( By K. P. S. Kamath )

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Stress-related Disorders and Treatment

1.What are various stress-related disorders?

When the balloon pops, one of four types of stress-related disorders could occur.

  1. Seemingly serious physical symptoms but no medical findings: Paralysis, blindness, deafness, loss of speech, numbness, pain somewhere in the body, dizziness, muscle twitching, seizures, exhaustion, loss of taste and smell, fainting spells, and many other similar symptoms. Repeated physical examinations and tests reveal nothing to explain the symptoms. Many patients in this category get a diagnosis of hysteria, somatization disorder, conversion disorder, atypical panic disorder, etc. Very often these symptoms stand for something the patient is trying to communicate non-verbally as we read before.

  2. Psychiatric disorders: Some common disorders in this category are mood disorders (major depression, bipolar disorder); anxiety disorders (panic disorder, generalized anxiety disorder, obsessive compulsive disorder, post traumatic stress disorders); psychotic disorders (free standing or associated with mood disorders). Postpartum depression, post-menopausal depression are also in this general category.

  3. Physical illnesses: High blood pressure irritable bowel syndrome, ulcerative colitis, heart attack, asthmatic attacks, stomach ulcers, fibromyalgia, chronic fatigue syndrome, migraine headaches, and other disorders.

  4. Disorders caused by bad habits: As we read before, many stressed-out people indulge in smoking, drinking alcohol, overeating, illicit sex and other vices which could lead to various serious physical disorders such as cancer, AIDS, heart and lung disorders, etc.

2. What is the process of treatment?

The first visit: In the initial psychiatric evaluation, the treating doctor takes a detailed history of the patient?s life. His job is no different than that of a detective collecting information from a witness at the scene of a crime. He begins by inquiring about various symptoms the patient currently suffers from, which necessitated the appointment with the doctor: ?What are your current symptoms that bother you?? He obtains information about the onset and chronology of progression of patient?s symptoms by intensely listening to and frequently empathizing with the patient?s suffering: ?You have had these symptoms for 6 months? Not having slept well for six months must make you feel tired all the time!? A doctor who is without empathy for the patient?s suffering would be unable to obtain important information needed to have a complete picture of the patient?s disorder. Nor would his treatment be successful.

The doctor would then obtain present history of the patient by inquiring into recent events and problems related to his family, friends and job. He would try to identify the recent precipitating event leading to popping of the balloon. The doctor would then carefully and gently probe into patient?s past history: his birth, childhood, adolescence and adulthood; and his relationships with important people in his life. The doctor would also try to find out, without exploring too vigorously, various traumatic experiences and situations the patient has been through in the past as well as more recently. He would then gently explore various painful emotions the patient had experienced in connection with recent traumas and situations. By now most patients break down and express their emotions such as sadness, helplessness and hopelessness related to their suffering as well as their ordeal with their illness.

This whole process is akin to playing tennis. A good tennis game consists of one serving the ball and the other returning it, and so on. The more the patient recognizes that the doctor is listening, empathizing, accepting and being kind, the more the patient would trust him with the information needed to help him. Experienced doctors are able to do this effortlessly in a very short time, say twenty minutes. The patient might give the doctor hundreds of bits of information at random. It is the job of the doctor to absorb these bits, put them in proper slots in his own mind, and make sense of them. Before long, the doctor has put the whole jigsaw puzzle together.

The doctor would then explain to the patient the connection between various life experiences and his persistent symptoms. A white board would serve this purpose well. Usually the patient is pleasantly surprised by the fact that seemingly unconnected events, problems, situations, emotions, actions and symptoms are all neatly connected. All of a sudden, it all makes sense. This look inside his mental processes is known as insight. The patient begins to become aware of his painful emotions and often releases them through crying, sighing or sobbing out of relief. Before the end of the first session, most people?s balloon has begun to shrink. Most feel significant improvement immediately thereafter. The doctor then recommends appropriate medication treatment to enable the patient to embark upon his path of recovery.

Treatment depends on the stage of stress at which the patient seeks help. If the patient is at Stage Two, the stage of distress, he is merely going through rough times.

Most often the person is grieving over a loss. Or he might be trapped in a life problem. As the patient is fully aware of his life situation, talking therapy alone might be enough. Some of these patients might need a small dose of sleeping aid or tranquilizer to help get through the difficult time.

If the patient is at Stage Three, the stage of low stress tolerance, he would need talking therapy to help him to raise his awareness about the buried emotions and to shrink his balloon. If symptoms are bad enough, these patients might need medications as well on a temporary basis. However, most people at this stage are reluctant to receive psychiatric treatment as their symptoms are progressing almost imperceptibly, and they have made their peace with it. They consult psychiatrists only after their balloon has popped. Many of these people are under the care of their clueless family doctors for numerous ailments and are already taking antidepressant and many other medications.

