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.

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.

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.

The History of Stress In Very Small Bites: 6

HansSelyeBy far the most important figure in the history of the concept of stress as applied to human behavior is Hans H. B. Selye (1907-1982), who is credited with starting modern research into the concept itself and its physiopsychological manifestations. In 1950, in addressing the American Psychological Association convention, Selye introduced his theory of stress reaction, which has since become the standard model of stress. In 1956, he published The Stress of Life, in which he elaborated his stress theory and perfected its definition of physiopsychological stress as “the nonspecific response of the body to any demand made upon it,” which could be a real or perceived threat, challenge, danger or change that requires the body and the mind to adapt.

Selye’s research made important contributions to psychology, biology and medicine. He had begun his work in 1926 when, as a second year medical student, Selye noticed many similarities among patients who, in spite of suffering from very disparate diseases, all seemed to have many symptoms in common. He would later describe this constellation of common symptoms as a syndrome, ‘‘the syndrome of just being sick.” 

His discovery of the stress response was a byproduct of his research on the effect of hormone injections in rats. Noticing that many of the rats became sick after receiving the injections and that the same sickness struck a control group of rats injected only with a neutral solution containing no hormones, he had the intuition that the rats could be having a reaction to the trauma of being injected rather than to the hormones. Selye surmised that being handled and injected caused high levels of sympathetic nervous system arousal in the rats, which eventually developed health problems such as ulcers. Selye coined the term "stressor" to label the traumatic stimulus that acted psychologically on the mind while at the same time producing a physical effect.

In refining his theory of the stress reaction, which he dubbed the General Adaptation Syndrome, Selye identified three distinct stages. The alarm reaction is the first stage, which occurs when the organism first becomes aware of the stressor. In the second stage of recovery or resistance, the organism mounts a response to the stressor, by mobilizing resources, using energy and repairing itself. The third stage of exhaustion occurs if the organism is unable to put an end to the stressor. This third stage also signals the onset of chronic stress.

With remarkable insight, Selye sliced the concept of stress into four variants. These he called eustress (the good stress caused by positive and exciting stressors), distress (the harmful stress caused by unpleasant or negative stressors), hyperstress (caused by stressors so overwhelming that they overcome all abilities of the body to adapt), and hypostress (the mildest stressors that barely cause a physical and psychological reaction, while still being noticeable).

Stress Like an Egyptian

hosni-mubarakPower stresses. Absolute power stresses absolutely. This easy paraphrase of a famous saying about the corruptive effect of political power can perhaps convey the enormous stress that tyrannical political power can cause at the micro and macro levels of a nation-state. The classic fight-flight-freeze stress reaction is magnified by the stark reality of the actual physical danger, and enormous emotional cost, that comes with ruling a country with an iron fist. An absolute ruler is nearly always unloved, feared, and only forcibly respected by his immediate entourage and of course even more so by his countrymen at large. This must be Mr. Hosni Mubarak’s plight right now, as his country of Egypt is in the throes of a more or less peaceful, and some say long overdue, revolution to overthrow his 40-year-old quasi-dictatorship. How is he coping?

The 82-year-old Mr. Mubarak is nothing if not a survivor of trauma. A seemingly perennial victim of acute traumatic stressors, he has survived three wars, an Islamic uprising and multiple assassination attempts. His beloved 12-year-old grandson, Muhammad, died suddenly of a brain aneurism. He came to power on October 7, 1981 when the president of Egypt, Mr. Anwar el-Sadat was assassinated not three feet away from then-vice president Mr. Mubarak in a hail of gunfire and grenades. It is possible that, since that day, Mr. Mubarak may suffer from posttraumatic stress disorder (PTSD).

This seminal traumatic event, and the others that followed, may have engendered in Mr. Mubarak a strong desire for safety and stability above all else. In the current circumstances, he has reacted to the calls for his resignation in true-to-character fashion with a staunch change-resistant response, which one Arab official has called, “his reflex adherence to the status quo.”

It is perhaps not coincidental that President Obama told reporters he believes that Mr. Mubarak’s decision not to seek reelection may represent an important “psychological break” that could transition the Egyptian president out of power. The decision must not have come easily for Mr. Mubarak, and must have required a significant departure from his usual modus operandi of maintaining the safety of the status quo.

