Appraisal: The WYSIWYG of Stress

LindauHarbor_EN-US1129072404From the cave to the modern city, survival has depended on the ability to quickly and reliably distinguish between harmless and dangerous situations. Today, distinctions are often subtle, complex, and abstract. The ability to make these distinctions has been made possible by the evolution of the prefrontal areas of our brain, which are capable of symbolic representation and can derive new knowledge about the self, world and the future through experience. This complex process of evaluation and distinction is called cognitive appraisal.

The cognitive appraisal of possible harm or loss, threat, and challenge is intimately implicated in the stress reaction. In recognizing harm or loss, we assess that some measure of physical or psychological damage has already occurred, e.g., an injury or an illness, some damage to our well-being or self-esteem, or the loss of a loved or valued person. In evaluating a threat, we assess damage or loss that has not yet occurred but that is anticipated, or perceived as likely to occur. Harm or loss that has already occurred is always suffused with threat because every serious injury or significant loss is also full of negative implications for the future. Challenges are often perceived as threats as every challenge, either psychological or physical, calls for the mobilization of our coping resources.

Stressed_WomanThus, in this process of appraisal, we come up with an assessment of the seriousness of the situation that is before us. What we see or do not see determines the level of physiopsychological arousal and how we will respond. The idea that our emotional and behavioral response to a stressor is determined by the meaning we attribute to an event or situation has a long tradition in Western thought. The Roman philosopher Epictetus famously stated, "Men are disturbed not by things, but by the views which they take of things.” A few centuries later, the same idea was expressed by William Shakespeare in Hamlet, "There is nothing either good or bad, but thinking makes it so" (Act II, Scene 2, line 259).

The immediate outcome of appraisal, whether of a threat or a challenge, is the notion that something must be done to manage the situation, because it is serious enough to warrant our attention. This first level of assessment is often referred to as primary appraisal. Subsequently, and often almost without pause, our task becomes that of evaluating what might and can be done, a second level of processing that we call secondary appraisal. While neither is more important than the other, secondary appraisal activity is crucial in the choice we make between fight or flight, i.e., between approach and avoidance. The WYSIWYG of appraisal is that, in most cases, what we see in the situation is how we choose to respond to it. Whereas some will see in a particular event nothing but a nuisance, others will see the same event as a dangerous threat.

Primary Appraisal: How Serious Is the Stressor?

What determines the quality of our primary assessment of a situation or event are its novelty, its predictability, and event uncertainty. Also important are time factors, such as the imminence, the duration, and the temporal uncertainty of the stressor. Additionally, primary appraisal is affected by the ambiguity of the stressor and by the timing of stressful events in our life cycle.

Generally, the more imminent a stressful event, the more urgent and intense our process of primary appraisal will be, as for example in deciding whether or not to step out of the path of an oncoming truck. The less imminent an event, the appraisal process becomes more deliberate and thus more complex, as in deciding whether to take a new job. Ambiguity is unfortunately a salient characteristic of many of today’s stressors. Greater ambiguity signifies that more factors can shape the meaning of the situation, and vice versa.

The timing of stressful events as they happen throughout our life cycle can also affect the quality of our appraisal. Many life events, such as the death of a child, are more significant and turn into crises because they occur "off time." Off time events are more threatening because they are often completely unexpected and therefore pose a challenge for which no preparation or anticipatory coping was possible.

Secondary Appraisal: Can I Handle It?

BearAttackOur individual assessment of a situation leads to an appraisal of our possible responses. When our vital interests appear to be at stake, secondary appraisal takes front and center and we can become literally and figuratively frozen in place, as we feel the enormous pressure of producing the right response.

Individual temperament, upbringing, personality, life experiences, and prior traumas play a leading role in determining the quality of our secondary appraisal.

A stress-prone individual is primed to make extreme, one-sided, absolute, and global judgments. Because the appraisals tend to be extreme and one-sided, the behavioral responses also tend to be extreme. A hostility-prone individual may be primed to react to a relatively minor slight by another as if it were a criminal offense and, consequently, will be inclined to attack the other verbally or physically. A person who is susceptible to fear reactions may interpret an unfamiliar noise as a gunshot or the start of an earthquake and will have an unstoppable urge to escape. A depression-prone individual may hear an otherwise humorous comment as a rejection and will want to withdraw.

In the primitive world of an instinctual stress reaction, the complexity, variability, and diversity of human experiences are lost and quickly reduced to a few crude categories. It is do or die, eat or be eaten, a survival of the quickest and strongest. In a more mature world of cognition, stimuli are analyzed along many dimensions or qualities, appraisals are quantitative rather than categorical, and are relativistic rather than absolutistic. When it comes to stressors, what you see can be just exactly what you get.

