Introduction

We have tended in psychiatry to emphasize the abnormal - exaggerated reactions to normal situations, depression and anxiety being classical examples. The depressed person cannot enjoy a life that should otherwise be pleasant, has a negatively distorted view of self and others, and is not even refreshed by the normal process of sleep. The person with an anxiety disorder worries beyond all reason, obsessing about details, fearful of the everyday world, worried about nonexistent medical ills.

However, the complementary domain is the topic of this talk, one in which there is indeed something to feel sad and worry about, the world of physical trauma and medical illness. In this territory, sadness and fear, if not outright depression and anxiety, are suitable reactions. Considerable dysphoria is an appropriate and associative response, not the problem.

We all expect life to roll along without trouble, without pain. Indeed, as Irvin Yalom, my mentor and a Strecker award winner has noted in his outstanding text (of many) on Existential Psychotherapy, we engage in a variety of "immortality projects" designed to forestall awareness of our deaths. Our work is so important, our responsibilities for others so immense, our faith in rescuers so vast, that death cannot overtake. Yet, as the existential philosophers taught, nonbeing is inseparable from being. True existence is sharpened, not dulled by confrontation with nonexistence, a theme that has great therapeutic value and will be returned to later. The very term "existential" in philosophy comes from the principle that existence and essence are inseparable. There is no realm of ideas independent of being itself. Existence is essential, and essence nothing without existence. Death is ultimately threatening, yet it is the ground upon which living has its meaning. Indeed, the specter of death is essential to feeling alive. Why else would so much of our entertainment involve Images of death? We feel alive in various transient victories over death, we enjoy flirtations with it in theory, yet avoid it in fact. Disease, disaster and death are part of the human condition, and therefore ought to be the domain of psychiatric understanding and treatment. There is an old French saying that "He who is laughing hasn't heard the bad news yet."

Am I not dragging our field into the domain of the 'worried well?' I would rather call it the domain of the 'worried ill,' people who suffer physically and mentally, and who are in need of and can benefit from our expertise, both psychotherapeutically and pharmacologically, although more the former than the latter.

Affect Suppression

This area has not to date been a classical part of psychiatry, shoulder to shoulder with studies of schizophrenia, bipolar disorder, depression and anxiety. For many years, to the extent it was studied, it was submerged in Axis II: it was thought that those who suffered from post-traumatic syndromes did so because of the effect of a traumatic stressor on a previously deformed personality, often coupled with a substance abuse disorder. But what happens when a normal person, devoid of personality, affective, or thought disorder, encounters one of the forceful vagaries of existence? How does life prepare one to deal with rape, physical injury, cancer, HIV infection? Strangely enough, the problems which most often occur with such individuals are the mirror image of the classical psychiatric conditions. Rather than showing an excess of inappropriate affect, they often demonstrate a lack of appropriate affect. Trauma victims are frequently dazed and underresponsive, cancer patients often strangely apologetic and serene instead of angry and scared, heart attack victims angry and impatient but not appropriately afraid. The therapeutic problem is not one of controlling and reducing the affect but unearthing and expressing it. More often than not this is an uncomfortable role for physicians, even psychiatrists, who are used to putting a pharmacologic damper on the inappropriate expression of feeling, rather than encouraging more of same. I sometime think that doctors are trained to treat crying as if it were bleeding: apply direct pressure until it stops.

I recall working as a medical student at Boston City Hospital, practicing 'front line' medicine. It was exciting because everything was at stake, and there were not nearly enough resources to go around. The shock cart had to be wheeled down the ward while the power cord was unrolled to maintain connection to the one existing AC outlet. Chunks of the ceiling would fall onto patient's beds. One of my patients narrowly missed execution via the sky falling because he was fortunate enough to be at x-ray when it fell. Despite or because of all this, I really became a doctor there. I recall the tragic death of a young alcoholic musician due to hepatic failure. We had resuscitated him the day before, but he surrendered in the face of irretrievably diminishing potassium levels. His fourteen year-old daughter stood screaming at the foot of his bed: "This can't be true, it can't be. He's not dead. I know he's not dead." The intern asked the nurse to bring a shot of Valium. "She's upsetting the other patients," he said. I offered to take her into a quiet room: "She is doing what she needs to do," I offered helpfully. If you don't let her do this now, I'll wind up seeing her when I'm a psychiatrist." I was getting nowhere, so I added, less helpfully: "If her crying bothers you so much, you take the Valium." She got the Valium.

