• drhancur

IT'S ALL IN YOUR HEAD

This blog is about "Stress". We hear often that most unsolvable maladies are due to it. But what in God's name is it? It is not a diagnoseable condition. In physics terms, it is a force, a pressure, which when applied to an object causes strain. When that strain is too great, then the object cracks or breaks or is crushed depending upon intensity of the pressure. Stress can be internal, like when we're worried about a job interview or external, like when we see flashing lights in our rear view mirror. For our purposes, stress leads to a response called "anxiety" and anxiety can cause all manner of physical and emotional problems. Although "stress" is a causal factor, it is not the problem. The problem is how we handle it and especially how we handle our response to it i.e. anxiety.


There is a common sense truism in behavioral health. You can't be anxious and relaxed at the same time. Of course, to say it that way is too unscientific so we coined the term "reciprocal inhibition" to fix that problem. Stress reduction strategies, really anxiety reduction strategies, are based upon that truism. While helpful, such strategies are really coping mechanisms as reducing anxiety probably increases our performance and certainly our comfort level, but does nothing to directly deal with the cause of the anxiety, stress. That occurs when we identify the stressors and make behavioral change to reduce or eliminate them. Psychotherapy is often helpful but is not necessary. The danger in dealing with stress is that we will engage in non-helpful or even harmful ways to try to reduce it. Substance use is a favorite, whether prescribed by a doctor or a bartender, but is likely to cause more harm than good over the long run.


As a psychologist, I am often the last stop on the healthcare assembly line for patients whose medical problems are due to stress. This is the way it usually goes. John or Betty sees their primary care physician with a complaint, pain. The pain can be headache, backache, stomach ache, some sort of ache. The doctor reassures the patient, may do bloodwork or radiologic study and then prescribes. When the patient does not respond positively, the doctor refers to a specialist. Neurologist, orthopedic surgeon, gastroenterologist, etc. The specialist reassures the patient, does more bloodwork and diagnostic study and probably prescribes. When the patient does not respond positively, a second referral is often made with the implication that the patient is the problem, not the ache. This process may actually occur multiple times as there are many specialties out there. Each time, the new specialist reassures the patient, only to throw their hands up in despair. The final step is when the doctor says to the patient: John or Betty, I have done everything I know how to do, the problem is ALL IN YOUR HEAD, it is due to stress, go see Dr. Hancur. Saying the problem is due to stress is tantamount to saying that the patient is imagining it, making it up.


By the time John or Betty is referred to me, they are feeling extremely frustrated and extremely defensive. When they first meet me, they unload all of it and declare that they are not making up the pain and that they resent like hell that they are in my office, in fact they resent me. Mind you, all I've said at this point is "hello". When the dust settles, we move on to deal with the causes of the stress and make the necessary changes to reduce or eliminate it. Unfortunately, the medical assembly line has produced its own stress as the patient often does think that they are the problem in addition to living with chronic pain. I attempted to deal with the assembly line problem many decades ago while working in a staff model health maintenance organization (HMO). The beauty of the staff model was that all of the medical specialties were located in the same building so access to each other and communication were much easier than the typical model where individual providers are scattered all over the place, each with their own scheduling and intake system. The idea is what I called a "Diagnostic Team". When a challenging patient was identified anywhere in the building, by orthopedics, internal medicine, neurology, anybody, we convened the Team to decide what diagnostic tests to perform in order to establish a treatment plan. So rather than each specialty seeing the patient upon referral from the previous unsuccessful doctor and starting all over again with blood and radiologic studies, the Team could decide what to do and what not to do by sitting around a table and discussing the case. This saved both us and the patient many months of appointments and repetitive tests along with the frustration of the failed treatment efforts--frustration felt by both the patient but also by the providers. Incidentally, the patients were often identified to the Team by the thickness of their charts, an inch or more was a certain referral. Such patients are often referred to in medical offices as "frequent flyers", somaticizers, "pains in the ..., or worse. And their valid medical complaints are regularly discounted as exaggerations. One such patient was referred to me by his internist because he had a fever! The Diagnostic Team would have helped along with an antibiotic.


So stress, whether internal or external, causes anxiety and we hate to feel anxious so we do all sorts of things to get rid of it. Unfortunately, what we usually do only reduces it for a short time and it returns with a vengeance. Over time it increases in intensity and the quality of out lives plummets. Chronic anxiety ruins our bodies and our minds. Many doctors like myself believe that depression is a form of anxiety and depression is often a result of living with chronic stress. The answer to stress and its consequences is to change our behavior. Medication by itself does not change behavior and therefore is not an effective treatment unless it is used as an adjunct or assist in an effort to effect behavior change. After all, our problems are "all in our head", right?

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