STRESS THROUGH THE LIFE CYCLE

Theory and clinical examples

Prof Solomon RataemaneSefako Makgatho Health Sciences UniversityPretoria, South Africa

IMPLICATIONS/MEANINGS• EXPRESSION OF TRAUMA AT DIFFERENT STAGES OF

DEVELOPMENT• HOW TRAUMA OCCURS AT SPECIF LEVELS OF GROWTH• HOW DO WE ASSESS TRAUMA AT THESES DIFFERENT STAGES• WHAT ARE THE TRIGGERS OF PSYCHO-TRAUMA AT DIFFERENT

LEVELS• IS IT ALWAYS POSSIBLE TO DETECT THE EFFECTS OF PAST

TRAUMA OR CURRENT TRAUMA?• CLINICAL SUSPICION OR A CLINICAL HUNCH MAY BE THE ONLY

GUIDE … AND THIS IS BASED ON EXPERIENCE

Historical Trauma & HT Response

• Cumulative emotional and psychological wounding• Exceeding over an individual lifespan and across generations• Caused by significant group traumatic experiences• It is an example of transgenerational trauma eg. Pattern of maternal

child abandonment at a young age across three generations• HT response is a constellation of features in reaction to this trauma

including self-destructive behaviour; suicidal thoughts and gestures; depression; anxiety; low self-esteem; ; anger; and difficulty recognizing and expressing emotions; substance abuse to numb the pain associated with trauma

• HTR is also associated with unresolved grief that accompanies the trauma

• Treatment depends on understanding cultural diversity, history, culture and realities of the client

Psychological Trauma(Wound)• Damage to Psyche as a result of a severely distressing event• Stress exceeds one’s ability to cope or integrate associated

emotions• Can be one experience, repeated experiences • With immediate effect; delayed effect showing in weeks,

months, years and even decades after exposure to event• Hence, THE TRAUMA LENS, taking a longitudinal view of the

persons current inability to cope with what may appear to be minor stressors (What was the initial trauma?)

• PT often involves physical trauma that threatens one’s survival and sense of security; harassment, sexual abuse, employment discrimination, police brutality, bullying, domestic violence, indoctrination, dysfunctional parenting, witnessing of such events, natural disasters; wars and acts of terrorism

Common Aspects to Psychological Trauma

• Violation of persons familiar ideas about the world• Violation of person’s human rights• Generation of a state of extreme confusion and insecurity• Worsened by further violation of self by societal institutions

that are supposed to provide help and redress• Differential responses noticed among people exposed to the

same stressful events due to resilience; past exposure; repeated exposure; supportive networks and other protective factors such as education, wealth and religion (social status)

Modes of transmission: Wentzel Coetzer (South Africa)• Four working models• In their discussion of mechanisms of trauma transmission, Ancharoff et al.,

(1998) propose the following four working models:• Silence. Silence can often communicate traumatic messages as powerfully

as words could. Silences in the family may develop in one of two ways. To avoid arousing further distress, family members may work hard to shun issues they believe might trigger discomfort and further symptomatology in the parent. Secondly, the parents’ behavior might inhibit discussions about sensitive issues.

• Over-disclosure. It is distressing to hear traumatic details without a concomitant effect. Parents may make graphic disclosures of trauma-related information to prepare their children how to survive in a world in which they believe there is no trust and where danger is omnipresent.

• Identification. Children who live with a traumatized parent may be continually exposed to post-trauma reactions, which can be unpredictable and frightening. These children tend to feel responsible for their parents’ distress and feel that if they could just be good enough, their parents would not be so sad or angry. Children of combat veterans for example, identify with their fathers’ experience in order to know him better. They attempt to feel what he feels, possibly leading to the development of parallel symptomatology.

• Re-enactment. Trauma survivors tend to re-enact their trauma. People close to trauma survivors could find themselves thinking, feeling, and behaving as if they too had been traumatized or were perpetrators.

TYPICAL SYMPTOMS/BEHAVIOUR OF THE TRAUMATISED SURVIVOR PARENT

• In studies done on World War II prisoners of war and their families, Bernstein (1998) and Op den Velde (1998) listed the following aspects as typical with regard to prisoners of war in their relationships to their families:

• A lack of emotional involvement with others.• Compulsive work habits that lead to a lack of social interaction.• A fear of closeness, related to wartime loss of friends, thoughts, and

nightmares of combat, deaths,• beatings, starvation, and isolation.• Denial, suppression and repression as coping mechanisms.• Feelings of guilt and anger.• Hyper-arousal, leading to increased startle reactions, feelings of fear, stress

and ever-present• agitation.• A desire to keep silent about frightening and life-threatening experiences

and putting up a brave front.• Sleep disturbance and recurrent dreams of traumatic events.

