Sunday, July 17, 2005

Stress and the Current State of Affairs - Dr Kamath

1. Why you should know something about stress

While moderate amount of stress is essential for normal growth and maturation, excessive stress combined with poor coping and managing invariably leads to loss of tranquility of mind; emotional disorders such as anxiety and depression; and physical disorders such as obesity, high blood pressure, fibromyalgia, chronic fatigue, irritable bowel syndrome, and many other disorders.
Stressed-out people often resort to drinking alcohol, taking street drugs smoking cigarette and overeating, gambling and promiscuous sex in a futile attempt to cope with their stress, not to mention driving around aimlessly. These bad habits, in turn, often cause, or contribute to, heart disease, liver disease, lung disease, stroke, diabetes, arthritis, high blood pressure, sexually transmitted diseases and other common serious physical disorders, not to mention financial problem.
Long term adverse consequences of these bad habits and complications thereof on family, marriage, children, society, personal finances, healthcare cost and national economy are mind-boggling. Over 50 per cent of my patients grew up in families with at least one alcoholic or drug-addicted parent. Over 75% of emergency room visits and 90% of hospitalization are for disorders directly or indirectly caused by stress.

2. Why are people referred to psychiatrists?

The myth that only so-called crazy people see psychiatrists is deeply ingrained in the minds of many people. “I am not crazy; I don’t know why I am here!” is the defensive statement I often hear from patients when they see me for the very first time. Indeed, a very small percentage of people treated by psychiatrists can be truly branded as “crazy” or “psychotic.” Even psychotic disorders, in which patients experience delusions and hallucinations, are now amenable to treatment if the patient cooperates with the doctor.
These days psychiatrists treat a whole cross section of society: doctors, lawyers, accountants, nurses, contractors, laborers, car dealers....... Almost all of these people are well-functioning, productive people in the society. They consult psychiatrists because they suffer from various persistent or recurrent physical and/or mental symptoms for which their personal physicians have found neither a physical basis nor medical relief. Suspecting underlying psychological factors as the cause of these persistent symptoms, physicians refer them to psychiatrists.
Some common persistent stress symptoms are: sleeplessness, exhaustion, loss of appetite, weight loss, poor concentration, loss of interest in usual activities, tearfulness, pain attack somewhere in the body, anxiety, tension, relentless worrying, panic attack, nervousness, crying, aches and pains all over the body, etc. Some common stress symptoms that appear episodically are: chest pain, stomach ache, flip-flopping of heart, shortness of breath, headache attacks, panic attacks, etc.
When no identifiable physical basis is found for these symptoms, they are referred to as stress-related. Stress-related does not mean one is imagining or faking his symptoms. It simply means that the symptoms are caused by chemical changes in the brain brought on by stress. Yes, what we think or how we feel affects every organ in the body.

3. How do people react when told their physical symptoms are stress-related?

Since most stressed-out people do not know what stress is or how stress could cause various frightening physical symptoms, they often assert that stress has nothing to do with their symptoms. A lot of them, especially the ones with severe physical symptoms, say, severe chest pain, or shortness of breath, are shocked out of their wits when told that there is nothing physically wrong with them. Their common question is, “How can my mind cause this chest pain?” Reassurance that there is nothing physically wrong with them often makes them feel worse instead of better! They would rather be told they had a heart attack! Such is the dread people have about so-called “mental illness.”
Some of these people try to cope with their predicament by indulging in a little bit of self-deception: “I have no more stress than any one else! This can’t be stress! I am not imagining this. I handle my stress just fine. My doctor does not know what he is talking about! He must have missed something!” Baffled and scared, they redouble their efforts to establish a physical basis for their symptoms by going on an expensive medical wild goose chase. They consult various hotshot specialists, undergo expensive tests, and often visit well-known medical center such as Mayo Clinic without getting an iota of benefit. Every year billions of dollars are wasted by stressed-out people on unnecessary medical tests and procedures. Uninformed doctors become their unwitting partners in this medical merry-go-round. Neither the medical community at large nor the health insurance industry has a clue about this major healthcare issue.
When, as it happens on rare occasions, people do admit having stress they insist they handled their stress well. When asked what they meant by stress or how they handled it, however, they are at a loss for words. Because of the ignorance about the phenomenon of stress and the stigma attached to the so-called mental illness people rarely consult psychiatrists before ordinary stress has progressed into a serious stress-related disorder such as depression, panic disorder and the like. Many are forced into treatment by family members, employers or legal authorities as a result of their dysfunctional behavior at home, at work place or in the community respectively. It is the goal of this little guide to remove these two scourges of mankind: Ignorance about stress and stigma of mental illness.