Angry? Aggressive? All You Need Is a Prayer

Pisa%20-%20Piazza%20dei%20Miracoli%20-%202Pray for Those Who Mistreat You: Effects of Prayer on Anger and Aggression is the descriptive title of a study published a few days ago in the peer-reviewed journal, Personality and Social Psychology Bulletin. According to its authors, Dr. Ryan H. Bremner of the University of Michigan, Ann Arbor, Michigan, Dr. Sander L. Koole of VU University, Amsterdam, The Netherlands, and Dr. Brad J. Bushman of Ohio State University at Columbus, prayer has a surprisingly strong and near instantaneous effect in reducing anger and aggression.

The study consisted of three experiments, which tested the hypothesis that the act of intentionally praying for others can significantly reduce anger and aggression after a provocation. In the first experiment, provoked participants who prayed for a stranger reported feeling their anger subside, whereas other participants who just focused their thoughts on a stranger did not report any lessening of their anger.

People often turn to prayer when they’re feeling negative emotions, including anger. We found that prayer really can help people cope with their anger, probably by helping them change how they view the events that angered them and helping them take it less personally.—Brad Bushman, Ohio State University.

In the second experiment, provoked participants who prayed for the individual who had angered them were less aggressive toward that person than were participants who just thought about the person who had angered them. In the third experiment, provoked participants who prayed for a friend in need reported acting less aggressively and feeling less anger than did people who simply thought about a friend in need.

These results are consistent with recent evolutionary theories, which suggest that religious practices can promote cooperation among unrelated people or in situations in which reciprocity would be highly unlikely. Also consistent with these findings are those previously published on Stresshacker about the connection between faith and stress, and that between longevity and spirituality.

Stuck On Wide Open: Emotional Dysregulation

domesticviolenceEmotional regulation is perhaps the most dramatically visible and the prototypical feature of an individual’s personality. Many people appear to be mostly in command of their emotions at critical moments, while others appear to be particularly (and sometimes explosively) reactive to environmental and interpersonal challenges. In general, affective or emotional instability, inordinate bursts of anger, intense efforts to avoid real or perceived abandonment, and unstable interpersonal relationships point to an underlying attribute of emotional dysregulation. This set of features has been popularized as belonging to “drama queens,” or persons who tend to react to every situation in an overdramatic or exaggerated manner.

Sometimes, instances of emotional dysregulation in children (“acting out” behaviors) or in adults under the most severe stressors can be viewed as the only available response in circumstances in which overwhelmingly strong emotion must be expressed, such as in the context of an emotionally abusive family environment or in times of great personal upheaval.

DramaQueen1A large body of research suggests that alcohol use can increase underlying emotional disturbance and disrupt cognitive functions that are very important in emotional self-regulation. Support for this hypothesis comes from studies that find associations between alcohol use and short- and long-term emotional change. In the short term, alcohol can disrupt emotional stability by effectively removing barriers against violence, verbal abuse, and inappropriate behaviors. In the long term, alcohol dependence and addiction can create a false persona in which it becomes difficult if not impossible to distinguish between the individual’s genuine personality traits and those modified or instigated by alcohol use.

Emotional disorders, particularly when they are characterized by pervasive emotional dysregulation, are often characterized by high negative emotionality and low positive emotionality. A significant challenge in trying to downregulate negative emotions is to become less vulnerable to negative or distressing emotions, with the objective of increasing calmness and resilience in stressful situations.

To achieve better emotional regulation, biological change and contextual change are needed. Biological change is achieved by reducing individual reactivity to emotional stimuli. Even when this reactivity may be due to genetic dispositions (temperament) and early developmental experiences (nurture), most people can learn ways to better control their emotional expression. There is a combination of skills and interventions that is particularly helpful in promoting biological homeostasis and emotional stability. These include treating any underlying physical illness that may have a negative effect on mood, balancing nutrition and eating to replenish and maintain physical resources, staying off non-prescribed mood-altering substances, getting sufficient but not excessive sleep, and getting adequate physical exercise.

Contextual change refers to learning and practicing emotional resiliency, which is the ability to minimize negative effects of stressful events and situations, and to maximize the positive effects of positive outcomes and opportunities. The skill of resiliency is learned and reinforced by intentionally accumulating positive life events, i.e., making a conscious and deliberate catalog of what’s positive in one’s life and referring to it often until it is present and readily available in time of need. It also consists of developing practical skills that build a sense of generalized mastery and promote self-esteem, e.g., completing school, obtaining additional job training, taking an assertiveness course, and the like.

What Causes (And Cures) Emotional Dysregulation

The amygdala has been implicated in emotional dysregulation, aggressive behavior, and psychiatric illnesses such as depression. Anxiety disorders and dysregulation may be the result of too much activity in the amygdala and not enough activity in the prefrontal cortex (PFC), which is the executive center of the brain that sets boundaries of behavior and responds to criteria of calm, assertiveness, and emotional regulation.

BDNFStress, coupled with a genetic vulnerability, decreases the production of brain-derived neurotrophic factor (BDNF). BDNF is a protein that acts on the nervous system by helping the survival of existing neurons and promoting the growth and differentiation of new neurons and synapses. A reduction in BDNF production causes a thinning of neuronal structures, which can results in emotional disturbance. These structural changes make the prefrontal limbic governing system vulnerable to disruption and dysregulation. Thus, emotional stress, loss, or  other significant psychological factors cause the system to lose self-regulation.

