An article with the above title appeared in the Friday, December 6, 2019 Wall Street Journal. The article is written by the Jewish psychoanalyst Erica Komisar of New York City. She draws her conclusions from her reading of the scientific literature, her experience treating anxious and depressed children, and her Jewish faith and community. Her advice transcends any particular faith. I recommend her article to you.
Ms. Komisar cites a 2018 study in the American Journal of Epidemiology that looked at how being raised in a household with religious or spiritual beliefs affects mental health compared to an equal size non- religious control group. The children that attended a religious service one a week or more scored more highly on tests of mental wellbeing and a lower risk of mental illness. These children also had a lower probability of drug use and early sexual behavior. The children also had a higher rate of volunteering, a greater sense of mission, and a greater ability to forgive. From a purely secular point of view, these attributes alone might be worth “faking it to you make it”.
Ms. Komisar then goes on to address what she sees at the root of much of the increased anxiety and depression in today’s children, existential nihilism. When there is no meaning to a life beyond the here and now day to day survival, no ultimate meaning and purpose beyond our existence, then a person is ripe for not only depression and anxiety but also despair. This has been addressed by numerous authors including, most notably, Dr. Fiktor Frankl. Therefore, I ask almost all my patients, “what is your reason for getting out of bed each morning, what is your meaning and purpose in life, what is the hope that keeps you going?”
Having this transcendent anchor point external to ourselves, but with personal meaning to the induvial believer as well as the community of believers, allows us to answer the big questions common to all children and to provide solace in their time of anxious questioning. This hopeful belief system allows us to talk frankly to our children about death. I will quote directly from Ms. Komisar’s article: “The idea that you simply die and turn to dust may work for some adults, but it doesn’t help children. Belief in heaven helps them grapple with this tremendous and incomprehensible loss. In an age of broken families, distracted parents, school violence and nightmarish global-warming predictions, imagination plays a big part in children’s ability to cope.”
Ms. Komisar states she is often asked by parents how they can instill gratitude and empathy in their children. These are virtues found in all religious traditions, even those without a deity or belief in an afterlife such as Zen Buddhism. Ms. Komisar states in her article: “It’s rare to find a faith that doesn’t encourage gratitude as an antidote to entitlement or empathy for anyone who needs nurturing. These are the building blocks of strong character. They are also protective against depression and anxiety.”
Finally, Ms. Komisar points out that religion provides a natural community. Ms. Komisar expresses this beautifully in the following passage: “The idea that hundreds of people can gather together and sing joyful prayers as a collective is a buffer against the emptiness of modern culture. It’s more necessary than ever in a world where teens can have hundreds of virtual friends and few real ones, where parents are often too distracted physically or emotionally to soothe their children’s distress.”
I will leave you with the final paragraph of Ms. Komisar’s article: “Today the U.S. is a competitive, scary and stressful place that idealizes perfectionism, materialism, selfishness and virtual rather than real human connection. Religion is the best bulwark against that kind of society. Spiritual belief and practice reinforce collective kindness, empathy, gratitude and real
connection. Whether children choose to continue to practice as adults is something parents cannot control. But that spiritual or religious center will benefit them their entire lives.”
Currently available antidepressants, at least in their initial action, exert their antidepressant effect by influencing monoamine levels in the brain. Despite increasing the monoamine levels within the first day, the clinical manifestation of the antidepressant effect may be delayed by days to weeks. Approximately one third of major depressed patients will have a 50% or more reduction in symptoms with the first agent prescribed. Although the total number of patients responding increases with subsequent medication trials, the proportionate response to each new drug is much less than to the original drug. This series of trials may take months to years. This scenario has led to the search for a medication that rapidly reduces depressive symptoms. Esketamine seems to fulfill those criteria.