4. What do doctors tell patients with stress-related disorders, and why?

When patients ask their doctors, “Why do I have this depression/anxiety disorder?” the commonest answer given even by some experienced doctors these days is, “You have a chemical imbalance.” The clear-cut message to the patient is: “This is a medical illness, no different than diabetes. We now have medications available to correct your chemical imbalance. This is not caused by a weakness in your personality. You are not responsible for having this problem. There is no need for you to be ashamed of it. So do not be so hard on yourself.”
Until the advent of psychotropic (“mind-altering”) drugs about 50 years ago, our understanding about various psychiatric disorders was based on various complicated theories proposed by psychoanalysts such as Sigmund Freud. To an average doctor, these theories were extremely complicated to understand and even more difficult to apply in the evaluation and treatment of “mental” disorders. Doctors often tried to apply these theories in practice without much success, or with hilarious results. Another common explanation was, “Depression is anger turned inwards.” Psychoanalysis contributed a lot to our understanding of the mind, but it did not have all the answers.
The discovery of antidepressant and antipsychotic medications gave the medical community the much needed evidence to believe that there is a physical/chemical basis for mental illnesses. The simple phrase “chemical imbalance” came in handy in explaining to patients the nature of depression and other stress-related disorders. In the late nineteen eighties, a new group of antidepressant drugs were released by drug companies for public consumption. These drugs known as serotonin specific reuptake inhibitors (SSRI) became very popular in no time due to the alleged ease of administration as well as lack of side-effects. The phrase “serotonin imbalance” is now on everyone’s tongue. The message to the patients was loud and clear: “A pill a day could correct your chemical imbalance and cure your mental disorder. Go for it.” The pendulum had now swung from one extreme of “it is all in your mind” to the other extreme of “it is all your brain chemicals.”
Originally this message was given to patients by the medical community to encourage them to give up stigma of mental illness and seek psychiatric help. Pretty soon, especially after the discovery of newer antidepressants, the drug companies jumped on this “medicalization” bandwagon and began to promote this concept so they could sell their highfalutin drugs to the burgeoning stressed-out population.
Over the past two decades, patients have come to like this new concept of “chemical imbalance” as well because now they do not have to feel ashamed or guilty for their stress disorder; they do not have to dig up all the old, buried traumatic issues in counseling; they do not have to take the trouble of learning new coping skills; they do not have to take any responsibility for all their stupid actions and behaviors which brought on their stress; they do not have to admit to any common human weaknesses which contributed to their behavior, and they do not have to do anything more than just take a pill everyday to alleviate their dreadful stress symptoms. They have little awareness that not wanting to know how they truly felt in their mind is the main reason why they are sick now. Prompt alleviation of their stress symptoms by medication further reinforces their tendency to bury the past and act as if nothing bad ever happened. Ignorance of all this effectively condemns them to repeat their past mistakes.
Doctors like this idea of “chemical imbalance” also because it saves them the time and the trouble to explore and understand patient’s seemingly complicated mind. In the absence of a useful model to explain the functions of the mind, or a simple interview technique to elicit hidden emotions and memories, they are completely at sea when it came to a “mental patient.” Now all they have to do is to make a list of patient’s symptoms and tell the patient, “Bingo! You have seven out of nine symptoms listed here. You have a chemical imbalance! Take this pill daily and in four weeks you will be well!”
To complicate matters further, unaware of the role of stress in sickness, the profit-motivated and short-sighted health insurance industry pays little for healing through introspection and self-awareness. Their simple message to doctors?: “Control symptoms as quickly as possible with drugs. Keep the cost down. Avoid sending patients to psychiatrists and psychologists. Counseling costs a lot more money besides being useless.” What the health insurance industry does not know is that millions of their clients go on expensive medical wild goose chase costing them billions of dollars every year, all because they mistake their stress symptoms for serious physical illness. The insurance industry has no choice but to pay for these unnecessary tests and treatment as they are ordered by lawsuit-phobic doctors to “rule out a serious medical disorder.”
This situation has been further complicated by the dearth of competent counselors who are able to explain to patients in simple words what is wrong with them; how they came to be in their predicament and what they could do to alleviate their symptoms. I have lost count of patients who tried counseling without gaining a penny’s worth of insight into their symptoms. When asked, “Did your counselor know why you suffered from this disorder?” the most common answer was, “I don’t think my counselor had a clue what my problem was. And I had no clue what he was talking about.” Some patients reported feeling totally baffled and horrified by the suggestion of the counselors that the root of their problem was that they were “fixated” or in love with the parent of the opposite sex. Obviously, the counselor was trying to explain the patient’s stress symptoms using outdated Freudian theories of mental illness. Uninformed or baffled counselors often indulge in such nonsensical “therapy” as relaxation therapy; deep breathing; touching fingers with the thumb, etc. as a way to justify the fee they charge them.
To make matters even worse -if that is possible- everyday we are bombarded with television and newspaper advertisements touting various “nerve medication” meant to control chemical imbalance in our brain. We are more or less guaranteed freedom from depression and anxiety if only we took a pill a day. Even the leading psychiatrists in this country, often financially linked to various drug companies, now talk as if medication alone could control all stress-related disorders. Hundreds of leading psychiatrists receive huge honorariums from drug companies to present hour-long lectures to family practitioners all over the country; or to present weekend-long seminars and symposia to fellow psychiatrists on how drugs could solve the “national epidemic” of depression and anxiety disorder. I have heard psychiatrist after psychiatrist exhorting their colleagues, “We must not be satisfied till we have controlled all symptoms of depression and have pushed the disorder into remission even if it means combining several antidepressant drugs!” No mention about any serious psychological, family or social factors that might be fueling patients’ depressive or anxiety symptoms making it hard to control them.
If psychiatrists do acknowledge the role of stress in producing or aggravating various disorders, it is usually in the form of a lip service, and the recommended remedies are invariably superfluous: deep breathing exercises, relaxation techniques, yoga, meditation, and other nonsense. The usual statement goes like this: “I then (after drugging up the patient) refer these patients for “psychosocial intervention” (whatever that means!), and deep breathing exercises and relaxation therapy.” I have never heard one reputable psychiatrist say anything meaningful when it came to coping with stress.
Nowadays, just about every medical doctor or specialist who has license to write a prescription -gynecologist, cardiologist, neurologist, urologist, cardio-thoracic surgeon, oncologist, nurse practitioner - freely writes prescription for antidepressant, anti-anxiety and even anti-psychotic drugs without taking a detailed personal, family and genetic history; without fully understanding and explaining either their benefit or risks; without fully knowing their side-effects, and without fully understanding potential long-term consequences of using these drugs.
Any psychiatrist reluctant to prescribe drugs is doomed. He might even be sued by brainwashed patients and their lawyers for not toeing the cook-book formulas of treatment increasingly promoted for the benefit of seemingly beleaguered psychiatrists who have, it often appears, stopped thinking for themselves. “Evidence-based treatments” proposed by some psychiatrists and promoted by the drug companies have taken the place of personalized treatment based on various highly sensitive patient-related factors (which we will soon study), commonsense, intuition and wisdom of years of practice. Annihilation of independent thinking psychiatrists seems to be T-O-T-A-L. The victory of drug companies appears to be C-O-M-P-L-E-T-E!.