Treatments such as antidepressant medications, lithium, electroconvulsive therapy, exercise, psychotherapy and good social support can reverse this process, increase the production of BDNF, renew neuronal growth, build more resilient self-regulating circuits, and return the individual to a healthy mood.

Disorders of Emotional Dysregulation

PTSD, or posttraumatic stress disorder, is characterized by very significant emotional dysregulation. Its sufferers experience unwarranted arousal—often caused by stimuli processed Depressed-Soldier-02outside of conscious awareness—and exhibit an exaggerated startle response, vivid intrusive thoughts, and flashbacks and nightmares related to past traumatic events. PTSD victims may frantically try to avoid physical or psychological reminders of their trauma, and may experience dissociative symptoms or emotional numbing. PTSD is a disorder of emotional dysregulation characterized by excessive fear, triggered by a severe and often life-threatening traumatic event.

Borderline personality disorder (BPD) is characterized by emotional dysregulation, the temporary but frequent inability to change or regulate emotional cues, experiences, actions, verbal responses, and nonverbal expressions. Individuals with BPD experience greater emotional sensitivity, greater emotional reactivity, and slower return to normal levels of arousal after intense stimulation.

Frontal lobe disorders, which have become rather common among combat survivors, are the product of traumatic brain injury and are characterized by emotional dysregulation, attention deficit, impulsivity, lack of inhibition,  poor insight, impaired judgment, and low motivation. These frontal-subcortical disorders can result not only from war zone trauma, but also from infection, cancer, stroke, and neurodegenerative disease. Explosive violence, often directed at family members, is a common occurrence, particularly in individuals in whom impulsivity, disinhibition, and emotional dysregulation are the most dominant features.

Finally, obsessive-compulsive disorder (OCD) is characterized by emotional as well as cognitive dysregulation, brought on by a disruption of both the “thinking” prefrontal and the “feeling” paralimbic networks.

In these and other disorders that feature emotional dysregulation, it is interesting to note that the anatomic structures that are affected have emotional as well as cognitive functions. This coincidence highlights once again the close interdependence of affective and cognitive operations in the human brain. We can’t feel deeply without thinking intensely, and vice versa.

Optogenetics Discovers Brain Anxiety Circuit

AmygdCingGyrusThe state of heightened apprehension and high arousal in the absence of immediate threat—commonly labeled as acute stress or anxiety—can be a severely debilitating condition. Over 28% of the population suffers from anxiety disorders that contribute to the development of major depressive disorder and substance abuse. Of all the structures of the limbic system, the seat of emotion processing, the amygdala plays a key role in anxiety, although by what exact mechanism still remains unclear. Newly published research carried out by a group of neuroscientists at Stanford University using the novel technique of optogenetics with two-photon microscopy has permitted a much closer exploration of the neural circuits underlying anxiety than ever before. The optogenetics approach facilitates the identification not only of cell types but also the specific connections between cells. The researchers noticed that timed optogenetic stimulation of the basolateral amygdala (BLA) terminals in the central nucleus of the amygdala (CeA) produced a significant, acute, and reversible anxiety-reducing effect. Conversely, selective optogenetic inhibition of the same projection resulted in increased anxiety-related behaviors. These results indicate that specific BLA–CeA projections are the critical circuit elements for acute anxiety control in the brain. The results were published in the March 17 issue of the scientific journal Nature.

A Closer Look at the Amygdala’s BLA and CeA Regions

BasolateralAmygdalaThe amygdalae (amygdaloid nucleus) are two identical almond-shaped brain structures located in each temporal lobe. Each amygdala receives input from the olfactory system, as well as from visceral structures. The amygdala in humans has been confirmed by functional MRI imaging to be the area of the brain that is best correlated with emotional reactions and plays a key role in the brain’s integration of emotional meaning with perception and experience. The emotional aspect of the response of the individual is passed on to the frontal cortex, where “decisions” are made regarding possible responses. In this way, the response of the individual can take into account the emotional aspect of the situation.

Additionally, the amygdala coordinates the actions of the autonomic and endocrine systems and prompts release of adrenaline and other excitatory hormones into the bloodstream. The amygdala is involved in producing and responding to nonverbal signs of anger, avoidance, defensiveness, and fear. The amygdala has been implicated in emotional dysregulation, aggressive behavior, and psychiatric illnesses such as depression. It has also been shown to play an important role in the formation of emotional memory and in temporal lobe epilepsy.

The basolateral amygdala, one of the two structures studied in the recent Stanford research, receives extensive projections from areas of the brain cortex that are specialized for recognizing objects such as faces in central vision. Extensive intrinsic connections within the amygdala
promote further coordination of sensory information.

Biological effects initiated by amygdala include increases or decreases in arterial pressure and heart rate, gastrointestinal motility and secretion, evacuation, pupillary dilation, piloerection, and secretion of various anterior pituitary hormones, especially the gonadotropins and
adrenocorticotropic hormone, which are key agents in the stress reaction. Interestingly, amygdala stimulation can also cause several types of involuntary movement, such as raising the head or bending the body, circling movements, occasionally rhythmical movements, and movements
associated with taste and eating, such as licking, chewing, and swallowing.