Mr. Mubarak appears to have rationalized his deep-seated aversion to change and his need to ensure survival and safety for himself, his family and the country he rules, with a near-absolute belief that he is the only person who can guarantee Egypt’s political, economic and social stability. It is nothing short of a psychological drama that he is now the focus and the very symbol of Egyptian crisis, the very instigator of chaos on the streets and political and economic turmoil.

For 40 years, Mr. Mubarak has lived in splendid isolation from danger in the presidential palace in Cairo or at his private residence in the seaside community of Sharm el Sheik, both heavily guarded by a corps of bodyguards. His acquaintances describe him as a man who does not show emotion, who can be forceful and aggressive in pursuing his views, but maintains a near-absolute control over the privacy of his feelings. As if the world around him was just too dangerous to risk betraying the slightest hint of weakness.

The History of Stress In Very Small Bites: 5

WalterCannonA key figure in our understanding of the mind-body interaction and the concept of stress is American physiologist, professor and chairman of the Department of Physiology at Harvard Medical School, Walter B. Cannon (1871-1945). He is credited with the discovery of the process of homeostasis and the fight or flight stress reaction. In investigating the process of homeostasis, Cannon hypothesized that if a living organism is threatened by change, the change is automatically interpreted as threatening and corrective mechanisms are initiated to avert the threat or restore the status quo.

The research that made possible the discovery of the mechanism of homeostasis began with the study of the emergency function of the adrenal medulla. Cannon and his colleagues at Harvard University linked emotional excitement to the physiological changes that occurred in response to the secretions by the adrenal glands. Cannon hypothesized that the sympathetic nervous system is responsible for mobilizing the body’s defenses  during intense fear or rage. He correctly identified these emotions as the prime movers of the body’s mobilization toward meeting a physical or psychological danger. The pathway of mobilization (the hypothalamic-pituitary-adrenal axis, HPA) initiates in the hypothalamus, which stimulates the anterior pituitary gland to secrete the activating hormone ACTH, which in turn stimulates the adrenal glands to produce excitatory hormones that activate the body’s defenses.

Got idea that adrenals in excitement serve to affect muscular power and mobilize sugar for muscular use—thus in wild state readiness for fight or run! — Entry in Cannon’s journal dated January 20, 1911

In 1929, Cannon first used the term fight or flight response to describe this emergency mobilization. He attributed the system-wide arousal of the body to a neurochemical produced by sympathetic nerve endings which he called sympathin, now known as norepinephrine. Cannon began using the term homeostasis in 1932 to describe the body’s physiological processes, controlled by the sympathetic nervous system, aimed at maintaining or restoring a stable internal environment.

In time, Cannon came to conceptualize physical and psychological stress as disturbances of homeostasis under conditions of cold, lack of oxygen, low blood sugar, and powerful emotions such as fear and rage. It was the first connection ever made, and verified by laboratory research, between the disruption of equilibrium caused by stressors and the body’s attempts to meet the threat and restore balance.

The History of Stress In Very Small Bites: 4

robert-hooke-1It was towards the end of the 17th century that the word stress came to assume a technical meaning through the writing of English natural philosopher, architect and universal genius Robert Hooke. Hooke’s work was, among his many areas of interest, focused on how bridges and other man-made structures could be made larger and capable of bearing heavy loads without collapsing.

It is thanks to Hooke’s law of elasticity (1675) that the words load (the demand placed on the structure), stress (the area affected by the demand), and strain (the change in form that results from the interaction between load and stress) came into usage.

The study of stresses and tension (another word generated within this context) eventually produced the idea that the workings and architecture of the human body were much like the machines and structures that were being invented and constructed during this time. This idea spawned another idea that profoundly influenced the way we think about stress. The idea followed the concept of the body as a machine to its logical conclusion: If mechanical structures are subject to wear and tear, and the body is built and behaves in a similar fashion, then so would the body suffer the impact of the wear and tear of life.

The History of Stress In Very Small Bites: 3

WilliamJamesAmerican psychologist William James (1842–1910) is credited with an important contribution to the understanding of stress and the interplay of physical manifestations and emotions. In his most important book, The Principles of Psychology, Vol.1 and Vol. 2 , James sets out the theory that bodily expression of stress, such as trembling or faster heart beat, precede rather than follow emotion. This view matters in that it seeks to tie emotions directly and perhaps causally with bodily expressions. Whether one comes before the other is less important than the fact that the physical and the emotional appear inextricably connected, in the wholeness of the human experience. What, James asks, would grief be “without its tears, its sobs, its suffocation of the heart, its pang in the breast-bone?” Not an emotion, James answers, for a “purely disembodied human emotion is a nonentity” (p. 1068).