We lack models in medicine for the appropriate expression of strong emotion. Indeed, we lack models in life for such expression. In our modern, 'advanced,' world, we try to clean away the details of destruction, abolish hints of death, turn away from the victims of trauma, crime, illness. Note how hospitals hide the transport of bodies to the morgue after death. Who ever sees a body being moved down the corridors of a hospital? It must happen - people die there. The hospitals employ an apparently empty gurney with a false bottom and a coffin-like box underneath to carry bodies. Even in places where death is an everyday occurrence, great pains are taken to make it invisible. There is a message in this about the emotion surrounding injury, dying, and death: keep it to yourself. In modern times, we remove the dying and clean up the dead, make them look asleep rather than gone beyond all hope of return. In prior centuries, most people had attended to dying relatives, seen dead bodies, buried members of their extended families. In this century much of this messy business is avoided, and what is left is sanitized beyond reason. We emphasize control over Images, experience, and emotion.

Yet we were born with emotions for a purpose. One can only speculate that the limbic system facilitated arousal and concentration on what was important. As our brains grew, it became possible to assimilate more and more information. Perception, memory and reverie could compete for attention with motor function and planned activity. There must have been survival advantage for creatures who were not lost in their immense capacity to imagine think, and remember, but who could quickly mobilize their resources to engage in one of the famous "four f's": fighting, fleeing, feeding, or making love. Emotion may have served as an 'all points bulletin,' orienting us to threat, loss, and opportunity, allowing us to search for the best, for example a mate, and accept the worst, destruction and death. In Civilization and its Discontents, Freud (Freud, 1927) pondered sadly that there was an epic struggle between the primal forces of id and superego, noting the pathetic ability of the ego to control these forces. Civilization, like the ego, was not so much the tip of the iceberg, but a precariously balanced rock, ready to fall into the abyss if the forces pushing on it got out of balance. "Where id was, there ego shall be," pronounced Freud. His emphasis was on using affect, mainly in the transference, in the service of understanding and taming it. Emotion was by definition irrational, representing transformations of deep irrational forces (hence the term "dynamic" psychiatry) and imposition of the distortions of early life relationship models on the current interpersonal world. But sometimes a feeling is just a feeling, and its absence may be more pathological than its presence.

Trauma and Emotion

This is especially the case in situations in which sudden and traumatic stressors have occurred. Nowhere has this been more clearly described than in Lindemann's classic paper, The Symptomatology and Management of Acute Grief, published in the American Journal of Psychiatry in 1944 (Lindemann, 1994). In one beautifully written manuscript, he describes the essential features of normal and pathological grief, thereby defining the basic elements of our current DSM-IV post-traumatic stress disorder, and delineates the essentials of psychotherapy for the disorder. While the paper is often best remembered for his graphic descriptions of the restlessness of those who suffered terrible losses during the Coconut Grove fire: their pacing, preoccupation with the deceased, somatic discomfort, and inability to sleep, he made another astute observation. The minority who showed a strange lack of such symptoms, for example the bereaved spouse who went to work the next day, who insisted on just 'carrying on with life,' had among the worst prognoses. Many had committed suicide by the end of the year. Thus while an excess of emotion did lead to poor outcome, so did an absence of emotion in an affectively evocative situation. Lindemann then went on to describe the fundamentals of psychotherapy with such individuals, which he called "grief work." This is the painful process of acknowledging, bearing, and putting into perspective (using the words of Elvin Semrad) the loss. One would not be free to cathect new objects in life until one had separated oneself from the old ones that had been lost, beginning to conceptualize the loss not only of the other (wife, child, parent, useful legs) but of the old self defined in relation to what was lost (husband, parent, child, skier). Only then could one begin to live a new and very different life. The process of grief work was more like an amputation than setting a broken bone. It not only hurt, it involved accepting a permanent loss and taking stock of what was left.