5. What are some possible long term consequences of this trend?

Since the doctors and the patients have both been indoctrinated - should I say brainwashed?- into believing that it is a simple matter of taking a pill to correct a so-called chemical imbalance, they have little incentive to go into the details of various traumatic events and problems that caused the chemical imbalance leading to the onset of patients’ disorder. Nor are they aware of the mental mechanisms causing the disorder. Most patients feel better after a few weeks and so they believe that their problem has been solved. Since they do not have the insight into various factors that brought on their disorder, they continue to make the same mistakes as before, and get sick again later in spite of on-going treatment. Some stay on these medications for the rest of their lives for the sake of maintaining their “quality of life.” To them it is no different than taking a blood pressure pill every day. Still some others, especially with family history of bipolar disorder, develop manic episode, requiring more serious and prolonged treatment with mood stabilizing drugs. In this case, the prescribing doctor neglected to take (“I am too busy for that”) a detailed genetic history on these patients; or he did not know of the fact that antidepressant medications could trigger bipolar disorder in patients who have personal or family history of that disorder.
This problem can be even more serious with children as noted in the recent “suicide risk black box warning” issued by the Food and Drug Administration for all SSRI antidepressant medications. The drug companies have been so thorough in wining and dining doctors and their spouses while raising their awareness about bipolar disorder that now we have hundreds of thousands of people casually diagnosed and treated by family physicians as suffering from bipolar disorder. Even minor mood instability -ups and downs of emotions- caused by everyday stress is nowadays misdiagnosed as bipolar disorder. Why? Because the drug companies now have come up with half a dozen new “mood stabilizers,” known as atypical antipsychotics, costing anywhere from five to ten bucks per pill.
The term “bipolar” is nowadays used as a pejorative term by the lay public. People use this term to put down people they don’t like, as in, “She is impossible to deal with. She is a bipolar!” People dread telling their doctors about their serious mood swings for fear of being told they have a bipolar disorder. Others go around bragging about their bipolar disorder to get welfare or Social Security disability benefits. These days many people talk loosely about, “wild mood swings.” When asked what they meant, they would say that some days they felt a little down and other days they felt normal. Thanks to the drug companies, we are on the verge of becoming a Bipolar Nation, if we are not already one!
This trend is nothing new. Over the past few years, as new drugs came into the market, doctors became busy treating millions of people for diagnoses promoted by drug companies. First they focused on schizophrenia. I remember the times -late sixties and early seventies- when just about every stressed-out patient was diagnosed as schizophrenic. Then they followed successively with depressive disorder; panic disorder; social phobia; attention deficit disorder; obsessive-compulsive disorder; post traumatic stress disorder, erectile dysfunction..... Now it is the turn of bipolar disorder. Future disorders you can expect to be announced soon for the purposes of raising awareness of the public: Chronic fatigue syndrome; fibromyalgia; chronic pain syndrome; restless leg syndrome; sleep apnea; stuffy nose caused by stress; constipation brought on by too little time to go to the bathroom..... You get the idea, right?
As new drugs are introduced to the medical profession, the public is bombarded with information about the targeted malady via T. V. and magazine advertisements. Unable to correctly interpret the information, many patients ask their doctors for specific drugs to treat their self-diagnosed disorder. Doctors are only too eager to oblige them primarily because they do not want to lose them as their clients. There is always another doctor around the corner ready to oblige them with a prescription. Of course there are other not so obvious reasons as well, which the reader could guess for himself. When my seriously ill psychiatric patients visit their personal doctors or other medical specialists for their other health problems, they are often routinely asked by these doctors or nurse practitioners, “Do you want me to write prescriptions for your nerve medications also?” Such is the level of trivialization of psychiatric medicines in this country today.
