Clinical Articles

by Edward Bruce Bynum, Ph.D., Director of Behavioral Medicine

It is not unusual occasionally for most of us to experience a sleepless night or nights of troubled sleep. These are usually associated with common stress or worry. Occasionally they may be due to medication. Sometimes it may be due to reaction to alcohol. This is called alcohol rebound syndrome. These almost always pass with time, a little rest, and occasional over-the-counter medication. There are some problems associated with medical disorders. These are known to initiated or prolong sleep disturbances. These can be chronic pain, a recent injury, or ongoing mild or even serious depression. Environmental blocks to sleep can be many. In a dormitory there can be excessive noise, there can be a strain in interpersonal relationships, and again a preoccupation with a current personal or family crisis.

It is important to know some basic knowledge about the structure of sleep. Sleep researchers today commonly divide sleep into four stages. They have also noted that all mammals sleep. In fact, the inhibition of sleep is referred to as sleep onset delay. It occurs in human beings when there is more than an hour between laying down to go to sleep and actually falling off to sleep. Sleep is a circadian rhythm and has a neurophysiological basis. This has been studied in laboratories with appropriate EEG and other monitoring equipment. It is known that sleep occupies a significant portion of our live when we are very young and also when we are of an advanced age. It goes on a long curve. Sleep also helps considerably with exercise. Therefore, there is a clearly established need for sleep. Also, when we are deprived of sleep there are consequences for our physical, emotional and psychological behavior.

Of course sleep and dreams go together. During sleep live there is a phenomenon of rapid eye movement (REM). Rapid eye movement is almost always associated with story-like imagery, emotional arousal, and a sense of meaningfulness about the phenomenon. When there is no opportunity for the person to experience REM for some prolonged period of nights, there is a phenomenon of REM rebound where in succeeding nights the person attempts to make up for the REM time that is lost with excessive REM activity. Also during sleep there is a phenomena of non REM activity, which indeed is most of the time in sleep. When one is awakened during a REM period, there is a story-like, dream-like, reverie-like experience. Sometimes extremely intense emotionally. However, when one is awakened during non REM, there is occasional mentation, it is fragmentary, and of relatively little emotional import.

Sleep is often interrupted by some of the afore mentioned activities. In situations like this and on a limited basis medication is helpful in restoring sleep. However there are positive and negatives aspects to sleep medication. Sleep also can be interrupted by poor eating habits and indigestion.

It is noteworthy that in all the higher mammals, but particularly in men and women, sleeping and dreaming is associated with physiological sexual arousal and occasionally the recognition of this arousal in dream experiences.

While most of us enjoy regular sleep and do not think about it much except when we go to get a good night’s sleep, occasionally individuals do experience significant interruptions in their normal sleep cycle. These constitute some of sleep disorders that are more troublesome. A sleep disorder that is troublesome is one in which one experiences a significant alteration in ones mood and capacity to function in the waking state. Some of the more primary sleep disturbances include narcolepsy. Narcolepsy involves the symptoms to irresistible daytime sleep. Also at times there is a transient weakness in the body referred to as cataplexy. Sometimes with narcolepsy occurs a brief sleep paralysis. Also occasional hypnogogic hallucinations which can be unsettling.

Another one of the primary sleep disorders is sleep apnea, of which there are three kinds. These are associated with neurological problems. They involve the interruption of the smooth inhalation-exhalation process. These can be referred to as central sleep apnea, upper airway sleep apnea, and mixed. Prolonged disruption between inhalation and exhalation and sleep can have cardiovascular repercussions in certain individuals, usually significantly overweight males.

Also in the primary sleep disorders are the phenomenon of primary insomnia. Primary insomnia is a difficulty in falling off to sleep. Here there is a persistent and consistent sleep onset delay sometimes of many hours. Often a person feels that they’ve gone through the whole night and slept very little or not at all. The other end of the spectrum expresses itself in primary hypersomnia. This is the tendency to sleep much, much more than is necessary. For the average person, between five and eight hours constitutes the widest range. Below four hours of sleep and above ten hours of sleep constitute cause for at least clinical consultation.

Some of the more unusual forms of primary sleep disturbance include nocturnal myoclonus. This is associated with a phenomenon of “restless legs” syndrome. This is where literally during the sleep cycle ones legs are moving. This can be particularly irritating to ones sleeping partner. In this disorder, the place of exercise and a physical massage and self-care cannot be underestimated.