The brain’s response to any medication is much more complex than increasing as certain neurotransmitter. Esketamine does not raise monoamine neurotransmitters. Instead, esketamine binds to the post-synaptic NMDA glutamate receptor blocking glutamate neurotransmission. There are a few other biochemical happenings at the receptor level that are necessary for this to effectively occur, but that is a bit in the weeds for this article. Another result of this binding is the activation of the mTOR pathway. This is a pathway that eventually leads to increased BDNF and increased synapse formation. Pay no attention to the acronyms, just know it’s a good thing to happen. Wikipedia can give you a fuller explanation. This is amazing in two ways. First, that protein formation (needed for the building of synapses) can be elicited and seen occurring within 2 hours of administration is remarkable. This occurs with typical antidepressants but may take weeks. Second, the BDNF increase and the onset of new synapse formation correlates with a decrease in depressive symptoms and suicidal ideations. A medication that can be administered intranasally in a psychiatrist’s office and reduce suicidal ideations and decrease depression within 2 hours is a large leap forward in psychiatric treatment.
A not unusual occurrence in medicine is that while looking for one thing we find another. This happens all the time at the drug discovery level with many of our drugs being developed for one disease while looking for a cure for another disease. A classic example is the development of the tricyclic antidepressants. All the antidepressants can trace their lineage in one way or another back to isoniazid. Isoniazid was being developed as a treatment for tuberculosis. When this drug was given to severely depressed patients at state hospitals, many of the patients had a remission of their depression. As is often said, the rest is history.
With the urine drug screens we have seen another bit of medical serendipity, although not nearly to the level of importance as the above example. About one year ago the state board of medical licensure mandated point of service urine drug testing when a physician writes a prescription for benzodiazepines (Xanax, Ativan, Valium, Klonopin, etc.), opiates (oxycodone, Norco, Hydrocodone, etc.), or stimulants (Adderall, Ritalin, etc.). The reasoning that led to this decision seems to be that people that are prescribed one addictive substance such as an opiate are often prescribed another addictive substance by the same or different physician (the VA study). These patients have an increased risk of fatal drug interactions leading to respiratory depression and death. In addition, patients who are addicted to heroin or other opiates obtained either legally or illegally are often using other drugs, particularly benzodiazepines, that increases the risk of a fatal overdose.
At the time of the promulgation of these regulations, I argued strongly to the medical board that the routine urine drug testing of patients prescribed benzodiazepines was unlikely to discover patients using opiates not already noted in the PMP (a computerized data base of all controlled substances prescribed to a patient nationwide). The physician is mandated to check the PMP each time a controlled substance is prescribed. Now, about one year into this experiment some clear patterns have emerged. The first is that my reasoning regarding opiates and benzodiazepines has been confirmed. However, a totally unexpected pattern and area of concern has been manifest.
Since the institution of the above regulations, the federal government has passed the Farm Bill. In this bill was the legalization of the production of industrial hemp. In addition, proliferation of states with legalized “medical” marijuana has exploded, making marijuana products, even in states without such laws, more readily available. What we have discovered at my clinic over the past year is that the number of urine drug screens positive for opiates who had a negative PMP has been very low. However, patients positive for THC, the psychoactive component of marijuana, has been large. In addition, over the past two or three months, we have seen a dramatic rise in the number of THC positive urines who claim to have only used CBD products. Why is this clinically relevant? Please read the next blog post.
Medical marijuana and recreational marijuana are derived from Cannabis Indica or Cannabis Sativa. The important ingredient is the resin produced by the flower. CBD products are derived from the flower of a Cannabis Sativa strain with a different genetic profile than the marijuana Cannabis Sativa. In the following paragraphs I will illustrate why I am concerned about the rise in CBD and THC usage, especially in patients with a psychiatric condition.
First, a major caveat: No one under the age of 25 or a patient with schizophrenia and possibly bipolar disorder should use compounds that contain THC.
There are two CB (cannabinoid) receptors in human tissues. These are found throughout the body including the brain (CNS or central nervous system). These receptors are CB1 and CB2. In the brain CB receptors are instrumental in neuronal maturation and especially in the expansion and pruning process that occurs starting at about age twelve years and culminating at around age 25 years. Use of marijuana in this age group has been associated with an early onset of schizophrenia. Despite the speculation that CBD may be beneficial in schizophrenia and other conditions, there are virtually no medical studies (especially, double blind, placebo-controlled studies, the gold standard) of any cannabis product on any medical condition.