In Lindemann's astute observation that too little emotion might presage pathological adjustment to traumatic loss lay the hint of a growing body of observations in traumatology today. Last year's annual meeting of the Society for Traumatic Stress Studies was devoted to "Dissociation and Trauma." There is increasing recognition that the apparent absence of response to trauma may represent the worst threat to psychological homeostasis. The police often misconstrue the numbing seen after a rape or other assault as evidence that nothing really happened. They have an image of an assault victim as someone who is hysterical: screaming, crying, restless. Yet many trauma victims are struggling desperately not to yield to the feelings of degradation, shame, despair, and terror which a physical assault provokes. It is as though yielding to the feelings is somehow yielding again to the assault. Indeed, such feelings come to symbolize the assailant: unbidden, intrusive, alien. A part of the mind comes to be identified with the unwelcome other. One is soiled internally by the assailant in memory, just as one was soiled physically. The bodily struggle is internalized, a fluctuation between intrusion and avoidance, as Mardi Horowitz, a Strecker award winner, has noted (Horowitz, 1976). Victims either intensively relive the trauma as though it were recurring, or have difficulty remembering it (Madakasira & O'Brien, 1987); (Cardena & Spiegel, 1993); (Christianson & Loftus, 1987). Thus, physical trauma seems to elicit dissociative responses.

Trauma and Dissociation

One of the important developments in the modern understanding of dissociative disorders is the exploration of the link between trauma and dissociation. Trauma can be understood as the experience of being made into an object, a thing, the victim of someone else's rage, of nature's indifference. As such it is the ultimate experience of helplessness: loss of control over one's own body. There is growing clinical and some empirical evidence that dissociation may occur especially as a defense during trauma, serving as an attempt to maintain mental control just as physical control is lost (Spiegel, 1984); (Kluft, 1984); (Putnam, Guroff, Silberman, Barban, & Post, 1986); (Spiegel, 1988); (Cardena & Spiegel, 1993) (Koopman, Classen, & Spiegel, 1994); (Marmar, Weiss, Schlenger, Fairbank, Jordan, Kulka, et al., 1994); (Bremner, Southwick, Brett, Fontana, Rosenheck, & Charney, 1992). One Dissociative Identity Disorder patient reported "going to a mountain meadow full of wild flowers" when she was being sexually assaulted by her drunken father. She would concentrate on how pleasant and beautiful this imaginary scene was as a means of detaching herself from the immediate experience of terror, pain and helplessness. Such individuals often report seeking comfort from imaginary playmates or imagined protectors, or absorbing themselves in the pattern of the wallpaper. Many rape victims report floating above their body, feeling sorry for the person being assaulted below them. Research on hostage taking situations report studies of survivors of life-threatening events indicate that more than half have experienced feelings of unreality, automatic movements, lack of emotion and the sense of detachment (Noyes & Kletti, 1977); (Madakasira & O'Brien, 1987); (Sloan, 1988). Depersonalization (a feeling of disconnection from one's own body) and hyperalertness are prominent experiences during trauma (Noyes & Slyman, 1978). Numbing, loss of interest, and an inability to feel deeply about anything, were reported in about a third of the survivors of the Hyatt Regency skywalk collapse (Wilkinson, 1983) and in a similar proportion of survivors of the North Sea oil rig collapse (Holen, 1993).

This is consistent with our studies of survivors of the Loma Prieta earthquake (Cardena & Spiegel, 1993). A quarter of a sample of normal students reported marked depersonalization during and immediately after the earthquake, and 40% described derealization (the surroundings seeming unreal or dreamlike). While the most common reported memory disturbance was intrusive recollection, 29% of the sample reported difficulties with everyday memory. One survivor of the Oakland/Berkeley firestorm who had lost his house reported a strange sense of detachment during the fire:

"It was as though I was watching myself on television. I had this image of myself talking to a policeman, asking if I could go to my home, and whether he had any information about where my son was. I thought that I seemed rather unemotional, and decided that I had better stay that way in order not to upset my wife. It felt like I was watching the experience rather than having it."

Dissociative symptoms have also been reported to have occurred during combat (Bremner, et al., 1992). Veterans with PTSD have been found to obtain higher scores on measures of hypnotizability (Stutman & Bliss, 1985); (Spiegel, Hunt, & Dondershine, 1988) and dissociation (Bremner, et al., 1992); (Marmar, et al., 1994) than those without PTSD. Such dissociative symptoms, especially numbing, have also been found to be rather strong predictors of the development of later Posttraumatic Stress Disorder (McFarlane, 1986); (Solomon, Mikulincer, & Benbenishty, 1989); (Koopman, et al., 1994). Thus, physical trauma seems to elicit dissociation or compartmentalization of experience, and may often become the matrix for later posttraumatic symptomatology, such as dissociative amnesia for the traumatic episode.