The phenomenon of nonrestorative sleep and “pseudoinsomnia” are also primary sleep disorders. In nonrestorative sleep, the person may indeed go to sleep but they do not experience that deep and satisfying sleep such as when they wake up in the morning they feel refreshed. These often occur during times of a prolonged stress. A person may awaken from a night of many dreams and feel tired and exhausted and even depresses during the day. They sleep but that sleep is just not restful. Also the person experiences a very, very light sleep such that they are not really sure if they fell asleep or if they were awake all night. This also can be very irksome.

There are also numerous medically related disorders involving sleep. Occasionally periodic hypersomnia is related to a medical disorder. The syndrome of Kleine-Levin syndrome is relatively rare but does occur. Here the person experiences a significant increase in food and sex drives and altered sleep habits. Occasionally ones REM sleep cycle is interrupted by intense anxiety. This can be the result of either a classical nightmare, in which imagery is remembered of a frightening nature, or a night terror. In the case of a night terror, one is suddenly awakened from sleep with a sense of intense dread and other worldliness and yet no memory of the content of one’s experience.

Rarer still is the phenomenon of painful nocturnal erections during sleep. This occurs almost exclusively in males. This is associated with a medical disorder. Also various thyroid dysfunctions are known to complicate the sleep cycle. Finally, excessive use of various stimulants such as caffeine and nicotine or in some cases alcohol are known to interrupt the normal flow of the sleep cycle. One also, therefore, has to be very cautious in one’s use of excess substances.

Finally, the sleep cycle can be greatly complicated by emotional and psychological difficulties. Clinical depression often results in difficulties falling asleep, many awakenings during the night, and excessive difficulty getting out of bed in the morning. In some cases, bipolar disorders exacerbate or create sleep disturbances. Schizophrenia in the beginning stages is often marked by significant changes in the sleep cycle. There is often REM deprivation accompanying difficulties in the waking state that occur during the initial or acute stages of schizophrenia. Alcoholism, alcohol rebound syndrome, conditioning and associations are a major factor in many sleep disturbances. Also psychiatrically speaking, paranoia, excessive vigilance, and recurrent experience of trauma memory are known to greatly disturb the sleep cycle.

There is the condition however of conditioned insomnia. This is when the environmental factors such as a very noisy living situation or expectations of difficulties at night can condition a person to have sleep onset delayed. Finally, there are various forms of sleep phobias. Some individuals experience difficulty falling asleep for fear of extremely bad dreams or even death.

There is a classification of sleep difficulties referred to as the parasomnias. Parasomnias are a phenomenon that occur during the waking state but are not associated with phenomenon that occur in the sleeping state. These are usually associated with the deepest level of the four stages of sleep, referred to as delta sleep. For instance, young children often experience not only nightmares but night terrors. The nightmare occurs during the regular REM sleep, but the night terror however, occurs during the deeper stages of delta sleep. Also the phenomenon of sleep walking or somnabulism occurs in the deepest level of sleep. The phenomemon of bedwetting or enuresis, mostly associated with young children, occurs in sleep. The phenomenon of soiling or encopresis is associated with neurological difficulties of adaptation in younger children and also difficulties in aging for older individuals. Nocturnal bruxism or grinding the teeth occurs during sleep. This is when during the REM cycle one is verbally working through or attempting to work through very psychological and emotional difficulties. The bruxism also occurs during the waking state.

Various therapeutic approaches to the difficulties of sleep cover the full spectrum. Often times the medical physician will prescribe a medication on a brief usage basis. Sometimes psychotherapy for anxiety and emotional disorders is a treatment of choice for sleep and other difficulties of the night. In some rare instances, when there is a differential or a complicated diagnosis, referral to a sleep laboratory if warranted. This information can be ascertained from one’s clinician. There are several excellent clinics in the area. Finally, there are various clinical medications to induce sleep, referred to as “hypnotics”. There are also behavioral methods to overcome primary and secondary insomnia. These often involve shifts in one’s life style, substance use, diet, and appropriate exercise to regulate one’s metabolism. The vast majority of sleep disturbances are transient and normal. It is when they are persistent and cause disturbances in one’s concentration during the day, mood, or expressions of prolonged anxiety, somatization and depression, that one should seek a professional consultation.