Cannabis products contain approximately 108 cannabinoids and 420 other compounds. CBD preparations are notable for their relative lack of THC (the content is supposed to be about 0.5%). However, this is not a guarantee of any type of purity. Commercially available CBD is still a mixture of a vast number of CBDs and other compounds. Although marketed as CBD or cannabidiol the preparation is far from pure cannabidiol. The reason that this is possible is because the FDA does not regulate the content, purity, safety, or investigate any clinical claim of CBD effectiveness. CBD does not even have to pass the over the counter drug review at the FDA. The over the counter drug review is much less stringent than the review of a prescription medication.
From a purely pharmacologic standpoint and for the sake of our conversation at the level of the brain, the major difference
In the November 2018 edition of Psychiatric Services Mary Brunette, MD, et. al., published a brief update on this timely question above. In the following blog post the reader should assume the material is taken directly from that review. Secondary references are contained within the article and the interested reader is referred to that article for further attribution and more in depth inquiry.
Thirty-three states and the District of Columbia have substantially reduced barriers for the sale and use of marijuana either through the legalization of medical and/or recreational marijuana or the decriminalization of the possession and use of marijuana. In Washington state 20,000 pounds of marijuana are produced each month. In addition, the marijuana industry has developed an array of products and delivery methods such as smoking, edibles, and concentrates. In addition, the industry profiles customers and heavily advertises to consumers. This all raises the question inferred in the title of this blog.
To borrow a phrase from an old Buick commercial, "this ain't your daddy's marijuana". When I was in college the THC content (the component in marijuana that gives you a high, the other component of marijuana CBD does not have euphoric/sensation altering properties) was anywhere from virtually non-existent to about 4%. Today the average street marijuana has a THC content of about 12% while the CBD component has decreased leading to a more rapid and potent high. Through genetic manipulation that would be the envy of Gregor Mendel and post harvest manipulation, we now have various products that vary the THC and CBD to produce custom products that allegedly have varying psychological effects. A sample of the offerings in Washington State include, Gorilla Glue Ethanol Shatter, with 75.8% THC potency; Billy Club Sativa, with 19.04% THC and <.05% CBD potencies; and Shark Shock Flower, with 9.21% THC and 11.8% CBD potencies. Marijuana is no longer, and perhaps never was, one entity but a variety of products with varying potencies, THC:CBD ratios, and CNS and peripheral nervous system effects.
What does this mean for the person with a serious mental illness such as schizophrenia or bipolar disorder? Psychiatrists have known for several decades that potent THC can cause psychotic symptoms in psychotic and non-psychotic individuals. When used heavily in adolescence THC increases the risk of developing schizophrenia. In patients that already have schizophrenia, THC worsens the symptoms and course of the illness. Heavy THC usage is associated with an increased risk of developing mania and depression, and in patients with a pre-existing mood disorder is associated with exacerbations of depression and mania. There is a common folk knowledge that marijuana is helpful in the treatment of PTSD but there is not a single controlled prospective published study of marijuana for this condition and retrospective, uncontrolled studies have been mixed.
Whether CBD is helpful for people with certain mental illnesses is unknown. (Part of the reason for the unknowing is that marijuana is illegal at the federal level. The DEA classifies marijuana as a schedule I drug. Researchers find grant money non-existent and all the marijuana that is used must be obtained from the farm at Ole Miss which is a strain from the 1960's). There was a study published in 2018 using a preparation of CBD without THC that reduced psychotic symptoms among people with schizophrenia. Beyond that, we do not have much evidence on which to hang our clinical hat.
In conclusion, outside of schizophrenia, bipolar disorder and use in adolescence, the evidence for benefit or harm from marijuana is anecdotal and conflicted owing to a lack of quality, prospective, controlled studies. Our current understanding is that marijuana is not universally good nor universally bad. However, it is not inconsequential. For patients in my clinic, I address marijuana use as another clinical factor that should be addressed with the patient. We do know the physiological effects of THC and CBD. We also know the the physiologic effects of the FDA approved medication we use every day in the clinic. In devising with the patient a treatment plan we must take all of this into consideration.
The simple answer is that the medical board requires it. The full explanation is a bit longer and more involved. Let me see if I can elaborate without too much editorializing.