LimbicSystemGeographyThe findings also show the involvement of the amygdala’s CeA region in mediating threat-related anxiety and acute fear-related behavioral and hormonal responses. Earlier studies had shown that stimulation of this same area reduces snake fear and pituitary-adrenal activity and that CeA lesions resulted in decreased expression of threat-induced freezing. Additionally, the CeA region of the amygdala was reported as being significantly involved in the consolidation of contextual fear memory, i.e., what permits us to remember so vividly and persistently objects or situations that have caused fear in us in the past.

Ultimate Stressors: A Complete Upheaval

minamisanrikuThe unexpected convergence of catastrophic events that generated widespread damage, loss and destruction in Japan readily meets the dictionary’s definition of disaster. The common characteristics underlying natural disasters such as earthquakes, tsunamis, hurricanes, and man-made ones such as terrorist attacks or nuclear accidents are the virtually total lack of anticipation, limited preventive planning and, subsequently, the drama of human vulnerability.

A few typical phases of disaster are readily discernible, regardless of the type of disaster or its location: an initial impact characterized by shock, fear, and anxiety; an heroic phase, characterized by survivors reaching out in concerted effort to prevent further loss of life and property; a honeymoon phase, within 2 weeks to 2 months after the disaster, when survivors are buoyed up by an outpouring of support, services and supplies. Later, a disillusionment phase may follow, when hopeful expectations give way to resentment as promises of substantial help are broken or snarled by red tape. Finally, a reconstruction phase, which may last several years, characterized by the affected communities’ efforts to rebuild and by individuals coming to grips with their personal losses.

japan-nuclear-reactor-meltdownThe goal of stress reduction and trauma management programs is to help survivors achieve their pre-disaster level of functioning. The majority of individuals exposed to a mass disaster will experience acute stress that may be short-lived and does not develop into a clinically diagnosable disorder, especially if rescue is rapid and effective (as in the recent case of the trapped Chilean miners) and reconstruction or restoration can happen in a relatively short time. However, a substantial portion of individuals exposed to traumatic events will experience clinically significant stress and subsequent mental health problems. These include Acute Stress Disorder, Posttraumatic Stress Disorder (PTSD), depression, chemical abuse and dependence, and anxiety disorders. In the Japanese situation, the rebuilding of families, homes and businesses may turn out to be painfully slow due to the obliteration of entire communities by the tsunami, which increases the likelihood of significant mental health consequences. On the other hand, the Banda Aceh, Indonesia experience shows that even after a near-total erasure of structures by the tsunami of 2004, a community will begin to come back to life—albeit after many years of continuous and painstaking reconstruction.

bandaAcehSome of the most frequently observed behaviors that occur following a disaster include intrusive reactions (efforts to process traumatic events), avoidance reactions (efforts to minimize distressing memories), and physical arousal reactions (efforts to keep the body prepared to survive additional threats). Intrusive reactions occur through recurring dreams about the event, persistent thoughts and images, and the experience of a continued sense of fear and danger. Avoidance reactions manifest as the survivor’s reluctance and resistance to discuss the event, to think about the event, or to revisit any reminders associated with the event. Physical arousal reactions include increased anxiety, hypervigilance, psychomotor agitation, difficulty sleeping, and concentration problems. All these post trauma reactions following a disaster of large magnitude should not be considered abnormal or necessarily indicative of mental health problems or of the need for continued treatment.

katrina_goes12In the best cases, first aid psychological support during major disasters takes place immediately after the event and may last up to one week. In the first critical days, rescuers engage survivors in conversations to determine whether they may be at greater risk for ongoing problems. An effort may also be made to identify survivors that are more likely to be at risk for further mental health problems, such as individuals with pre-existing personality and psychiatric disorders, those who exhibit the severest symptoms, those who lack social support, those who have a history of interpersonal difficulties, and those who have been previously exposed to trauma. Psychological first aid consists of a set of procedures that facilitate a survivor’s adaptive coping, and is based on the premise that safety, calm, self-efficacy, connectedness and hope must be promoted. In the initial, critical phase it is vital to provide survivors with human contact and engagement, physical and emotional safety and comfort, environmental stabilization, information, practical assistance, connections with social supports, information on available help, and linkage with collaborative services.

9-11In the second phase, after the first week and up to one month after the disaster, the primary goal of psychological aid is to promote anxiety management, further reduce stress, and begin the process of restoring normal functioning. This is accomplished through the development of targeted services such as psychoeducation, psychotherapy, skills enhancement, cognitive restructuring, and relaxation training. Care givers also remain alert to any signs of the development of mental health issues, such as derealization (a belief that the world has become strange or unreal), depersonalization (an unnatural feeling of detachment from one’s body), and flashbacks. In the final phase of recovery, taking place within 1 month and 3 months after the event, psychological care is provided to those in need—often for years afterwards.