TYPICAL SYMPTOMS/BEHAVIOUR OF THE TRAUMATISED SURVIVOR PARENT• Sleep disturbance and recurrent dreams of traumatic events.• Feelings of detachment and diminished interest.• Emotional distance within marriage.• Difficulties in these persons’ response to the physical illness of friends and

family.• Mood swings without appreciable precipitants.• Sudden anger outbursts.• Extended work hours prior to retirement.• A high prevalence of psychiatric morbidity.• Neurotic over-activity combined with tenseness and irritability, as well as

psychosomatic syndromes• such as hypertension, myocardial infarction, asthma, and gastric

ulcers in high frequency.• Living in the past and present at the same time – trying to survive in the

present, and struggling to• separate themselves from the grief, guilt, anger and fear of the past.• In retirement, fears of illness and death of family members emerge, leading

to feelings of• abandonment. This could intensify behavior such as withdrawal,

depression, alcoholism, and marital• conflicts.

Clinical Examples • 50 years old Social worker – unable to communicate about the

past

• Final year medical student – affected by a clinical presentation

• 17 years old teenager – presenting with conduct disorder

• 7 years old child presenting with extreme hyperactivity

• 49 years old man presenting with hyper - sexuality after release from political detention, and hurt many partners

• 12 months old with a problem of poor feeding and loss of weight

What is stress?• Is a normal, physical response to events that make you feel

threatened or upset your balance in some way

• The body’s Stress Response• When you perceive a threat, your nervous system responds by realising a flood of stress hormones, including adrenaline and cortisol• These hormones rouse the body for emergency action• Your heart pounds faster, muscles tighten, blood pressure rises, breath quickens, and your senses become sharper. • The physical changes increase your strength and stamina, speed your

reaction time, and enhance your focus – preparing you to either fight or flee from the danger at hand

Some stress response syndromes:

• Major Depressive Disorder• Acute Stress Disorder (with anxiety and depressive features)• Adjustment disorder (with depression/anxiety and brief

psychosis• Post Traumatic Stress Disorder (Immediate or delayed): intense

fear; reliving (flashbacks); avoidance behaviour (emotional numbing); hyper-vigilance (irritability)

• Continuous PTSD: (Gill Straker in South Africa) due to frequent exposure to high levels of violence usually associated with civil conflicts and political repression; and settings where gang violence is endemic and continuous exposure to life threats in high risk occupations such as police, fire and emergency services

Need for understanding • Appreciate the immediacy of trauma• The suppression of response• The delay in response • Transmission from generation to generation• Transmission across historical epochs• Relevance of training (specific) in interviewing & counseling• Advocacy for dealing with individual and collective trauma• Brain mechanisms involved • Identification of internal and external triggers• Choice of appropriate, evidence –based therapies

Stress warning signs and symptoms of stress overload

•Cognitive Symptoms

• Memory problems• Inability to concentrate• Poor judgement

• Seeing only the negative• Anxious or racing thoughts• Constant worrying

Stress warning signs and symptoms of stress overload

•Emotional Symptoms

• Moodiness• Irritability or short temper• Agitation, inability to relax• Feeling overwhelmed• Sense of loneliness or isolation • Depression or general

unhappiness

Physical Symptoms

• Aches and pains• Diarrhoea and constipation• Nausea, dizziness• Chest pain, rapid heartbeat• Loss of sex drive• Frequent colds

Behavioural Symptoms

• Eating more or less• Sleeping too much and too little• Isolating yourself from others • Procrastinating or neglecting responsibilities• Using alcohol, cigarettes, or drugs to relax• Nervous habits (e.g. nail biting, pacing)

Things that influence your stress tolerance level

• Your support network• Your sense of control• Your attitude and outlook• Your ability to deal with your emotions• Your knowledge and preparation

Cause of Stress

• Major life changes• Work or school• Relationship difficulties• Financial problems• Being too busy• Children and family• Natural disasters and • Acts of terrorism

Common external causes of stress

Common internal causes of stress

• Chronic worry• Pessimism• Negative self-talk• Unrealistic expectations / Perfectionism• Rigid thinking , lack of flexibility• All-or-nothing attitude

Symptoms of Victimization: Frank Ochberg

• Shame: deep embarrassment, humiliation and mortification• Self-blame: feeling responsible for what happened• Subjugation: feeling belittled, powerless and dehumanised• Morbid hatred: obsessive vengeance and preoccupation with hurting

the perpetrator (real or symbolic)• Paradoxical gratitude: pathological transference (Stockholm’s

syndrome); positive feelings towards the victimizer “thankful that you did not kill me”

• Defilement: feeling dirty, disgusted, disgusting, “like spoiled goods”, rotten or evil

• Resignation: broken will or despair due to repetitive trauma• Second injury/ Second wound: re-victimisation in criminal justice

system, health, mental health and other systems• Socio-economic downward drift: and with risk of repeated

victimisation due to psychosocial and vocational impairment

Effects of chronic stress

• Long –term exposure to stress can lead to serious health problems

• Pain of any kind• Heart disease• Depression• Weight problems• Digestive problems• Sleep problems• Autoimmune disease• Skin conditions, such as eczema

Hector Peterson (Hero)