Thousands of casually treated depressed and anxious people have now become “immune” to the drugs caused by the effect of accumulating stress in their system due to unresolved recent issues; newly emerging issues and resurfacing of old issues. So these patients are now declared as “refractory” cases, or “treatment resistant” cases, or “treatment challenges.” Now they are put on three, four or even five medications to “aggressively control” their symptoms: two or three antidepressant drugs to complement each other, plus an antipsychotic drug for “augmentation” or “mood stabilization,” plus an anti-anxiety medication to control “jitters”, a drug to control aches and pains, another to keep the patient awake during the day time, and of course, sleeping aide at night to get away from it all.
All these developments suit the drug companies just fine. This multiple drug regimen, which was looked down upon until recently by the medical profession, has been given a new spin and a new politically correct title by leading psychiatrists backed by drug companies: creative polypharmacy, which means the art of giving patients multiple medications to treat a wide range of symptoms. The idea is to make all patients completely symptoms-free. We are about create heaven on earth by using prescription drugs.
To the drug companies, this is exactly what the doctor ordered, pun intended. For, they have a whole new list of drugs in the pipeline to treat every conceivable symptom; every new side-effect from drugs, and newer high sounding disorders that they bring to the
attention of the public every year in the garb of “raising awareness.” Recently a reputable drug company released a new antidepressant drug which purportedly targets pain associated with stress-related disorder. They justify such actions by saying, “Look at all these millions of people out there who are enjoying quality life because of the pills they are taking! Without these pills they would be languishing in State Hospitals!”
True enough. There was a time in the recent past when hundreds of thousands of people were “warehoused” in poorly managed state run facilities all over the U. S. I know. I have worked in two of them. Most of these patients have been liberated from the state facilities and are now housed in various non-hospital setting. Drugs have, indeed, reduced human misery to a great extent. But that is not the whole story.
We are yet to take stock of long term adverse effects of various psychiatric medications on physical as well as mental health of people taking these drugs for years. We do know that most of them cause significant weight gain, making the already existing obesity problem still worse. Some of them, known as atypical antipsychotics, could cause metabolic syndromes such as diabetes and high cholesterol levels, or hormonal changes. Diabetes, hypertension, arthritis, heart disease, stroke, and even death are some of the complications from obesity as well as some psychiatric drugs.
Some drugs cause serious sexual dysfunction such as difficulty in reaching orgasm or loss of interest in sex. We do not know how many marriages have broken up due to these common but often unspoken problems. Drug companies would say, “Don’t worry. We now have drugs for these problems also. Shell out just ten bucks per pop.” Our enthusiasm to bring drug treatment to stressed people seems to have blinded us to these and many other as yet undiscovered potentially serious health hazards.
In our zeal to eliminate stigma of mental illness, we have made it even worse. Tell any depressed patient that his malady is caused and aggravated by poor coping with stress, and that education and counseling in expert hands would help a great deal. The reply is predictable. “This is a genetic illness, a chemical imbalance. I am not imagining this. I have never had stress in my life. How could counseling help? You are wrong, mister!”
Because of our increasing reliance on chemicals, both legitimate and illicit, to cope with stress brought on by various life events and problems, we, as people, are gradually losing touch with our true inner self: emotions that rule our lives. We are rapidly degenerating into a pill-popping, quick-fix, blame-something-else-for-our-problem society. If this trend continues, soon phrases such as self-awareness, insight, introspection, soul-searching, search for inner truth, etc. will disappear from our vocabulary. We will soon lose our ability to calm ourselves down using our inner mental and spiritual resources. Instead we will become -if we are already not one- increasingly dependent upon chemicals: alcohol, illicit drugs, antidepressants, mood stabilizers, antipsychotic drugs, tranquilizers, sleeping aids, pain medications and other chemicals yet to be released, just to cope with everyday life events and problems. “Do you have any new drug in the market?” is the question I am frequently asked by my clients as well as non-clients. This degradation of our “personal-responsibility” society into a “drug-dependent” one is gradual and almost imperceptible. That is why no one seems to be alarmed about it.