References
Peter Hauri, Ph.D., Sleep Disorders, Upjohn
Diagnostic and Statistical Manual of Mental Disorders (DSM IV)
Kingman P. Strohl, MD, The Biology of Sleep Apnea, Journal of Science and Medicine, Oct. 1996, pg. 32 – 41

by Edward Bruce Bynum, Ph.D., A.B.P.P.
Director of Behavioral Medicine

Long before the advent of psychotherapy and psychiatric medication, there were many well tested ways and methods to realize mental clarity and emotional stability. In fact, every human culture over the centuries has evolved a wide variety of these methods within its own context. Some of these methods involved relaxation. Many involved a form of guided imagery with powerful images, techniques and symbols that affected the body and mind. Still others evolved disciplines of mental clarity and insight that enabled the practitioner to move beyond the mental and emotional clutter of their lives and open into a sense of serenity, luminosity and consciousness difficult to describe in words or common emotional expression. These three are, while overlapping at times, actually distinct practices with very different goals.

Relaxation methods are not identical to guided imagery and guided imagery is not identical to meditation. Relaxation of various kinds, particularly the clinical relaxation strategies, generally focus on decreasing somatic and physiological stress and their associated medical symptoms. Various strategies of relaxation and stress management are very effective in this approach. Relaxation is not identical to trance. Relaxation however can be a useful mental diversion. Relaxation can also be very helpful in increasing “ease” and decreasing “dis-ease”.

There are several very well known clinical relaxation strategies widely used in clinical practice. The most common is the Jacobson Progressive Muscle Relaxation. This involves systematically briefly tensing and then relaxing in sequence sixteen basic muscle groups in the body. It develops a healthy sense of relaxation and peace. Another is autogenics, which involves a gentle repetition of images and phrases to create a physical and subjective state of ease and relaxation.

Guided imagery is somewhat different than relaxation. Guided imagery may also use muscle relaxation, but it also involves effective use of images and the decreasing of physical and psychological stress. Guided imagery, unlike the clinical relaxation approaches, may involve light trance states, but not always. Guided imagery definitely requires a certain “safe context”. The method involves some mild focus on internal moving imagery which tends to absorb attention and concentration. However, guided imagery is not identical to clinical hypnosis. Guided imagery has many techniques which vary. Some of these are idiosyncratic to the person or the therapist using it. However, some guided imagery can be effectively done with tapes that are bought. Guided imagery in the past has been used for healing and many of the same techniques are used today.

Meditation is a mental discipline that is thousands of years old. Meditation is actually a body of knowledge and techniques that is open to observation and replication and therefore “scientific” in its methods. They can lead to significantly altered states of consciousness and in some cases help the individual move into a “unitive conscious experience” that transcends the normative boundaries of conception, perception and experience. The goals of meditation are alternately liberation and freedom, goals that are radically different from the goals of guided imagery and those of clinical relaxation.

Meditation may or may not involve religious or spiritual beliefs. Meditation in diverse traditions as a discipline is quite wide and diverse. The traditions of Buddhism are replete with different meditative disciplines. This includes the Mahayana, to the Mahamudra lineages to the full spectrum of Tantric meditative schools and all their techniques. In Hinduism there are different meditative techniques associated with the different yoga paths. The eight major schools of yoga all have highly evolved meditative disciplines. In each one, the use of breath and physical posture is associated with various specific and replicable states of mind. It is particularly in the paths of Hinduism that the techniques and pathways of Hatha, Raja, and Kundalini yoga are most noticeable.

Even within meditation there are different styles of absorption and insight. However, these are by no means limited to so called “Eastern” methods of meditation. In the “Western” and other traditions meditation is also a well known and deeply respected tradition. In the Christian Esoteric Tradition, monks of various contemplative orders have used meditation for hundreds of years. These lead at times to ecstatic states of consciousness. These are popular today in our postmodern era. They also have roots in the pre-Christian era.

Prayer may be experienced as a variation on meditation. However, prayer is a path that uses imagery and verbal statements fused with the primordial intuition of faith and spiritual consciousness to create its particular condition. Jewish mysticism, particularly in the Cabalistic and Hasidic traditions, has spawned many meditative disciplines. In the technique of “evenly suspended attention” which one finds in the Caballa and in a peculiar way in early psychoanalysis, one can see the affinity to other forms of meditation, in particular the Vipassana meditation of Buddhism . In Islam there are various traditions, the most notable being the Sufi tradition.