The convergence of multiple disasters onto a finite geographic region at the expenses of the a limited number of individuals may appear as capable of affecting a specific locale only. In reality, as Chernobyl, Katrina, 9/11 and Banda Aceh have demonstrated, the repercussions quickly have a planetary impact. Stress is no longer a local phenomenon.

Japan-QuakeThanks to instantaneous communication and the transmission of color images via multiple media channels, the experience is quickly shared by the entire planet. This also means that stress is radiated from the epicenter of the disaster outward to all who view and hear it, thus creating intrusive, avoidance, and arousal reactions on a global scale. Moreover, the economic and political consequences of disaster are immediately felt by the financial markets, at the fuel pump, and even in the supermarket aisle.

The world of stress has never been so small.

Tsunami Deja Vu: Greece and Alexandria

800px-Kamakura_tsunamiWe’ve never seen anything like the pictures emanating out of Japan. Modern video and still photography technology give us an unprecedented view of a phenomenon of vast power and consequence. It might seem like something that has never been witnessed before. However, the impact of a tsunami (Japanese: 津波, lit. “harbor wave”), only by chance a Japanese word that has entered into worldwide parlance, was reported in chilling detail by at least two prominent Greek and Roman historians.

Over four centuries before Christ, the Greek historian Thucydides wrote in his History of the Peloponnesian War about a tsunami that had struck Greek coastal towns. We can recognize the imagery more readily now, as it parallels the footage we are seeing out of Sendai, Japan.

thucydidesThe next summer [426 BC] the Peloponnesians and their confederates came as far as the isthmus under the conduct of Agis the son of Archidamus, intending to have invaded Attica; but by reason of the many earthquakes that then happened, they turned back, and the invasion proceeded not. About the same time (Euboea being then troubled with earthquakes), the sea came in at Orobiae on the part which then was land and, being impetuous withal, overflowed most part of the city, whereof part it covered and part it washed down and made lower in the return so that it is now sea which before was land. And the people, as many as could not prevent it by running up into the higher ground, perished. Another inundation like unto this happened in the isle of Atalanta, on the coast of Locris of the Opuntians, and carried away part of the Athenians’ fort there; and of two galleys that lay on dry land, it brake one in pieces. Also there happened at Peparethus a certain rising of the water, but it brake not in; and a part of the wall, the town-house, and some few houses besides were overthrown by the earthquakes. The cause of such inundation, for my part, I take to be this: that the earthquake, where it was very great, did there send off the sea; and the sea returning on a sudden, caused the water to come on with greater violence. And it seemeth unto me that without an earthquake such an accident could never happen.—Thucydides (ca. 430 BC), History of the Peloponnesian War, (89), Thomas Hobbes, Ed., London: Bohn.

Centuries later, Roman historian Ammianus Marcellinus described the tsunami caused by a large earthquake that devastated Alexandria, Egypt in 365 AD. In this even more evocative description, the effects of the retreating sea and its catastrophic return are described in terse and dramatic language.

Ammianus_BookWhile that usurper of whose many deeds and his death we have told, still survived, on the twenty-first of July in the first consulship of Valentinian with his brother, horrible phenomena suddenly spread through the entire extent of the world, such as are related to us neither in fable nor in truthful history. For a little after daybreak, preceded by heavy and repeated thunder and lightning, the whole of the firm and solid earth was shaken and trembled, the sea with its rolling waves was driven back and withdrew from the land, so that in the abyss of the deep thus revealed men saw many kinds of sea-creatures stuck fast in the slime; and vast mountains and deep valleys, which Nature, the creator, had hidden in the unplumbed depths, then, as one might well believe, first saw the beams of the sun. Hence, many ships were stranded as if on dry land, and since many men roamed about without fear in the little that remained of the waters, to gather fish and similar things with their hands, the roaring sea, resenting, as it were, this forced retreat, rose in its turn; and over the boiling shoals it dashed mightily upon islands and broad stretches of the mainland, and leveled innumerable buildings in the cities and where else they were found; so that amid the mad discord of the elements the altered face of the earth revealed wondrous sights. For the great mass of waters, returning when it was least expected, killed many thousands of men by drowning; and by the swift recoil of the eddying tides a number of ships, after the swelling of the wet element subsided, were seen to have foundered, and lifeless bodies of shipwrecked persons lay floating on their backs or on their faces. Other great ships, driven by the mad blasts, landed on the tops of buildings (as happened at Alexandria), and some were driven almost two miles inland, like a Laconian ship which I myself in passing that way saw near the town of Mothone, yawning apart through long decay.—Marcellinus, A. (360) Res Gestae, Vol. II, (26) 15-19.

Worst Stress Relievers: Alcohol

aaManet_1882_BarFoliesBergeresMany people, including clinicians, researchers, and social and problem drinkers believe that drinking alcohol is somewhat effective as a temporary stress reliever. The relaxing effect of alcohol on the central nervous system, its disinhibiting and empowering effects on social impulses, and its perceived beneficial action on physical and emotional pain are often suggested as reasons why people begin and maintain their drinking, despite its abuse potential, side effects, and medium- to long-term ill effects on health. Conger (1951) proposed the Tension Reduction Hypothesis, which posits that alcohol can reduce tension and that people learn to drink alcohol to avoid or reduce unpleasant stress. Clinical observations and studies appear to support this theory.