This all started with the 'opiate crisis". I put opiate crisis in quotation marks because whether or not there has been (the number of opiate related deaths seems to have peaked about 1-2 years ago) a crisis very much depends on where one lives. The story of America's opiate epidemic has been told in an excellent book, Dreamland: The True Tale of America's Opiate Epidemic by Sam Quinones. There are many individuals, corporate entities, and regulatory agencies that acted in their own self interest without regard for the longterm impact on patients and society at large. A short list of these entities include certain pharmaceutical companies, especially Perdue Pharma, an enterprising group of Mexican nationals, corrupt pill mills, the Joint Commission on the Accreditation of Hospitals, and the American citizenry's insatiable appetite for addictive psychoactive substances. Most of this is documented in the above referenced book.
Perdue Pharma developed and aggressively marketed the powerful narcotic Oxycontin. Oxycontin is about 1.5 times as potent as Morphine. Having a potent narcotic is welcome relief to those suffering for acute severe pain such as after surgery, major trauma or cancer pain. Compared to fentanyl, oxycontin is a lightweight in morphine equivalents. Fentanyl is 70 to 100 times as potent as morphine. Fentanyl is used multiple times each day in the operating and procedure rooms. If that were the end of the story all would be well.
Enter the Joint Commission on the Accreditation of Healthcare Organizations (JACHO). In the 1990's JACHO declared pain to be the 5th vital sign (after temperature, heart rate, blood pressure, and respiratory rate). This was not based on any scientific findings but was more of a compassionate public relations campaign foisted on the healthcare community. You will notice that the four standard vital signs are objectively measurable and reproducible both within the same patient and between patients. Pain, on the other hand is a totally subjective experience with a very strong emotional component. One might argue that psychiatrists deal with largely subjective symptoms and still manage to relieve suffering through the judicious use of medication. One difference is that for the major psychiatric disorders, excluding attention deficit disorder, the medication is largely non-addictive and not fatal in overdose. (Tricyclic antidepressants are the major exception to the fatality statement, and benzodiazepines to the addictive statement).
Oxycontin was supposed to have a coating that made it difficult or impossible to have it rapidly absorbed. Patients with addictions soon learned that this coating was easily removed and the oxycontin could be ingested or injected resulting in an immediate "high". To summarize: We have a potent opiate that can be injected for an immediate high, it is readily available not just for hospital use but for routine outpatient use, aggressively marketed to physicians and hospitals as a largely non-addictive or at least not likely to be abused pain reliever, a disorder, pain, which had previously been regarded as a symptom, the disorder is wholly subjective and not independently verifiable, and the leading accreditor of healthcare organizations (and if you don't have this accreditation you are out of business) telling the healthcare community they must aggressively treat pain as they would an elevated blood pressure or fever without regard to the underlying cause. What could possibly go wrong?
The rest of the story developed rapidly. Pill mills sprouted in Florida (why do scams of this sort seem to arise in Florida?) and West Virginia. Other areas had this pill mills but these areas were ground zero. The price of oxycontin on the street rose. A group of enterprising Mexican nationals saw a market niche and began importing tar heroin from Mexico. They had excellent customer service, prompt delivery, and they were able to undercut the price of oxycontin or white heroin from Asia. People began to die.
But I still don't understand why I have to take a UDS if I'm just taking Xanax 0.5 mg twice a day. The lethal dose of Xanax by itself is so large you would likely choke to death on the volume before you died from the drug. Also, if I'm a pain patient taking Percocet,
(a popular combination of oxycodone and acetaminophen) I would die from liver failure from the acetaminophen before dying from the oxycodone component. What gives?
Drug addicts don't use just one drug, they use drugs in combination. Among opiate addicts the favorite combination is an opiate with a benzodiazepine, most often Xanax or Klonopin. The opiate decreases respiratory drive and agitation associated with a decreased oxygen level and the benzodiazepine decreases arousal. The user is likely to die at lower blood levels of each drug when they are combined.
In 2016 the Centers for Disease Control (CDC) promulgated practice guidelines strongly recommending against the practice of combined prescriptions. About this same time, most states instituted the Prescription Monitoring Program (PMP), a computerized data bank of all controlled substances that is searchable by patient. Most states medical boards or legislatures have mandated the checking of the PMP and strongly recommend following the CDC guidelines. This approach is rational and will make the prescribing physician aware of any other controlled substance prescribed by another physician so that appropriate clinical decisions can be made with he patient.