In the various African traditions there is a coordinated use of breath, rhythm and incantation in the creation of meditative states which radically alter ones mental and psychological condition. Particularly in the African traditions which spread to the Caribbean, South American and throughout Africa itself, the use of the group is a powerful modality. It is in groups that so called “possession phenomenon” is more likely to occur. The group form becomes a “wave” form that changes the behavior of the individual form. This is part of the power and the secret and why it remains largely unfathomable in our individualistically oriented society. The possession phenomenon is grossly misunderstood and pejoratively imagined in the “western” imagination. It is also different from the phenomenon of ecstatic absorption, which is referred to as “lae-lae”. These are also associated with, but quite distinct from, different kinds of states of mind created by various forms of so called “divination”. Ifa is the most prominent in this tradition as far as the West African diaspora is concerned.

There are also the Native American traditions that involves a vision quest. In these, there is meditation associated with other kinds of phenomenon. More common in the Native American traditions associated with meditative states are the traditions and disciplines associated with various forms of Shamanism.

In all of the above disciplines, with their great variety and degrees of intensity and methods, one thing should be noticed. All of these disciplines create a body of data that is open to empirical observation, a shared methodology, and replication. These are all the hallmarks of what constitutes a science in the modern form. In the Age of Doubt and logical positivism there is a tendency in contemporary science to feel that the only “real sciences” are those in which one can measure things in a certain manner. We confuse the real with the physical thereby reducing the world to sensation and object. This is a prison. The canons of science are a body of knowledge empirically derived by observation, replication, and methodology. Each one of the above is open to critical inspection based upon this paradigm.

Obviously different methods are applicable for different people, which is why there are so many “different paths”. The correct “fit” has a lot to do with the training, cultural differences and individual intuition. This is why there are so many conflicts, because many people believe that something that fits well for them should somehow fit well for someone else.

There is a contracting tendency in the faith of rationalism, a constricting process in the heart of conventional faiths. These both mirror each other seducing the eye of the practitioner into believing its own vision is the only way to really see. This helps reduce the other to mere ignorance and ashes and elevates its own perception of the world into that of the pure and the elite. Religion is not identical to meditation. Meditation is similar to but not identical to prayer. It is clear today that meditation and prayer have enormous health benefits to the psyche and also the physical self. Meditative disciplines go quite well with lifestyle changes of a positive nature. This is one reason why meditation is more and more being brought into healthcare.

Many forms of psychotherapy at times confuse certain techniques of psychotherapy with meditation. Meditation and psychotherapy however have different aims. They are not substitutes. However, the use of meditation in psychosomatic medicine has demonstrated positive effects. The use of meditation in developing emotional lucidity and mental clarity has also been established.

There are times in one’s life in which it is more advantageous to explore meditation than at others. When there is a life stage change and increasing psychological maturity, this is an ideal time to explore different meditative paths. It is also the case when there are increasing health issues. Finally, when one is developmentally emerging into a state in which spiritual issues are more important in one’s life, e.g. mid-life crisis era, that is a time to explore the varying kinds of meditative experience. Some meditative experiences will cross fertilize and integrate well with different religious strategies and some will not. This must be established by each individual. The Diagnostic and Statistical Manual (DSM IV), the “bible” of psychology and psychiatry, has recently recognized the “authenticity” of a spiritual experience and differentiated it from regressive fantasy and mental disorder. In other words, there is little less hubris today in science and medicine, and spiritual experiences are no longer relegated to psychopathological states as they have been in the past. This bodes well for the union of psychiatry, psychology and spiritual practice for the next millennium.

References
Edward Bruce Bynum, Ph.D., The African Unconscious, New York, NY, Columbia Teachers College Press, 1999
Edward Bruce Bynum, Ph.D., Transcending Psychoneurotic Disturbances, Ithaca, NY, Haworth Press, 1994
Roger Walsh, MD, Ph.D. and Frances Vaughn, Ph.D. (eds), Beyond Ego: Transpersonal Dimensions in Psychology, Los Angeles, CA, J.P. Taucher, 1980
Ken Wilber, The Atman Project, Theosophical Publishing House, Wheaton, IL, 1980
H.H. Rama, Choosing a Path, The Himalayan National Institute of Yoga Science and Philosophy, Honsdale, PA, 1985
Namgyal, T., Mahamudra: The Quintessence of Mind and Meditation, Shambhala, Boston and London, 1986
Gyatso, G. K, Clear Light of Bliss: Mahamudra in Vajrayana Buddhism, Wisdom Publications, London
The information provided in this column is for educational/information purposes only. The intention is not to provide medical advice or replace the services of a trained healthcare professional. Please take specific issues or medical concern to your healthcare provider. For further information please visit the UHS Mental Health web page at www.umass.edu/uhs/mentalheath.