Individual differences in the effects of alcohol on stress

Individual differences in stress-reducing effects of alcohol vary greatly. Where one individual may feel immediate relaxation from a relatively small amount of alcohol, others find that the initial effect of drinking actually increases their level of arousal. Gender, personality traits, drinking history, and a family history of alcoholism are factors that play a role in these very different responses. Individuals whose personality is characterized by sensation seeking or impulsivity traits are at increased risk for developing alcohol-related problems. Some researchers have suggested alcohol produces enhanced anxiolytic effects on these personalities, and thus increases the reinforcement value of drinking. Although no uniformity of results has been shown in these studies, they offer at least some support for this hypothesis.

From the mid-1960s through the mid-1970s, several experimental studies analyzed the effects of alcohol on stress among alcoholic participants. Although these studies were impressive for their intensive monitoring of participants over extended periods of time, the reliability of the results was limited by the small number of participants. The most reliable and valid studies confirmed an association between alcohol consumption and improved emotional states, e.g., reduction of stress levels, among these alcoholic participants.

Situational factors in stress reduction by alcohol

Situational or transient circumstances may modulate the effects of alcohol on stress. Alcohol appears to reduce stress more frequently when consumed while experiencing a pleasant, distracting activity such as a party or watching television, less so if consumed without distraction. 
There also appears to be a temporal relationship between drinking and the experience of a stressor. Alcohol consumed after a stressor has occurred, e.g., upon returning home after a stressful day, appears to be less effective in reducing stress. On the other hand, if alcohol is consumed prior to experiencing the stressor, e.g., drinking just prior to attending a party, its relaxing effects appear to be more prominent.

Cognitive stress-reducing effects of alcohol

Other hypotheses attribute the anxiety and stress-reducing effect of alcohol to its pharmacological effects on information processing. One theory views alcohol as an agent that narrows an individual’s perception of immediate stress cues and reduces cognitive abstracting capacity. This mechanism of action has the result of restricting attention to the most proximal and immediate aspects of experience. In other words, alcohol reduces the range of awareness (and thus of anxiety and worry) to such an extent that the perception of stressors is greatly reduced.

How might alcohol reduce stress?

Alcohol affects the autonomic nervous system as well as the neuroendocrine system, in particular the hypothalamic-pituitary-adrenal (HPA) pathway that is responsible for the mobilization of the organism during the stress reaction. The HPA axis is also instrumental in regulating immune protection by stimulating the production of cytokines that control inflammatory process and fight infection by pathogens.

The multifarious avenues of  communication among the neuroendocrine, immune, and nervous systems are so complex and ramified that alcohol impacts all systems, in both feed-forward and feedback directions. Alcohol is one of the few substances that readily crosses the blood-brain barrier, which permits it to have direct access to brain cells—with significant deleterious effects. Alcohol increases the resting heart rate, but it can also produce a paradoxical decrease in blood pressure in both humans and animals, much like stress, whose impact on heart rate and blood pressure is inconsistent.

The bottom line on stress reduction and alcohol

A relationship between alcohol and the physiological arousal of stress is undeniable, although the nature of this association is complex, controversial and far less than positive. The most reliable research has shown that the effects of alcohol on stress vary greatly depending on the psychophysiological characteristics of the individuals studied, their environment, the alcohol dose, the nature of the stressor, and the timing of the intake of alcohol and the stressful experience. Thus, while we can say that stress, alcohol, and alcohol addiction can form an interrelated complex, the nature of this relationship cannot be construed as ultimately beneficial. The relative ease and frequency of addiction to alcohol, the ineffectiveness of many strategies for prevention and treatment of alcohol abuse, and the variable benefits of alcohol as a relaxant pose a significant challenge to the widespread idea that alcohol may be an effective stress reliever.

Can Food Be Stressful? The Evidence

aaRenoir_NiniAuJardinScientific investigators in the 1970s began to ask if a correlation existed between food and behavior. They have discovered quite a few coincidences. New and increasingly more sophisticated studies have revealed the effective existence of a food-behavior correlation in children and older adults. In a review of 10 years of studies conducted between 1985 and 1995, Breakey found evidence of a relationship between what children eat and the way in which they behave. “The most important discovery,” he concluded, “has been the presence—in nearly all studies—of one statistically meaningful variation of behavior as a result of a dietary change” (p. 193). Moreover, these studies have revealed a consistency of response to dietary variations which is also statistically significant. Although other studies have established a correlation between changes in the diet and improvements in hyperactivity and insomnia, Breakey’s unexpected discovery was that the parameter primarily influenced by the intake of certain foods is mood, most of all stress and irritability. According to a recently published study by noted psychoneuroimmunologist Janice Kiecolt-Glaser, diets that promote inflammation (i.e., stress) are high in refined starches, sugar, saturated and transfats, and are low in omega-3 fatty acids, natural antioxidants, and fiber from fruits, vegetables, and whole grains.