Indeed, more extreme dissociative disorders, such Dissociative Identity Disorder, have been conceptualized as chronic Posttraumatic Stress Disorders (Spiegel, 1984); (Kluft, 1984); (Spiegel, 1986). Children exposed to multiple trauma are more likely to use dissociative mechanisms which include spontaneous trance episodes (Terr, 1991).

These and other data led to the inclusion of a new diagnostic category in the DSM-IV: acute stress disorder. The diagnostic requirements of this disorder are 3 of 5 dissociative symptoms (depersonalization, derealization, numbing, amnesia, or reduced awareness of surroundings), along with one intrusion, one avoidance, and one hyperarousal symptom. The disorder must occur within one month of the traumatic stressor, last for at least two days, and lead to distress or dysfunction (1994).

This literature increasingly suggests that many dissociative disorders should be thought of as chronic posttraumatic Stress Disorders. With repeated trauma in childhood, the likelihood of dissociative symptoms seems to increase (Terr, 1991). In addition, claims against parents for physical and sexual abuse have become increasingly common, and organizations of parents claiming to be falsely accused have arisen. This pits those who have suffered the aftermath of childhood trauma against those accused of victimizing them. The distorting effects of trauma on memory can include the development of dissociative reactions during or after it, limiting the information taken in and encoded, constraining the way it is stored, and making retrieval more difficult for the defensive purpose of keeping negative affect at bay (Spiegel, 1994). At the same time, processes of retrieval are subject to suggestive influences which are intensified by the use of hypnosis. This happens either by suggestively altering the content of memory or increasing conviction about the certainty of memory (McConkey, 1992); (Dywan & Bowers, 1983). This has led to widely publicized court cases in which therapists have been successfully sued for 'implanting' false memories of sexual abuse. Especially when the product of psychotherapeutic exploration finds its way into the courtroom, careful independent corroboration of the information reported is crucial. Nonetheless, if there is a syndrome related to suggested or false memories, there is also one for real memories. Indeed, false memories are the exception which proves the rule. In order to produce a suggested false memory, one must repress a true memory. If you mistakenly report the presence of a stop sign near an automobile accident, you must eliminate the conflicting memory of the yield sign which was really there.

The therapeutic task with such patients is to help them acknowledge, bear, and put into perspective these traumatic memories which have been kept at bay in a rigid and artificial manner. This can be conceptualized in Lindemann's (Lindemann, 1994) sense as grief work. It involves bringing into consciousness painful memories and the associated affect, making them acceptable to consciousness by restructuring them and providing emotional support, and helping the patient move beyond them. Semrad taught that a critical part of interviewing and psychotherapy was following the affect. He generally looked bored by the content of a patient's pronouncements, but watched like a hawk for a hint of affect. The affect must be made bearable for this to be accomplished. One way of doing this is asking patients to picture a divided image of a moment of trauma, for example seeing the assailant on one side, and what they did to protect themselves on the other. This means facing the worst of what was done to them, but at the same time seeing also what they did at the time that was adaptive and protective. This makes a painful memory more bearable and complex, emphasizing not just victimization but successful coping as well.

Medical Trauma

In traumatology, we study the effects of damage done to the body on the mind. In an odd way in our studies of medical illness, we have come full circle, examining effects of the mind on the body. How does coping better with evidence and progressive physical disease influence the way the body copes with this disease?

Emotional Repression and Cancer

There is growing evidence that repression of emotion is associated with poorer prognosis among cancer patients. In a thoughtful and conservative review, Jensen (Jensen, 1991) reaches the following conclusion: "There is no valid basis for assuming a correlation between women's risk of developing cancer and the behavior and personality" (p. 204). He recommends, however, a study of "restrained aggression and introversion" as the most promising area of continued investigation. This area of interest is based upon early work by Greer and Morris (Greer & Morris, 1975) who found that suppression of anger was associated with a higher risk of having a malignant rather than a benign breast lump. Later Greer et al.(Greer, Morris, & Pettingale, 1979); (Greer, 1991) found that patients who demonstrated a "fighting spirit" as opposed to hopelessness/helplessness were more likely to survive longer with cancer. Derogatis, Abeloff, and Melisaratos (Derogatis, Abeloff, & Melisaratos, 1979) divided metastatic breast cancer patients into two groups, one with less, one with more than one year survival. The long survivors were rated as less pleasant and cooperative than the short survivors, consistent with the 'fighting spirit' concept. However, it should be noted that the long survivors had received significantly less radiotherapy, suggesting either that they were less ill or were less weakened by treatment. Similarly, Temoshok (Temoshok, Heller, Sagebiel, Blois, Sweet, DiClemente, et al., 1985) found that malignant melanoma patients with the so-called 'Type C' personality style, self effacing and non-assertive, and thicker tumors at one- year follow-up.