Common-sense says, we lose our fortune, we are sorry and weep; we meet a bear, we are frightened and run; we are insulted by a rival, we are angry and strike. The hypothesis here to be defended says that this order of sequence is incorrect… that we feel sorry because we cry, angry because we strike, afraid because we tremble… (Principles of Psychology, pp. 1065–6).

IndustrialRevolutionContemporary to James is the novel view of physical fatigue as both a mental and physiological phenomenon. By the late 19th century, the word fatigue was being used in connection with mental hygiene as pertaining to work performance and industrial efficiency. The industrial revolution, realizing that efficiency and high productivity could create significant psychological problems, required a re-organization of the workplace that reduced symptoms of emotional and mental instability and enhanced the workers’ adjustment to what at the time were far less than ideal working conditions. The profit motive fostered this seemingly unlikely marriage between productivity and mental health. Industry became concerned with the loss in industrial efficiency and sought to prevent it by improving the workers’ physical and mental health. This development led to the new disciplines of organizational psychology and ergonomics, the design of equipment that minimizes negative health consequences.

The History of Stress in Very Small Bites: 2

descartesIn the 17th century, French philosopher Rene Descartes, without addressing the concept of stress reaction in his writings, nonetheless had a profound impact on psychology, the new scientific pursuit of many of his contemporaries who were beginning to understand the impact of psychological stress on human functioning.

Descartes’ thoughts also touched on the relationship between mind and body. In his view, mind and body were clearly separated, although he recognized that the body could somehow influence the mind, or vice versa. In particular, as Descartes put it, 

…as regards the soul and the body together, we have only the notion of their union, on which depends our notion of the soul’s power to move the body, and the body’s power to act on the soul and cause its sensations and passions (Descartes, R., Oeuvres de Descartes, 11 vols., eds. Charles Adam and Paul Tannery, Paris: Vrin, 1974-1989.)

georgebeardAn important contributor to the understanding of psychological stress was the noted American physician George Beard (1839–1883), a specialist in diseases of the nervous system. Beard hypothesized that the newly imposed demands of the Industrial Revolution on 19th century life may cause an overload of the nervous system.

He variously labeled this overload as neurasthenia, a weakness of the nervous system, or nervous exhaustion. This condition, very much equivalent to our modern understanding of chronic stress, was characterized by Beard has exhibiting symptoms of severe anxiety, unexplained fatigue, and irrational fears—a state of affairs that caused an inability of the individual’s nervous system to meet the demands of daily life.

Disaster! 9 Critical Crisis Management Skills

aaCezanne_BendOfRiverDisaster strikes…an event with sufficient impact to produce significant emotional reactions, and one that can carry significant consequences. In the range of our ordinary experience, such an event may be extremely unusual. Perhaps it is the first time that we have been in a car wreck, an earthquake, a flood, lost our job, missed the mortgage payment, or discovered a very unpleasant and unexpected truth about a person or a situation. The first time, any of these events constitute a serious crisis, with wide-ranging impact. The second or third time, these events continue to be real crises but may be approached with enhanced skills and capability to cope with their aftermath.

Whenever and however often these critical and extremely stressful events may occur, a few outcomes can be predicted as very likely to be experienced by most people. First, there will be potential and actual traumatic reactions to the event or incident, either immediate or somewhat delayed. Expecting no reaction or minimal reaction is unlikely, and a severely restricted reaction or no reaction at all may be a sign of poor cooping skills, an attempt to deny the impact of the stressor, or to minimize its seriousness. Second, there will be acute manifestations of stress (some purely psychological, other physical, or a combination of both) that must be managed and mitigated. Third, the stressful event may have an impact on the individual’s ability to function in his/her usual occupation, school, or even in carrying out daily routines. Fourth, the stressor may be of such magnitude and effect that short-term psychological or medical treatment may be necessary. Fifth, the best mitigating effects are produced by family support, peer group support and continued interaction in the workplace; isolating is an instinctive reaction when in emotional pain, but it is proven to be counterproductive when dealing with a severe stressor.