As far as I can tell, through accessing data bases of drug laws in other states, Mississippi is the only state that requires a UDS for a routine benzodiazepine or other controlled substance prescription. If the physician follows the CDC guidelines and accesses the PMP before each benzodiazepine prescription, then the only patients that the UDS will "catch" are those that are taking opiates from friends, family or abusing heroin or buying opiates off the street. Experience with this screening will tell if this slice of the public is as large of a public health concern as the medical board has indicated.
Sorry for the long absence from the blog site. The previous posts have explained various aspects of my practice or provided what may be referred to as helpful hints for mental health. I now plan to move to a more wide ranging group of topics. Today's topic concerns the rise in prior authorization requests.
Psychiatry has been particularly hard hit by medication prior authorization requests. This topic has been widely discussed in professional circles but perhaps not so often between physicians and patients. As the immediate past president of the Mississippi Psychiatric Association, a former member of the American Psychiatric Association Assembly (the legislative body of the APA) and an active member of the Mississippi Medical Association, I have debated and advocated for prior authorization reform. We were able to get a uniform prior authorization request for the various Medicaid programs, but have been less successful with the various commercial insurance companies. The most likely reason for this is that prior authorization ( hereafter referred to as pa) do not come from your insurance company directly but from a pharmacy benefits management company (pbm).
Nationally, pa requirements have become a major topic of concern. How big is the issue? Last year the Cleveland Clinic spent about 10 million dollars on prior authorization requests. An AMA survey of 1,000 practicing physicians found that on average medical practices spend two business days per week per physician to comply with pa protocols. One third of practices employ staffers who do nothing all day but process pa requests. On average, a practice will complete 29.1 pa requests per physician per week that requires 14.6 hours to process. About half of the requests are for medical services while the other half is for prescriptions.
Pa request originate with the pbm. Pbms make their profit by billing the insurance company, receiving rebates from the pharmaceutical manufacturers, and discounts from the pharmacies. The goal for the insurance company is to pay the pbm as little as possible, the goal of the pbm is to make as much profit as possible. Pbms can increase profit by: 1. obtaining greater rebates from the manufacturer, 2. paying the pharmacy less for the medication, 3. receiving payment from the insurance company for medication coverage and limit the patient's utilization of the medication and therefore pocket the difference as profit. Number 3 is where the prior authorization comes in to play. By excessive, onerous and burdensome prior authorization requests the pbm drives down medication utilization.
In the past, the pbms largely focused on expensive medication services delivered in hospital outpatient services, infusion centers and chemotherapy delivered in physicians clinics. These have generally been chemotherapy agents for cancer or rheumatologic diseases. In both of these areas the pa is requested from the party that is delivering the service and being paid for the service.
In the case of a pa request from a pharmacy, the physician is being asked to devote additional time and effort to obtaining a service (dispensing a medication) for which the physician is not compensated, but the pharmacy and pbm are being compensated. The fee that the patient and the patient's insurance company pays to the physician at the time the clinical service is delivered at the office covers only the face to face time, effort, and clinical decision making at the time of the consultation (coding guidelines and CMS guidelines). In the past, the pbm companies targeted only new medication that were many times more expensive than existing medication. Over the past year there has been a move to require prior authorization for generic and relatively inexpensive medication. We have received pa requests for Benadryl, Cogentin (on the market since the 1960's), Elavil (on the market since the 1950's) and other similar medication.
We often hear from patients something along the lines of "the pharmacy said you just have to authorize the medication". If it were that simple. Completing a pa usually consists of either logging onto the pbm website or filling out a pa form. The pa usually requires such things as a diagnosis, length of treatment, other medications that have been utilized to treat the condition, including doses and dates, reasons for not continuing these medications, and the reason the requested medication is the only one that will treat the condition (and then only if FDA indicated and not "off label"). In addition, a pbm may require that you be prescribed and fail to respond to two other medications before the requested medication will be allowed. As you can see, this is not a simple request but requires going through your entire medical record. Because there is clinical reasoning involved it can only be completed at the highest level by the physician. The medication is then almost routinely denied. The most common denied medications in my practice are second generation antipsychotics, controlled release stimulants, and newer antidepressants.