A study by Christensen & Christensen investigated the correlation between the course of schizophrenia and national statistics relative to fat consumption. They have found that countries with better prognosis for schizophrenia were those in which the national diet included a higher proportion of fat from fish and from vegetables. In essence, the patients who consumed greater amounts of omega-3 fatty acids showed less severe symptoms, a finding supported by a variety of other studies. If anti-oxidant agents can help in blocking the damage caused by free radicals, the treatment with these food supplements could restore cellular structure. Such a therapy, along with counseling on dietetic factors and lifestyle, could beneficially influence the prognosis of schizophrenia.

New research is also focusing attention on the role that anti-oxidants in the diet may play in the treatment of mood disorders. It is hypothesized that fatty acids may have stabilizing effects on mood with a mechanism similar to that of lithium and of valproic acid, by modifying the pathways of transmission of neuronal signals. In their action on bipolar disorder, they appear to mimic lamotrigine’s mood stabilizing and antidepressant properties. The mechanisms of action must be further clarified, as it is still unclear whether fatty acids show a specific pharmacological effect or a mere compensation of nutritional deficits. The concomitant intake of anti-oxidants vitamins (vitamins C and E) may optimize the effect of fatty acids, further preventing oxidation. A double-blind 4-month clinical study of 30 patients with bipolar disorder has shown the effectiveness of fatty acid supplements in comparison to a placebo (olive oil), added to the usual therapies. The experiment group of patients had a significantly longer period of remission as compared to the control group. Kiecolt-Glaser also cites epidemiological studies that demonstrate significant inverse relationships between annual fish consumption and major depression—the more fish eaten, the lower the prevalence of serious clinical depression.

Adjuvant nutritional therapies have also been studied in patients who showed a relapse despite continuing antidepressant treatment. A double-blind study that added omega-3 or a placebo to the conventional treatment has shown statistically significant improvements in the experiment group in as little as three weeks. Also, melatonin seems to perform as a scavenger of free radicals, beyond its well-known properties of regulation of gonadal function and of biological rhythms (e.g., as a sleep aid). Research data suggest that melatonin may positively influence neurodegenerative processes that are involved in the formation of free radicals and the release of excitatory aminoacids.

Ultimate Stressors: Public Drama, Private Pain

charlie-sheenRecently televised interviews with Mr. Charlie Sheen appear to have focused attention on the symptoms and manifestations of the manic phase of bipolar disorder. A public display of inflated self-esteem or grandiosity, profuse talkativeness, increase in goal-directed activity, psychomotor agitation, and the excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish investments) are the textbook criteria for a manic episode. More privately, the individual in the grip of mania also experiences a decreased need for sleep, flight of ideas or racing thoughts, and distractibility. When this disturbance is sufficiently severe, it can cause marked or total impairment in occupational functioning, usual social activities and relationships with others and may necessitate hospitalization to prevent self-harm or harm to others. Episodes of mania, whose symptoms are the opposite of those denoting depression, are rarely seen alone. Usually, the manic state is preceded and followed by depressive periods in an alternating fashion, with each state lasting from many months to a few weeks, the latter being described as ‘‘rapid cycling.’’

This constellation of symptoms was known, until a few years ago, as manic-depressive disorder. Nowadays, it goes by the somewhat more cryptic label of bipolar disorder. The neurochemical basis of bipolar disorder is not exactly known. One of the most valid hypotheses regarding the neurochemical mechanisms of bipolar disorder is the synergy between two neurotransmitters that determine mood states, whereby a lower than normal release of norepinephrine produces a disordered mood (significantly higher or lower than the normal range), while the levels of serotonin determine the direction the symptoms will take, i.e. downward toward depression or upward toward mania.

What Bipolar Disorder Feels Like

The subjective experience of these intense mood swings ranges from abject despair and hopelessness to not entirely distressing and almost pleasurable. Depression produces a pervasive
and relentless sense of gloom, inadequacy, rumination, guilt, and worthlessness. No logic, willful effort or remembrance of wellness seems capable of dispelling these cognitive and emotional experiences, often for prolonged periods.

Mania reverses and accelerates upward from the disappearance of depression, through a state of well-being that can be considered a normal mood state. Normality soon becomes exuberance, enters into a state of unexplained euphoria, and finally culminates into a chaotic state of racing, incomprehensible, disconnected thoughts, and bizarre behaviors. Given a choice, the individuals so affected report that they much prefer the state of mania, in which they experience a release from inhibitions, a hedonistic focus, and a pursuit of pleasure and gratification that can be nearly devoid of accountability or restraint. Self-medication with alcohol and illegal drugs is often present in the manic phase, which sets up a circular relationship that exacerbates its symptoms and impedes treatment and recovery.

