User:Anthonyhcole/Distress
Distress[edit]
Suffering. What is it, what does it do to us, what is its role in mental illness?
In 1968 Ronald Melzack and Kenneth Casey re-imagined pain as more than just a sensation,[1] and this model underpins all modern thinking in pain psychology and pain neuroscience. They described three dimensions of pain:
- sensory-discriminative: sense of the quality,[2] location, duration and intensity of the pain
- affective-motivational: unpleasantness and urge to escape the unpleasantness
- cognitive-evaluative: cognitions such as appraisal, cultural values, distraction and hypnotic suggestion.
It is the affective-motivational dimension, the unpleasantness, that harms us.
Unpleasantness is also called "suffering", "discomfort", "torment", "anguish", "hurt", "negative affect", "negative valence", "negative hedonic tone", "aversiveness" and "distress".
I'll use "distress" and sometimes "suffering" here.
Distress is found in three classes of feelings:
1. It is a dimension of unpleasant homeostatic feelings like pain, hunger, fatigue and hyperthermia. Unpleasant homeostatic feelings torment us with distress until we satisfy them with specific behaviour (in pain: withdrawing and protecting, in hunger: eating, in fatigue: resting, and in hyperthermia: stepping into the shade).
2. Distress also plays a role in negative emotions like grief, anger and fear, and negative moods like misery, irritability and anxiety.
3. And it is an essential part of some social feelings (e.g., empathy, rejection, shame).
Distress likely evolved first and was enlisted by homeostatic feelings, emotions and social feelings as they emerged later in animal evolution.[3]
It is likely that just one neural network generates distress, and every unpleasant homeostatic feeling, emotion and social feeling employs this one distress network.[4]
What does distress do to us?
I am studying the effect of distress on human emotion, cognition and social engagement and I have focussed on three causes of distress — hunger, sleep deprivation and pain — because each of these has a body of scholarship addressing, to some extent, its affective, cognitive and social impacts.
What I've found is, each of these distressing homeostatic feelings generates in humans the same set of clinically significant symptoms:
- negative mood states (misery, anxiety and irritability) and exaggerated reactivity to negative affect (neuroticism),
- slowed mental processing speed, reduced working memory capacity and impaired attention control, impulse inhibition and emotion regulation, and
- impaired social feeling/social engagement.
Until someone finds an instance of distress that does not cause this cluster of symptoms, I shall assume all distress, regardless of its cause, produces this syndrome.
If distress is intense, these symptoms are significant and disabling. If you doubt that, reflect for a moment on your own response to intense pain, nausea or sleep deprivation. How's your concentration? Working memory? Thinking speed? Empathy? Mood? Emotion?
I'm pretty sure no one has described this suffering syndrome before, but, if I'm wrong about that, I know no one has applied it to mental illness like I am about to below.
This syndrome is found and is a major contributor to disability in all instances of distressing functional mental disorder.
Look, for example, at the extract below from the "associated features" of schizophrenia in DSM-5-TR. Compare my underlinings in that text with the symptoms of suffering listed in the bullet points above.
All the elements of the distress syndrome, except neuroticism, are found in the DSM associated features of schizophrenia.
Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the absense of an appropriate stimulus); a dysphoric mood that can take the form of depression, anxiety or anger; a disturbed sleep pattern (e.g., daytime sleeping and nighttime activity); and a lack of interest in eating or food refusal. Depersonalization, derealization and somatic concerns may occur and sometimes reach delusional proportions. Anxieties and phobias are common. Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments. These deficits can include decrements in declaritive memory, working memory, language function, and other executive functions, as well as slower processing speed. Abnormalities in sensory processing and inhibitory capacity as well as reductions in attention are also found. Some individuals with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind).
Eugen Bleuler in 1911 addressed exaggerated reactivity to affect in his unmedicated schizophrenic patients:
Particularly in the beginning of their illness, these patients quite consciously shun any contact with reality because their affects are so powerful that they must avoid everything which might arouse their emotions. The apathy toward the outer world is, then, a secondary one springing from hypertrophied sensitivity." (p. 65)[5]
Try to imagine a seriously functionally mentally ill person without this syndrome: without anxiety, irritability, misery or neuroticism; without slowed thinking, attenuated working memory or poor attention control; imagine they have healthy impulse-inhibition, emotion regulation and social engagement, too. Would you even call them ill? Eccentric, maybe, but ill?