While I and my staff are always wiling to advocate for the best possible care for my patients, advocacy is not without cost. Insurance companies do not reimburse the physician or physician staff for the time, effort, and clinical judgement involved in completing a pa. The insurance company pays only for direct face to face medical care delivered at the time of the clinic visit. Therefore, if you wish the office to complete an pa and advocate with your pbm on your behalf you will be charged for the service.
Philosophically, I am a capitalist and do not begrudge companies realizing the profits they can generate. I also have to deal with my own personal physician and pharmacy benefits and purchase insurance coverage for my family and employees. In my roles above I have advocated for my fellow physicians and our patients with insurance executives and government officials. I believe that transparency and sunlight are essential for good working agreements, such as those between you, me, your insurance company, pharmacy and pbm (my guess is you didn't know there were so many people involved in our transaction). I hope this post has gone some small distance in making the pharmacy benefits coverage provided by your insurance company a little more transparent and enlightened.
Friedrich Nietzsche, the existential philospher stated, "He who has a why can endure almost any how". When Nietchze said this he was referring to the power of meaning in one's life. A few decades later, a physician, who had most likely read Nietzsche, was caught up in the Holocaust. This physician was Viktor Frankl. Dr. Frankl was imprisioned in several different concentration camps and witnessed and endured almost inconcievable human cruelty and suffering. Dr. Frankl relied on his meaning and purpose in this life to not only endure these hardships but to grow in his personal strength of character and resilience. Dr. Frankl went on to write a book about his experiences and the insights he gained from them. This book was published in 1963 as "Man's Search for Meaning". Below is an excerpt from that book.
We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that
cannot be changed. For what then matters is to bear witness to the uniquely human potential at its best, which is to transform a
personal tragedy into a triumph, to turn one's predicament into a human achievement. When we are no longer able to change a
situation--just think of an incurable disease such as inoperable cancer: We are challenged to change ourselves.
We see here that severe psychological distress does not preclude posttraumatic characterlogical growth. Perhaps you think that Dr. Frankl is some sort of oddity, that more ordinary people cannot experience this level of meaning and growth. More recent studies have found that among veterans of the Iraq and Afganistan wars who had higher levels of posttraumatic stress symptoms also had the greatest amount of personal growth. The authors speculate that perhaps the trauma must be disruptive enough to force the individual to reassess, revise, and rebuild fundamental aspects of his or her psychological, philosophical, and/or spiritual life. (1)
What is meaning for one person may not be meaningful to the next person, and what is meaningful at one point in one's life may not be what is meaningful at another stage of life. Meaning in life is not handed to us or gifted to us but must be searched for and discovered and put in to action in our daily lives. Dr. Frankl founded a therapy based on these principles called Logotherapy. Unlike some journeys of psychological discovery that look to the past, logotherapy looks to the future and focuses on the patient's strengths rather than solely on psychopathology.
Some of you may notice that I often will ask a patient what he or she does that brings meaning to his or her life. This is not idle talk but rather a way to gauge how prepared you are to face the "hows" of life. Each person need some reason to persist day after day in this life in a meaningful way, otherwise one is merely alive but not living. More recent authors have expanded on Dr. Frankl's theme. A more recent iteration of this is the Purpose Driven Life by Rick Warren. I encourage you to get a copy of Dr. Frankl's book and give it a good read. It may be life changing.
1. Southwick, SM and Charney, DS. Resilience. The science of mastering life's greatest challenges. Cambrige University Press. 2012
Frankl, VE. Man's search for meaning: An introduction to logotherapy. Beacon Press. 1963
Warren, Rick. The purpose driven life. Zondervan. 2002
All of us admire the courageous and brave. Often times these same people are described as fearless. But, fearless is not the same as courageous or brave. Courage is doing the task despite being fearful. Fearless is more associated with foolish. Fear is one of our six basic emotions. It is ubiquitous. Fear is not the same as anxiety or worry but we often worry and are anxious about things we fear. Fear need not be a physical entity but may also be events such as loosing a job, social rejection, or in severe cases fear of loosing the basic necessities of life.
Fear activates the fight or flight mechanisms reviewed in the blog on the stress response.This response is adaptive in the short run to help us avoid a fearful stimulus or to help us conquer that stimulus. Fear becomes maladaptive when we do not flee or conquer the feared stimulus but rather remain fearful without action. This leads to the chronic stress response that involves other factors such as cortisol that over the long run has deleterious effects on various parts of the brain.