An individual in a state of mania can be frightening, annoying, or amusing to the casual observer. It is perhaps easy to overlook the nature of the behavior, especially when there is an assumption of intent. In most cases, however, the individual has virtually no control over thoughts, words and behaviors and little if any insight into their bizarre, provocative, and sometimes dangerous presentation. The loss of reality testing, judgment and moral restraint of bipolar disorder is sure to cause psychological pain to the people who experience it and to the people who love them. Mr. Charlie Sheen has been variously portrayed as victim and perpetrator, and variously diagnosed by experts and entertainment reporters.

Bipolar Disorder: A Brief History

The first connection between a manic state and depression as belonging to the same neurochemical disorder was established in 1686 by the French physician Theophile Bonet, who observed individuals who appeared to cycle between high and low moods, and described their presentation as ‘‘manico-melancolicus.’’ In the middle of the 19th century, two other French researchers, Falret and Baillarger, who had independently observed the same cycling of moods in their patients, arrived at the same conclusion that the symptoms must be two different presentations of the same illness. Falret described the disorder as ‘‘circular insanity’’  and hypothesized a hereditary component to the disorder. In the late 1800s to early 1900s, German psychiatrist Emil Kraepelin elaborated the description and classification for manic–depressive illness that is considered the standard presentation that we see today.

It was John F. J. Cade, a doctor in the Mental Hygiene Department of Victoria, Australia, who introduced and promoted the belief that manic–depression was a biological disorder of the brain. On the basis of his research on neurochemistry, Cade administered a lithium salt preparation to several highly agitated manic patients and observed a remarkable reduction in symptoms, with a near return to a normal mood state. Lithium is currently the standard of care for the pharmacological treatment of bipolar disorder, and still the most effective in the management of its symptoms.

Worst Stress Relievers: Pain Medication

painmeasurementscale Who is to say for sure how much pain I have right now, I had yesterday morning, or will have this afternoon?   Only I can know for sure the pain I am feeling—and I can lie, to myself and to others.  Herein lies the greatest challenge of addiction to pain medication. There is no objective measuring tool for pain. The best we can do is to ask the person to rate his or her own pain on a scale of 1 to 10, with all the accuracy that can be expected from such a subjective assessment, which isn’t very much because pain can always feel more intense than it actually is, physically or sometimes just psychologically.

The sad result of the greater availability of pain medication, its greater potency, the beneficial effects felt by the individual by taking what amounts to a legal hit of morphine is an ever increasing number of people who are dying from abusing or misusing pain medication.  Among some groups, deaths from prescription drug overdoses are more than ten times higher than they were in the late 1960s. These are the results of an age-period-cohort analysis using data from the US Vital Statistics and the US Census, available online.

In the absence of significant pain, prescription painkillers are ingested because of their very powerful relaxing effects on the central nervous system and for the sensations of well-being that characterize their action. The presence of hydrocodone, which is the equivalent of synthetic opium, in these drugs makes them highly addictive. The first signs of a painkiller overdose include loss of appetite, nausea, vomiting, stomach pain, sweating, and confusion or weakness. Later symptoms may include pain in the upper stomach, dark urine, and yellowing of the skin or the whites of the eyes. Overdose symptoms may also include extreme drowsiness, pinpoint pupils, cold and clammy skin, muscle weakness, fainting, weak pulse, slow heart rate, coma, blue lips, shallow breathing, or no breathing.

The rapid increase in mortality due to accidental poisoning that has been observed since 2000 is almost tenfold for whites and threefold for blacks over the study period. This appears to result at least in part from the coming of age of baby boomers who, as they age, are becoming addicted to prescription medications, most especially pain killers. The majority of prescription drug abuse involves painkillers, according to the Drug Enforcement Administration. In the US, Vicodin (containing acetaminophen and hydrocodone) is the most commonly abused prescription drug.

The greatest proportion of overdoses appears to occur in people in their 40s and 50s. While in 1968 about one per 100,000 white women in their early 50s died from accidental poisoning, the number has risen to 15 per 100,000 in 2007. Among black women of the same age, accidental poisoning deaths increased from about two per 100,000 to almost 17 per 100,000.

getty_rm_photo_of_woman_taking_prescription_pain_medication What’s the fix for this nationwide epidemic?  In the absence of an objective pain measure, it is hard to imagine how anyone can take exception to the screams of pain that can come from someone who is in the process of becoming addicted to pain medication, or already is.  Many doctors have taken the no-hassle course of prescribing, rather than questioning the veracity of the patient’s pain.  Many other medical practitioners, such as dentists and surgeons, have taken to dispensing large quantities of “samples” to patients who have had even the simplest procedure, “just in case you feel any pain.”  Of course, the patient takes the stuff, the pain (if any) goes away, and the powerful effects of the drug go to work by inducing a high that feels incredibly good. At this point, and in many sad cases, only a few short steps separate the patient from the addict.

More recently, the DEA has cracked down on pharmacies and doctors, with the intent of reducing the supply of these medications. More needs to be done to stop the flow, but also and most especially to educate the public on the potential addictive nature of these substances. They do work extremely well against pain, but at what cost?