What is distress doing in functional mental illness? What is its role?
Recently, a historian of psychiatry told me, "Suffering is central to serious mental illness. Whether it is the cause or the effect, or something of both, is an open question."
I'm sure it is an open question in his mind but the causal relationship between mental disorder and distress is not an open question in psychiatry.
In psychiatry, at least in its bible the DSM, it is always mental disorder that causes distress, never distress that causes mental disorder. Look at this from DSM-5-TR's diagnostic criteria for major depressive disorder:
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
This formulation occurs throughout DSM-5-TR,[6] and it has been a feature of the DSM since its third edition in 1980 when the lead author laid down new essential criteria for every diagnosis, including: the symptoms must be distressing to the individual or the symptoms must impair the individual's ability to function.
I believe distress, in mental disorder, is causing the same devastating set of clinically significant symptoms it causes in hunger, sleep deprivation and pain, and psychiatry should find and treat the source of peoples suffering. While social and emotional distress must, of course, be addressed, the physical, extracerebral body should not be ignored. Look for nutrient deficiencies, hormone imbalances, inflammation, pain, fatigue, any kind of constant or recurring distressing homeostatic imbalance.
This paragraph matters: The features that distinguish one DSM entity from another — mania, delusions, hallucinations, obsessions, etc. — may be summoned by distress from a propensity in the patient's biological inheritance reinforced by life experience and social state (diathesis-stress, an old idea[7]), so, eliminating ongoing distress may at least to some degree ameliorate these eccentricities, while resolving the seriously disabling affective, cognitive and social harms of suffering.
So, why aren't your patients complaining to you about these terrible distressing feelings? Well, some of them are and you are telling them these feelings don't exist or don't matter and are the product of their imagination. Some of them are inured to the feeling that has been with them for so long it is now just how life feels. Inuring can make consciousness of, the sensory dimension of, an unpleasant experience disappear while not diminishing the suffering at all.
You're working in a room with an annoying, loud, grinding, rattling airconditioner. In time, you no longer notice it, no longer attend to it, you forget that it's there. Then, when it finally shuts down, you experience relief, your mood lifts, your mind is clearer, you are more convivial. You might even be surprised at just how much distress you had been under due to that stupid airconditioner. And so it goes with all constant, familiar, unsurprising negative sensory, emotional or social experiences.
Notes and citations[edit]
- ^ Melzack, Ronald; Casey, Kenneth (1968). "Sensory, Motivational, and Central Control Determinants of Pain". In Kenshalo, Dan (ed.). The Skin Senses. Springfield, Illinois: Charles C Thomas. p. 432.
- ^ "Quality" in pain science means the unique sensation that distinguishes pain from other feelings like itch, nausea and thirst, or the characteristic that distinguishes one pain from another, e.g., tingling pain vs. burning pain.
- ^ Antonio Damasio in his 2021 book, Feeling and Knowing, puts the appearance of basic discomfort and wellbeing before the emergence of homeostatic feelings in evolution.
- ^ Damasio, ibid, says, "But we often overlook the fact that our psychological and sociocultural situations also gain access to the machinery of homeostasis in such a way that they too result in pain or pleasure, malaise or well-being. In its unerring push for economy, nature did not bother to create new devices to handle the goodness or badness of our personal psychology or social condition." P.127.
- ^ Bleuler, Eugen (1911). Dementia Praecox. Translated by Joseph Zinkin in 1950. New York: International Universities Press.
{{cite book}}: CS1 maint: numeric names: translators list (link) - ^ From page 23 of DSM-5-TR: "In the absence of clear biological markers or clinically useful measurements of severity for many mental disorders, it has not been possible to completely separate normal from pathological symptom expressions contained in diagnostic criteria. This gap in information is particularly problematic in clinical situations in which the individual's symptom presentation by itself (particularly in mild forms) is not inherently pathological and may be encountered in those for whom a diagnosis of 'mental disorder' would be inappropriate. Therefore, a generic diagnostic criterion requiring distress or disability has been used to establish disorder thresholds, usually worded 'the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.'"
- ^ Kendler, Kenneth S. (July 2020). "A Prehistory of the Diathesis-Stress Model: Predisposing and Exciting Causes of Insanity in the 19th Century". American Journal of Psychiatry. 177 (7): 576–588. doi:10.1176/appi.ajp.2020.19111213. ISSN 0002-953X.