing our physical posture, we can better prepare our body and our mind to take on stressful situations. Intentionally assuming certain postures can have the immediate effect of improving self-confidence in such situations, e.g., a public speech, a job interview, disagreeing with someone, preparing for a sports challenge or even taking a financial risk. As it turns out, “Fake it ‘til you make it” is not just a phrase:  even minimal postural changes, if sustained over time, can  improve our health and well-being, even if we may often feel quite powerless due to lack of resources, occupying a lower rank in an organization, or being part of a low-power social group.

How Does Posture Reduce Health Risks?

forrest-gump-p111Although short-term high cortisol levels are a normal reaction to stressors large and small, being in a position of lower power (at work, at home, in social groups) has been shown to cause a higher incidence of stress-related illnesses (Cohen et al., 2006). For people who hold positions of power or are able to exercise more power at work, at home or in social situations, the contrary is true. Their typical combination of high testosterone coupled with low cortisol is often associated with leadership capabilities and a higher resistance to disease. The stress-marking hormone cortisol is lower when we are in a position of power, indicating a lower level of reactivity to stress. The continuous state of alarm and elevated cortisol experienced by low-power individuals can produce negative health consequences such as inflammation, high emotional reactivity, a high allostatic load, stress-related illnesses (irritable bowel syndrome) and memory loss.

In short, arranging our body posture to indicate power (regardless of whether we feel powerful or not) causes specific advantages and adaptive psychological, physiological, and behavioral changes, with more positive subsequent behavioral choices. A simple two-minute pose can embody power and instantly make us more powerful. Who’d have thunk it?

When Stress Hurts: Curing Psychogenic Pain

villa-Era-Vigliano-Biella_Current treatments that effectively reduce or eliminate psychogenic pain is the subject of this, the sixth and last post in the series on the close association between psychological stress and psychogenic pain. Encouraging news for psychogenic pain sufferers from the pharmacist: A growing number of patients reports that by taking antidepressants they have experienced a significant reduction in the frequency and intensity of pain. More specifically, relief of psychogenic pain with antidepressants has now been thoroughly documented in the treatment of pain associated with bulimia (Faris et al., 1998), vulvodynia (Stolar & Stewart, 2002), chronic pain of undefined origin (Davis, 1990; Pilowsky & Barrow, 1990), migraine headaches (Kaniecki et al., 2006), chronic pain associated with depression (Bradley, Barkin, Jerome, DeYoung, & Dodge, 2003), functional bowel disorder (Drossman, Toner, & Whitehead, 2003), neuropathic pain (Fishbain, 2000; Saarto & Wiffen, 2005), and post-herpetic neuralgia (Max, 1994).

Non-pharmaceutical Treatments

As we have seen in a previous post, there is a strong emotional and affective component to pain of any origin, whereby pain always has a depressive effect on our mood. There is also ample evidence that pain is often the unwelcome companion of depression, anxiety, psychological trauma, anger and irritability. Even the mere expectation of pain, in the absence of any noxious stimuli, appears sufficient to produce it  and its perception, as has been documented in functional MRI (fMRI) changes to specific brain structures (Fields, 2000; Keltner et al., 2006). Conversely, diverting cognitive attention or causing distraction can mitigate pain, as shown in PET scans of cortical activation (Petrovic, Petersson, Ghatan, Stone-Elander, & Ingvar, 2000).

SH_Rcmds_sm UnlearnPain_BookHoward Schubiner, MD and Michael Betzold are the authors of Unlearn Your Pain, an excellent book that seeks to help reverse chronic pain by promoting a thorough understanding of its principal cause, learned nerve pathways (see Stresshacker’s explanation of the concept in this post). It offers a revolutionary step-by-step process that has been reported to work well by many psychogenic pain sufferers. It is Stresshacker’s recommended book resource.

Psychological Treatments That Can Eliminate Psychogenic Pain

The effectiveness of purely psychological interventions in the relief of chronic or acute pain is supported by the fact that pain and stress share many of the same biochemical processes, neural pathways and CNS structures (see this post for a full explanation).