Kune and colleagues (Kune, Kune, Watson, & Bahnson, 1991) conducted a large scale case control study of 637 new cases of colorectal cancer compared with 714 age and gender matched community controls. They found that the cancer patients were significantly more likely to report histories of unhappiness in childhood and recent adult life, and also to have strong responses of discomfort to feelings of anger, including 'feeling like giving up,' 'feeling depressed,' feeling 'keyed up,' or 'blowing up.'

Dean and Surtees (Dean & Surtees, 1989) conducted a six to eight year follow- up of 122 women with primary breast cancer. At the follow-up time (mean 6.7 plus or minus 0.77 years) 37 patients had recurred and 22 had died--all but one of breast cancer. The authors found that denial (but not fighting spirit) was associated with improved survival. A more robust finding was that patients with psychiatric disorders, using the RDC or the general health questionnaire, had a lower risk of subsequent mortality. The authors view this as consistent with their overall finding that patients who expressed distress have better rates of survival. The finding that denial was a stronger positive prognostic variable than fighting spirit raised anew the question often seen in the cardiovascular disease literature (Lazarus, 1985) about whether in some circumstances denial can be protective and adaptive.

Stavraky and colleagues (Stavraky, Donner, Kincade, & Stewart, 1988) found that more purely psychological variables predicted increased mortality in a sample of 126 lung cancer patients. Those with a high need for sympathy and devotion had a three-fold increase in risk of mortality. Patients who described themselves as being emotionally reserved had an adjusted odds ratio regarding mortality of 3.9. Thus, need for social support and being the kind of person who was unlikely to go out of one's way to get social support seemed to result in sharply elevated mortality risk.

Despite some studies showing an absence of relationships between psychological and social variables and disease outcome, for example Cassileth's (Cassileth, Lusk, Miller, Brown, & Miller, 1985) widely-cited article, there continue to be studies suggesting a bidirectional relationship. High distress, especially about somatic symptoms, predicts proximate mortality, which is not surprising. However, more interestingly, difficulty expressing distress has been shown in several studies to predict longer-term poor outcome.

Social Support and Survival with Cancer

Medical Effects of Psychosocial Intervention in Cancer

1. building strong supportive bonds;
2. encouraging emotional expression;
3. dealing directly with fears of dying and death;
4. reordering life priorities;
5. improving relationships with family and friends;
6. enhancing communication and shared problem solving with physicians; and
7. learning self-hypnosis for pain control.

Dear Eva,
Whenever the wind is from the sea
Salty and Strong
You are here.

Your zest for hilltops
And the sturdy surf of your laughter
Gentles my grief at your going
And tempers the thought of my own.

Madeline Salmon

"What I found is that talking about death is like looking down into the Grand Canyon (I don't like heights). You know that if you fell down, it would be a disaster, but you feel better about yourself because you're able to look. I can't say I feel erene, but I can look at it now." (Spiegel, 1993a)

Conclusion

Thus we have evidence that adverse events influencing the body profoundly affect the mind, and conversely, that positive influences on the mind may positively affect the body, at least its relative resistance to the progression of disease. This applies not only to cancer the example given here, but to heart disease as well (Ornish, 1982); (Thoresen & Powell, 1992). Feelings, the limbic load, may be one of the crucial transducing elements, converting physical trauma into mentally accessible and workable information, and transforming caring and support into better behavioral, endocrine and immune function. As we well know, Descartes was wrong. It is not "Cogito ergo sum" ("I think, therefore I am"), but rather "Sentio et sum", "I feel and I am." Feeling and being are intertwined, and this presents a major therapeutic opportunity for psychiatry.