In critical incidents or severe stress situations, the first 24-72 hours after the event are the most crucial. It is important to provide to others or seek out for oneself a reduction in the intense reactions to the traumatic event. While it is normal and expected to have a stress reaction, even severe, people should be facilitated in their return to their routine as quickly as feasible. In this respect, re-establishing access to one’s social network prevents isolation and reduces anxiety. In recognizing similarities to others, being understood and supported while in pain, and not being judged or criticized for their reaction, people often are better able to cope with the challenges of troubled times.

Here are 9 ways of managing acute stressors that have been proven to work:

  1. Reaction. Allowing ourselves to have an appropriate reaction that is physical (e.g., crying), psychological (feeling upset), and social (reaching out for help), without much concern for how our grief or sorrow may “damage” our image with others. An attempt to look strong and to show no emotion in the face of a significant stressor may work in the short term, but if the reaction to its impact is not allowed to take place, this may create a situation of chronic stress over time.
  2. First Aid. Psychological “first aid,” education and follow-up are important. Talking to trained peers, chaplains, and/or mental health professionals may be just what is needed in the critical first few days following the incident. Longer term counseling or medical help may be needed to manage any anxiety or mood disorders (such as depression) that could be triggered by the stressor.
  3. Comfort. The basic human needs to be comforted and consoled when in distress and being protected from further threat or distress, as far as is possible, are important. This may mean moving away from the scene of the incident at least for a time. It is not unusual to need and benefit from a few days out of town visiting welcoming family members or very close friends, following a disastrous event or a major personal crisis.
  4. Basic Needs. Immediate care is needed to address any physical necessities caused by the severe incident. In the case of a natural disaster, shelter, food and warmth become critically important and take precedence over psychological interventions.
  5. Reality Testing. Seeking goal orientation and support for specific reality-based tasks (“reinforcing the concrete world”) is important in mitigating the effects of a severe stressor that may make the individual feel like “the world is coming to an end” or “this is too much to even comprehend” and any severe symptoms of derealization or detachment.
  6. Relationships. It is important to facilitate the reunion with loved ones from whom the individual has been separated. If this disruption of relationship occurs, reuniting parent and child, or spouses, or siblings, is critically important. If an immediate reunion is not possible, providing good information as to the loved ones’ whereabouts and health is the next best thing.
  7. Talking. At the earliest opportunity, the telling of the “trauma story” and the expression of feelings as appropriate for the particular individual should be facilitated. Even though not everyone may be willing to go into details as to what happened, at least not right away, providing the earliest opportunity to say what happened and what it means to the person affected is critically important.
  8. Ongoing Support. If the individual seems to be “lost” in the magnitude of the event, linking the person to systems of support and sources of help that will be ongoing is never a bad idea. The key is the continuity of support. For some incidents or severe stressors such as the loss of a loved one, this support may need to continue for weeks and months to come.
  9. Regaining Mastery. Eventually, after all the critical “first aid” interventions have been taken care of, the goal becomes the restoration of some sense of mastery, a regaining of control over one’s life, a new beginning and the ability to deal effectively with the new situation created by the incident. The memory of what happened will most certainly never go away, but its traumatic impact on distress and functioning is meant to fade over time, when new ways of coping have been successfully put in place.

The History of Stress in Very Small Bites: 1

I did consent,
And often did beguile her of her tears
When I did speak of some distressful stroke
That my youth suffer’d.
William Shakespeare (1605) THE TRAGEDY OF OTHELLO, MOOR OF VENICE

Here can I sit alone, unseen of any,
And to the nightingale’s complaining notes
Tune my distresses and record my woes.
William Shakespeare (1595) THE TWO GENTLEMEN OF VERONA

william-shakespeare-portraitFrom the vulgar Latin districtia (being torn asunder), through Middle French destrece,  Middle English distresses, modern English distress and, by aphesis, stress. Used in the 15th century to mean applied pressure or physical strain, in the 17th century the word stress began to be used to mean hardship or adversity.

In the 20th century, stress took on its current meaning of psychological disturbance, ill health and mental disease. Using the physiological concepts of stimulus and reflex arc, freudSigmund Freud enlarged the concept of stressors to include internal “stimuli of the mind” which he called instincts. As opposed to an external stressor, an instinct “never acts as a momentary impact but always as a constant force. As it makes its attack not from without but from within the organism, it follows that no flight can avail against it.” "Instincts and Their Vicissitudes," in Collected Papers of Sigmund Freud, ed. Joan Rivière, Vol. IV (New York: Basic Books, 1959), p. 69.