A person may also become conditioned to fear. Most people are acquainted with Pavlov's dogs. Pavlov took his dogs natural tendency to salivate when presented with a tasty treat and paired it with a the sound of a bell. Over a period of time the dogs learned to associate the bell with food so that when Pavlov rang the bell but did not present food the dogs still salivated. This same phenomenon is demonstrated in people that have been in very fearful situations. A common scenario is the person who has been in a car wreck. A certain percentage of these people will develop fears with the concomitant stress response to cars, driving, and sometimes even the thought of driving. There may be no good way to "get over" this but there ways to "get through" this fear.
The process by which one faces the fear and learns to overcome the fear is called extinction. Although other areas of the brain are involved in the fear response, the fear is primarily an amygdala based response. The inhibition of the amygdala based response is largely accomplished through the action of the prefrontal cortex (the thinking part of the brain). Extinction involves experiencing the feared stimulus in a safe environment and staying with that stimulus until the stimulus is no longer feared in that safe environment. Physiologically, the prefrontal cortex develops enhanced cortical suppression of the amygdala based response. Psychologically, the person develops a new story about the fearfulness of the previously feared stimulus.
A psychotherapy that is utilized in dealing with fear is called cognitive processing therapy (cpt). CPT "focuses on emotions such as anger, humiliation, shame, guilt, and sadness which trauma survivors often experience in addition to fear and anxiety". (1). This therapy utilizes the Socratic method and helps the patient confront and discard secondary thoughts and subsequent emotions related to the original fearful experience.
Experience has shown us several useful ways of facing fear and using fear as an opportunity for personal growth.
First, use fear as a guide. Fear is a normal part of life. When afraid focus on your goal at the time and your mission at the time. This may not be as severe a a soldier taking an objective in combat but in patients with agoraphobia may be a goal and mission to go to the grocery store. Don't focus on the fear, focus on the mission.
Second, view fear as an opportunity. Carrying out your mission and goal in the face of fear helps you develop courage, self-esteem and mastery. You may not conquer the fear but when you succeed in your mission despite the fear you build both confidence and competence.
Third, learn as much as possible about what is feared. The unknown elements in an activity or decision that has to be accomplished are often the most feared. In the absence of concrete information about activity or decision and the processes and actions that must be taken to accomplish the activity or decision, our minds make up all sorts of fearful scenarios that are often not based in reality. Think back and remember a situation, such as coming to see a psychiatrist for the first time. The is usually some sort of fear involved about this unknown encounter. Then think back to how good it felt to accomplish this task. This usually results in thinking the phrase, "now that wasn't so bad". Learn as much about the feared activity or object ahead of time and you will be better prepared to undertake courageous actions.
Fourth, practice the skills necessary to succeed in facing the feared object or situation. This includes such things as facing the fear with a friend, having a back-up plan, and utilizing the stress reduction techniques addressed in other blogs.
Fifth, face fear with spiritual support. We are all acquainted with the Psalm: "yea though I walk through the shadow of death, I shall fear no evil, thy rod and thy staff they comfort me" Perhaps the psalmist overstates the lack of fear but he does address the comfort of being able to trust in a divine presence as a protector greater than any earthly force that may be aligned against us.
1. Southwick, SM and Charney, DS. Resilience. The Science of Mastering Life's Greatest Challenges. Cambridge University Press. 2012.
Earlier this year I read an outstanding book with the title above. A chapter from this book was the basis of my last blog on exercise and the reference for the book is given there. With this post, I wish to review some of the material presented in the introduction to that book and look at the question: "what is resilience?".