6. What is the truth?

Uncontrolled stress ultimately leads to chemical imbalance in the brain. No doubt, medications do bring our brain chemicals back to normal to some extent. However, this is just symptomatic treatment to alleviate current misery. It is like trying to control blood sugar with diabetic medications instead of educating and motivating the patient to healthier lifestyle: exercise, weight loss, better eating habits and the like. The patient now has to make a decision: 1) Do I believe that this is a permanent chemical imbalance for which I will need medications forever, like my doctor tells me? Or, 2) Can I learn to cope with stress better and bring brain chemicals back in balance myself so I do not have to take medications forever?
It is my firm belief, having taken care of thousands of stressed-out patients, that anyone with adequate intelligence and capacity for self-awareness; and a mind that is open, uncontaminated with skepticism, and not bogged down by denial, can learn to cope with stress better and thus gradually reverse chemical imbalance in the brain. One might need a little assistance in the beginning with medications to control serious symptoms of their disorder. This is no different than one temporarily needing a plaster cast to fix a broken bone. Patients could gradually learn to keep their brain chemicals in good balance and enjoy good mental health by understanding how the mind works; knowing about stress; learning better methods of coping with stress, and by changing their mental attitudes and behaviors.
The truth is that almost all patients come down with stress-related disorder due to ignorance about stress; stigma of mental illness; poor coping skills; stupid patterns of behavior; cultivated human weaknesses; bad attitudes, and many other factors. If the reader is serious about overcoming his stress-related disorder, he must face these realities and train himself to overcome them rather than hide behind the “chemical imbalance” facade. Understanding stress is the first step in this direction.


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