The Cardiopsychology of Stress

Happy2011What effect does psychological stress have on cardiovascular physiology? Does psychological stress contribute to cardiovascular disease? These important questions are the domain of cardiopsychology, the discipline that studies how psychosocial stressors impact the onset, course, rehabilitation and the illness processing (coping) of cardiac diseases. In this post, we look at the effects of stress on the normal heart in healthy condition, and the effects of acute or chronic stress on individuals with cardiovascular disease.

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Tuvalu_EN-US163122471The body responds to stress primarily through the mobilization of resources initiated by the autonomic nervous system and endocrine activity. Endocrine activity consists of sympathetic adrenomedullary, pituitary-adrenocortical, and thyroid responses. The most important stress hormones released by sympathetic adrenomedullary response are epinephrine and norepinephrine. The stress hormones released in the pituitary-adrenocortical response are adrenocorticotrophic hormone (ACTH) and cortisol.

Psychological conditions shown to have an effect on cardiovascular disease include anxiety disorders, panic disorders, and depressive disorders. There is compelling evidence that acute psychological stress triggers major autonomic cardiovascular responses and cardiac events. Nonetheless, the evidence that chronic stress causes cardiovascular disease is highly controversial. Although the most prevalent opinion among cardiologists, psychiatrists, physiologists, and psychologists is that psychological stress has an effect on cardiovascular disease, these effects are not easily quantifiable or attributable with any degree of precision. What we do know is that acute stress is often accompanied by cardiovascular changes, some of which can be dangerous to certain individuals.

Data on whether chronic stress may, over time, cause cardiovascular disease are less convincing. For example, there is little validated evidence that people with anxiety-related disorders have a higher prevalence of cardiovascular disease than their less anxious counterparts. Moreover, except for postmyocardial infarction depression, there is insufficient evidence that individuals with cardiovascular disease have a higher prevalence of psychological disorders than those who have no cardiovascular disease.

{tab=Normal Heart}
MaldiveAtolls_EN-US1893647453Acute mental stress alters baseline parameters on the normal heart and vascular system in good health condition. Under acute stress, it is quite normal for blood pressure to rise, due to the action of neural mechanisms that regulate stress-induced blood pressure changes as a stress reaction to a dangerous situation that requires an increase in cardiac activity.

Structures of the central nervous system involved in this rapid arousal include the medulla oblongata, the medial geniculate body, the limbic system (amygdala and hypothalamus), and the brainstem. Psychological stress-induced changes in blood pressure are usually predictable and can vary depending on many variables, including duration of stress, time of measurement, expectations, psychological preparedness, and individual background.

Specific effects of psychological stress on the cardiovascular system are increased cardiac output, higher stroke volume, stronger forearm blood flow, increased left ventricular ejection fraction, higher peripheral vascular resistance, and increased cardiac microcirculation. These effects are not dangerous on the normal heart and vessels in good health condition, and they generally subside and return to normal levels after the stressor has passed.

{tab=Acute Stress}
SnowyChristmas_EN-US2022031457As in the healthy heart, acute stress increases blood pressure (generally by 10–20% and sometimes to hypertensive levels) in individuals with cardiovascular disease. Acute stress also increases the heart rate of individuals with cardiovascular disease, and angina pectoris and ischemia may result from this increase in heart rate. In some cases, the stress-induced increase in heart rate also alters cardiac electrical stability and may cause life-threatening arrhythmias.

Acute stress may also cause coronary artery vasoconstriction, reduce left ventricular ejection fraction, and induce or exacerbate left ventricular wall motion abnormalities in individuals with cardiovascular disease. In this respect, studies have shown that frequent anger among individuals with cardiovascular disease may increase their vulnerability to cardiac complications.

Psychological stress produces strong limbic-hypothalamic activity, which may contribute to the yet unclear etiology of essential hypertension, i.e. high blood pressure that does not appear to have specific organic causes. Conversely, the presence of hypertension, borderline hypertension, and genetic risk for hypertension may have an impact on blood pressure reactivity to psychological stress, thus setting up an apparent circular causality between stress-hypertension-higher reactivity to stress.

Individuals with high blood pressure are characterized by a greater arterial wall-to-lumen ratios compared with healthy individuals. Thus, the same quantity of norepinephrine causes a greater increase in peripheral vascular resistance compared to healthy individuals who have a smaller arterial wall-to-lumen ratio. Also, individuals who are already suffering from angina pectoris react to stress with a greater elevation of blood pressure.