As with the term "stress", resilience is a term borrowed from the material sciences. And why not? Most of us in psychiatry have more than a little "physic's envy". Resilience refers to the property whereby materials return to their previous shape after being bent or stretched, i.e., stressed. Some materials have very little resilience and break upon being stressed while at the other end of the spectrum some materials return to the original configuration with their original properties, i.e., very resilient. There is another materials sciences term not mentioned in the book but alluded to in the many examples of perseverance that are cited and that is "tempered". This term is often used in referring to the manufacture of steel. If the steel is reheated and cooled after being cast it is said to be tempered. This improves the steel's elasticity and hardness. In this regard, I often think of someone such as Senator John McCain who endured a great deal of torture at the hands of the enemy as a war captive. Yet, he emerged from that episode tempered due to his resilience. I make this distinction to point out the difference between the two terms and their metaphorical validity. Resilience does not change the underlying properties of the material, it is the underlying properties that allow the material to be resilient. In tempering the material's properties are changed so that the resulting material is better suited for the purpose for which it is designed. The most commonly used metaphor for resilience is the green twig compared to the dry twig. The dry twig breaks from stress, the green twig bends, returns to it's previous shape and continues to grow. Perhaps we will in later posts return to this metaphor when discussing attachment to and interaction with our families, friends, and environment.
Now that we have our definition of terms out of the way, let's dig a little deeper into resilience not as a materials property but as a psycho-biologic property. Resilience is not any one specific thing but rather a property that is complex, multidimensional, and dynamic. When responding to stress a person may show greater competence in some areas of behavior and interactions than others and these competencies may be in flux over time. For example, a person experiencing difficult work relationship may become more competent in managing work related relationships but at the same time not show an increase in managing family relationships. In 2003 Conner and Davidson published a rating scale that is purported to measure resilience. This scale ranks 25 characteristics on a 0 to 5 scale (higher numeric ranking reflects greater competency in that particular characteristic). The 25 items are listed below.
1. Able to adapt to change
2. Close and secure relationships
3. Sometimes fate or God can help
4. Can deal with what ever comes
5. Past success gives confidence for new challenges
6. See the humorous side of things
7. Coping with stress strengthens
8. Tend to bounce back after illness or hardship
9. Things happen for a reason
10. Best effort no matter what
11. You can achieve your goals
12. When things look hopeless, I don't give up
13. Know where to turn for help
14. Under pressure, focus and think clearly
15. Prefer to take the lead in problem solving
16. Not easily discouraged by failure
17. Think of self as strong person
18. Make unpopular or difficult decisions
19. Can handle unpleasant feelings
20. Have to act on a hunch
21. Strong sense of purpose
22. In control of your life
23. I like challenges
24. You work to attain your goals
25. Pride in your achievements
If you are thinking that this list describes the qualities of Navy Seals or Army Rangers, you would be correct. Instructors for these courses are not necessarily looking for the absolute strongest or the absolute smartest young men (although these are qualities they seek) but rather they are looking for the most resilient. When you are in a tough situation you are looking for someone who will bend and not break, someone who will adapt and not stick to a rigid consistency.
This all begs the question, Is resiliency an innate quality of the individual or is it a learned group of behaviors? Perhaps the best we can say about this is that resilience is common but the achievement of resilience is easier for some than others. Almost everyone can learn to be more resilient, even if everyone cannot attain the resilience of a Navy Seal. All of us have the opportunity to mange stressful events in our everyday life, view adversity as a challenge to be managed and even use as a facilitator of personal growth, and practice making clear decisions under stressful situations. In a previous blog post I outlined the physiology of the stress response. In that post I pointed out that some stress in the acute situation is beneficial, but long term stress in harmful to any organism including humans. Let me quote the authors of Resilience. "Most of us have been taught to believe that stress is bad. We have learned to see stress as our enemy, something that we must avoid or reduce. But the truth is, when stress can be managed, it tends to be very good and even necessary for health and growth. Without it, the mind and body weaken. If we can learn to harness stress it can serve as a catalyst for developing greater strength and even greater wisdom."
Even though my practice is psychopharmacology I must admit that we do not have any medication to facilitate resilience. We have medications that will modify the stress response at a physiologic level but no medications that will give one the characteristics of resilience. However, developing resilient behaviors and attitudes may lead to requiring less medication to mitigate the stress response.
In the next few blog posts I will review some of the literature on ways to become more resilient.
1. Southwick, SM and Charney, DS. (2012) Resilience. The Science of Mastering Life's Greatest Challenges. Cambridge University Press.
2. Connor, KM and Davidson, JRT. (2003). Development of a new resilience scale: The Connor-Davidson resilience scale. Depression and Anxiety 18: 76-82.