Decreasing psychological stress through better stress management or counseling has been documented as effective in treating low back pain that is co-occurring with depression (Middleton & Pollard, 2005). There is also evidence that psychosocial interventions are efficacious for pain secondary to arthritis or cancer (Keefe, Abernethy, & Campbell, 2005). Multidisciplinary approaches, including relaxation therapy, biofeedback, behavior modification, hypnosis, desensitization and cognition therapy, have also been proven successful in treating chronic pain of unknown origin (Singh, 2005). Biofeedback therapy can be particularly successful in reducing colorectal pain (Jorge, Habr-Gama, & Wexner, 2003). Hypnotherapy, cognitive therapy, and brief psychodynamic psychotherapy appear to work well in patients suffering from irritable bowel syndrome (Blanchard & Scharff, 2002). Hypnosis has been proven effective in relieving oral pain (Golan, 1997), cognitive behavioral therapy for functional bowel disorder (Drossman et al., 2003), behavioral therapy for the treatment of headaches (Lake, 2001); and family therapy interventions have been associated with successful psychogenic pain treatment (Liebman, Honig, & Berger, 1976; Roy, 1987).

Previously in this series:

9 Ways to Beat Procrastination…Tomorrow.

Langisjor_EN-US2321196967Procrastination is three times as stressful as getting things done right away. First, because tasks that need doing aren’t getting done; second, because it is stressful to think about all that needs to be done…and remains undone. Third, procrastination in itself is a source of stress due to its impact on self-esteem and psychological well-being.

Procrastination is a delay in deciding to start a task or in completing it. Men and women in roughly equal percentage suffer from this debilitating condition. Situational procrastination happens to everyone and simply describes an occasional delay that does not indicate a habitual pattern. Dispositional procrastination applies to people who delay many tasks on a regular basis, including tasks that are important and sometimes even critical to optimal functioning. Among dispositional procrastinators, two major types can be discerned based on their presumed motivation: arousal procrastinators, who (often subconsciously) need to be motivated to act by the adrenaline rush that comes from cutting it close to the deadline, and avoidant procrastinators, who are de-motivated to act by their fear of failure or success and/or by task aversion.

Here are nine ways to beat procrastination that have been proven to work with many people. (Try one or two, if you have some time…perhaps tomorrow?)

1. Learn to Tell Time

lastminuteHabitual procrastinators, even when faced with simple tasks, don’t seem as capable to estimate the time necessary to perform the task as non-procrastinators. They overestimate how much time it will take to finish the task, and are therefore reluctant to begin it; or they underestimate how long it will take to complete it, and are afraid of not being able to finish it. Learning to better estimate time to task completion is a skill that needs to be developed by procrastinators who, for whatever reason, seem to fall short of its mastery.

GTD-cover2. Banish Disorganization

Not being able to plan a task, misplacing some of the things needed to perform a task effectively, or losing track of what has already been done are areas that cause people to delay starting a task or its completion.

Getting rid of the very idea of disorganization is the start of a better strategy for getting things done. The enormously popular book Getting Things Done: The Art of Stress-Free Productivity may help…

3. Post-It and Read It

Sometimes the simplest things carry the most value. Any procrastinator can benefit from the little yellow notes strategically posted in visible locations that act as silent reminders of tasks that need to be done. If the notes are read and acted upon, procrastination can become a less frequent problem.

4. Make It Easy to Concentrate

Not having a specific, designated place in which to concentrate and focus exclusively on a task introduces the scourge of distraction to the misery of indecision. Being in a place where there are too many other stimuli competing for attention is not a winning strategy. Getting in the zone and achieving flow is key to task completion.

LeoMarvin5. Take Baby Steps

Sometimes even a relatively simple task can appear complex, until it is broken down into smaller chunks. Behavioral psychologists recommend chaining, which is a series of responses needed to perform a particular target end-behavior or, in simpler terms, baby steps. Getting things done one small chunk at a time. Simple. It works.

6. Take Small Time Bites

Complexity of the task can be compounded by the (often incorrect) estimation of the total  time needed to complete it. To take care of this aspect of the problem, it helps to break down the task into small bites of time—say, 5-minute segments—instead of staring at the total time needed and freezing in place.

7. Put the 80-20 Rule to Work

Even the best laid out strategy of eliminating procrastination cannot be accomplished in one day. We simply can’t go from “total procrastination” to “total completion” in one fell swoop. A more realistic and achievable plan may be to apply the 80-20 rule, where success means completing at least 80% of the tasks, instead of aiming for 100%.

8. Seek Role Models

Go with a procrastinator and you’ll learn to procrastinate more. Seek non-procrastinators as role models, get past the negative comparisons, and you will learn useful techniques and approaches that may come natural to them, but can be a godsend on the way to getting things done.

9. Take Responsibility

Everyone knows that there are consequences for delays and for failing to get things done. Procrastinators know that, too. Unfortunately, the habit of making excuses that can be accepted by others simply sharpens the skills for coming up with “reasons” that just sound plausible. A procrastinator who is willing to take responsibility is only a few short steps away from kicking the habit.