{tab=Chronic Stress}
KugaCanyon_EN-US1699950676Chronic stress and prolonged bereavement have been shown to increase the risk of cardiac death. A large-scale study showed that stress due to the death of the wife caused a 40% increase in the death rate of the surviving husbands during the first 6 months of loss, with two-thirds of those deaths attributable to cardiovascular disease. A similar increases did not occur among widows following the death of their husbands.

Studies conducted on individuals who exhibit type A and type B personality patterns have tested the hypothesis that personality may affect the inset, course, and outcome of cardiovascular disease. Type A personalities are those characterized by time-urgency, high competitiveness, ambitiousness, and frequent hostility. Type B personalities are unhurried, more relaxed, and less competitive. The results of these studies show that if there is a correlation between personality patterns and cardiovascular disease, this correlation is very weak. Thus, type A or type B personalities appear to have similar outcomes in the convergence of stress and cardiovascular disease.

Anxiety is a significant factor in producing chest pain even when coronary arteriography is normal, and anxiety disorders have been confirmed as a debilitating factor. Major depressive disorder is the second significant factor, and this disorder appears to predict future cardiac events among patients with coronary artery disease. Chronic anxiety, helplessness, and depression have been specifically linked to angina pectoris and sudden death by cardiac arrest. More than 300,000 Americans experience sudden (within minutes) death each year. Excluding acute myocardial infarction-induced ventricular arrhythmias, about one in ten sudden deaths are due to cardiac arrhythmias (particularly ventricular arrhythmias).

Research by Rahe and others on the health impact of significant life changes discovered that individuals who suffer a myocardial infarction are more likely to have had a major life change during the 6 months preceding the heart attack. In another study, Rahe and Lind provided evidence that life change occurs more frequently among victims of sudden cardiac death compared with survivors of myocardial infarction.

The relationship between chronic psychological stress and hypertension remains controversial. Psychological stress-induced increases in heart rate and blood pressure reactivity do have an immediate effect on blood pressure readings. Nonetheless, this clearly demonstrable increase in blood pressure following a sudden and significant stressor does not appear to carry on to produce long-term effects on blood pressure.

In summary, the extent of coronary artery disease, the degree of left ventricular dysfunction, and the presence of arrhythmias appear to determine individual vulnerability to stress-induced sudden cardiac death. When individuals are already suffering from advanced cardiovascular disease, stress-related precipitants of sudden cardiac death are ubiquitous and may be impossible to avoid. Acute stressors often contributing to sudden cardiac death include bereavement, unemployment, financial distress, dislocation, lower education levels, individual responses to psychological stress, and social isolation. Research results are somewhat contradictory in establishing a clear association between cardiovascular disease and such factors as gender, personality patterns, anxiety, panic disorder, PTSD, bereavement, depression, and occupation.

{tab=References}
REFERENCES
1. Dimsdale JE. Psychological stress and cardiovascular disease. J Am Coll Cardiol 2008;51:1237– 46.
2. Culic V, Eterovic D, Miric D. Meta-analysis of possible external triggers of acute myocardial infarction. Int J Cardiol 2005;99:1– 8.
3. Kloner RA. Natural and unnatural triggers of myocardial infarction. Prog Cardiovasc Dis 2006;48:285–300.
4. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. J Am Coll Cardiol 2007;49:1230 –50.
5. Smith SC Jr., Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol 2006;47:2130 –9.
6. Bhattacharyya MR, Steptoe A. Emotional triggers of acute coronary syndromes: strength of evidence, biological processes, and clinical implications. Prog Cardiovasc Dis 2007;49:353– 65.
7. Davidson KW. Emotional predictors and behavioral triggers of acute coronary syndrome. Cleve Clin J Med 2008;75 Suppl 2:S15–9.
8. Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol 2005;45:637–51.
9. Strike PC, Steptoe A. Behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique. Psychosom Med 2005;67:179–86.
10. Strike PC, Magid K, Whitehead DL, Brydon L, Bhattachatyya MR, Steptoe A. Pathophysiological processes underlying emotional triggering of acute cardiac events. Proc Natl Acad Sci U S A 2006;103:4322–7.
11. Thrall G, Lane D, Carroll D, Lip GY. A systematic review of the effects of acute psychological stress and physical activity on haemorheology, coagulation, fibrinolysis and platelet reactivity: implications for the pathogenesis of acute coronary syndromes. Thromb Res 2007;120:819–47.
12. Tofler GH, Muller JE. Triggering of acute cardiovascular disease and potential preventive strategies. Circulation 2006;114:1863–72.
13. Rahe, R., & Lind, E. (1971). Psychosocial factors and sudden cardiac death: a pilot study. Journal of Psychosomatic Research, 15(1), 19.