If the patient is at Stage Four, the stage of disorder, he is clearly down with a disorder such as major depression or panic disorder. Since they now are said to have a ?chemical imbalance? most of these people would need medication therapy, at least till they have learned newer coping skills. Right medication given in appropriate doses gradually reverses the chemical imbalance and causes stress symptoms to improve or disappear within in 4 to 6 weeks. Counseling to help them to deal with both immediate and chronic stressors is essential once the patient has good control of his symptoms. The practice of getting counseling before complete control of symptoms is fraught with the danger of making medications ineffective. On the one hand we are trying to coat the balloon with medication; on the other hand, we are shaking up the patient?s soda bottle in counseling, and thus making the balloon get even bigger. It is like telling a patient with broken arm to get into physical therapy immediately after a plaster cast is put. This kind of mindless ?therapy? happens all the time because the therapists often do not have a clear idea of the process of healing. A lot of these people end up in psychiatric hospital immediately after the ?therapy? begins.

It is almost impossible to convince most chronically ill people to get into counseling. In fact, most acutely ill people refuse to pursue counseling immediately after they feel better with medication treatment alone. The best results are obtained when medication therapy is combined with education (reading a book like this or attending a seminar on stress management) and counseling (to help deal with stressors such as unfinished grief, marital problems etc.).

Follow-up visits: Most patients notice a significant improvement by the time they come back for their follow up visit two weeks later. This is not because of medication treatment, but because their balloon has shrunk due to the beneficial effects of the first interview. The first office visit reassured them and made their fear of psychiatrist and treatment go away. Since they are now doing something about their disorder, they no longer feel helpless, hopeless and frustrated. Knowing that they now are under the care of a competent doctor; that they are not going crazy; that they can get hold of the doctor whenever they want to; that the treatment would not cost them an arm or a leg; and many other factors like these cause their balloon to get rid of fear, helplessness and hopelessness. Now that the balloon has shrunk significantly, they feel better. However, they must still address issues that brought on their disorder in counseling.

If patients return two weeks later to report, ?I am worse than ever!? it is usually because the patient has a secret agenda which he has not revealed to the doctor. It could be he wants to go on disability; he wants to get off work on sick leave; he wants addictive drugs, or something else which he has not told the doctor as yet. The doctor must know that he can?t save them all.

Nearly 75% of people in stage four receive medication treatment for many years or forever because of their inability or unwillingness to change, or to learn newer ways of coping with stress. Most of my clients do not read this guide even when I give them a free copy of it. Most have lost their copies within a few days. Others say they don?t have time to read it. Still others come up with excuses such as, my dog ate it. Indeed, the dog looks very calm and completely relaxed after eating this book!

About forty percent of my new clients are temporarily ?cured? with treatment within eight months. They somehow shrink their balloon and feel better. They are able to wean themselves off of medications. Many of them develop a second breaking point some years later as they have learned nothing about why they had their first episode in spite of my best efforts. Of the remaining sixty percent, many drop out and focus on their physical disorders adding to health care cost. To them, somehow running to doctors for physical ailments seems much more acceptable than having to talk or think things out. Others continue on their medications for ever. This latter group might need additional medications every two or three years, as they develop what is known as ?breakthrough? disorder. This means the pressure in the balloon has broken through the coating of medications over the balloon (see below).

As years pass, it takes almost nothing to precipitate a major episode of a disorder. Their balloon is so full and so ready to pop that even an insignificant event such as minor illness of spouse is enough to bring on a bout of depression or anxiety attack even when the balloon is fully coated with one or more medications. The interval between these episodes gets shorter and shorter. These people have almost no ability to recognize a precipitating event. They are neither aware of how they feel about it, nor are they able to verbalize their emotions. They don?t see any connection between an obviously stressful event and onset of their episode, partly because the event seems so trivial. The focus of treatment now is squarely on supportive therapy (being kind and understanding), medication and more medications. Many of these patients are constantly on the verge of committing suicide. Some ultimately graduate to stage five.

It is almost impossible to help patients who are at Stage Five. Most of them are under the care of family physicians or specialists for serious medical diseases such as heart disease, high blood pressure, obesity, or suspected rare disease such as Lyme disease, chemical allergy, etc. Some of them have given up any effort to get well. Besides, many of them are secretly fearful of getting better for fear of losing disability benefits or attention of their loved ones. Suicide is fairly common. They trust no one with their head.

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