{/tabs}

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.

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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When Stress Hurts: The Credibility Gap

StMarksSquare_EN-US761640507How the brain processes and maintains psychogenic pain is the subject of this, the fifth post in the series on the close association between psychological stress and psychogenic pain. Hope is hard to come by for swift and lasting relief of chronic back pain, muscle pain, headaches, migraines, stomach pain, and other stress-related conditions. Medication can help but carries the dangers of addiction or dependency. Non-medical remedies do exist and can work well, but may not be as well known or easy to apply. So the pain continues without relief in sight. And then there is the credibility gap.

Unbelievable Pain That Is Hard To Believe

Even though there is no diagnosable medical condition in the body, and even though
the physical injury that may have originated the pain is now healed, the pain is real. Unexplained. Mysterious. Intense. This is hard to accept by the sufferer, by family and friends, by physicians and pharmacists. There is no “proof” of its existence or intensity that anyone can see. This apparent credibility gap, in itself, creates additional stress to the pain sufferer, which (you guessed it) creates even more pain.

The best illustration, and the best indirect proof that psychogenic pain is real, is offered by “phantom limb” pain, a well-known condition not uncommon among amputees. Significant pain is felt in an arm or a leg that has been amputated. Clearly, there can not be anything wrong with a limb that is no longer there—yet this pain can be excruciatingly intense. What’s going on? What we know about phantom limb pain is that it is created by overly sensitized nerve endings that stop at the point of amputation, but continue to transmit previously learned and now outdated pain information along “stuck” pathways to the brain, as if the arm or the leg was still there. These pathways produce a continuing cycle of pain that can last for months, years, or even decades.

A similar phenomenon of “stuck” pathways takes place in psychogenic pain. Let’s see how it works.

How the Brain Processes Psychogenic Pain

Psychogenic pain is produced when overly sensitized nerve pathways are established between the brain and certain parts of the body, which may be initially provoked and later maintained by a continuing psychological stressor.  The nervous system learns to process psychological distress along these neural pathways (exactly why this happens we aren’t quite sure) and the longer the stress goes unattended, the more sensitized and overactive these peripheral nerves become, producing significant amounts of pain to the muscles, the head and other parts of the body.

The brain interprets these nerve signals and transforms them into the experience of pain. The event that started this learning process in the nerves may have been an injury or a stressful event earlier in life, or the pain may just appear without any directly verifiable reason. Only a careful and detailed look at our current situation and life history can reveal the stressors that may have originated and continue to maintain psychogenic pain.

The Case for Fibromyalgia

Musculoskeletal pain localized in the lower back, shoulders, and arms appears frequently to be unrelated to physiological disease. Fibromyalgia has reportedly become one of the most frequent reasons for patient referrals to rheumatology clinics. It is a disorder that affects many musculoskeletal structures and is characterized by persistent pain, sleep and mood disturbances.

Fibromyalgia origins have been traced to stuck pain pathways in the central nervous system, which cause decreased levels of pain-reducing serotonin and increased levels of substance P in the cerebrospinal fluid. These pathways are further reinforced over time by a stress reaction to the pain. Just about everyone who has chronic fibromyalgia pain reacts to it with fear, anger, anxiety, frustration, and other negative thoughts and emotions. Anger and sadness specifically have been recently linked to an increase in fibromyalgia pain.

Psychological stressors, negative thoughts and emotions, conscious or subconscious,  thus appear to be major causative factors in psychogenic pain and its related syndromes, such as fibromyalgia. The decreased activity, diminished income, difficult relationships that are byproducts of constant fibromyalgia pain do nothing but add to the misery of it all, making the pain-producing nerve pathways even stronger.

In our next and final post on this series we will take a look at the medical and non-medical remedies that have been devised to cure psychogenic pain.

Previously in this series:

Next:

  • Medical and Non-Medical Treatments for Psychogenic Pain