by Edward Bruce Bynum, Ph.D., Director of Behavioral Medicine

Everyone reading this article has at some point in the past had a headache. In fact, during a course of a year most of us have at least several headaches. Usually these headaches are mild tension headaches or stress headaches. They subside with rest and perhaps occasionally a little aspirin. They often occur around normal stressful life episodes. Sometimes alcohol and the rebound from alcohol can exacerbate headaches, as can some medications. Some headaches, however, are more troublesome. These headaches are the more intense, recurrent, and exacerbating headaches associated sometimes with certain kinds of food, allergies, ecological and environmental conditions, and place a drain upon our system. Certain foods such as monosodium glutamate will exacerbate a headache. Certain conditions such as intense sunlight are known to bring on certain kinds of headaches. These headaches also usually pass with time or can be avoided with a little planning.

Other types of headaches, however, are more clinically significant headaches and each has it’s own pathophysiology. In the following we shall describe several of these headaches along with their neural and somatic physiology and the specific symptoms associated with them and their association with other syndromes. The most common variety of headache is the muscle contraction or tension headache. This usually occurs on one side of the face but sometimes can occur bilaterally. Often the neck and shoulders are associated with this situation. There is a great deal of tension in the neck and shoulders and sometimes in the mouth and jaw. Sometimes the conditions of bruxism and temporal mandibular joint pain occur with these kinds of muscle contraction headaches.

Another common variety of headaches are the migraine headaches. There are essentially three different kinds of migraine headaches. A migraine headache is a vascular headache, which is to say it involves the veins and arteries primarily in the body. This is how it is different than the muscle contraction and tension headache which involves mostly muscle tension. The migraine headaches involve vascularvaso constriction. In the common migraine headache this vaso constriction has two phases. The first phase is one of vaso constriction in which a person may experience some coolness in the hands and fingers, some sensitivity to light, occasional nausea, and a sense of mild dread. In the classical form of this migraine headache there is a slight aura perceived around objects. This is due to the fact that the vaso constriction is occurring primarily in the back of the head, the occipital regions of the brain where visual stimuli and information are processed. The third form of migraine headache is the mixed migraine headache, which a mixture of both the common and the classical migraine headache. In some rare instances there are headaches that involve more complicated and serious medical disorders such as stroke and hemorrhage. Stroke, which is referred to as a cerebral thrombrosis, accounts for about 55% of all cases of stroke. Also there is a form of headache called a hypertensive headache, which develops when the hypertension or high blood pressure becomes moderate or severe. The headaches are usually occipital, moderately severe and nagging and throbbing in character as are other migraine headaches. This is again how migraine headaches are somewhat different in general than muscle contraction headaches. Migraine headaches tend to throb, whereas muscle contraction headaches do not throb as much. This of course is not absolute. Finally, there is a cerebral hemorrhage referred to as a subarachnoid hemorrhage which produces a particularly intense kind of headache. This kind of headache is caused by an aneurysm in 50% of the cases and by arteriovenous malformation in approximately 10% of the cases. The other 40% are made up by causes such as hypertensive intercranial hematoma or blood dyscrasia. The latter three headaches of course are the ones that we are most frightened of. The headaches that result from brain tumors are also exceedingly rare. Headache is the initial symptom in about 20% of patients with brain tumors and is present during the course of the illness in about 90% of patients.

The other kind of common headache is a sinus headache. This headache occurs as a result of congestion and blockage in the sinus areas. It is related to the condition of sinusitis, rhinitis, and other upper respiratory complications. Finally, the other major form of common headache is called the cluster headache. Unlike the muscle contraction headache and the migraine headache, the cluster headache has no warning and can hit very quickly. In this way it is somewhat similar to the sinus headache, although in the sinus headache one usually has a sense that one’s sinuses are congested and so there is some warning. There are very few prophylactic measures that can be taken with a cluster headache other than prophylactic medication.
Mixed and multiple headaches are those headaches that involve both migraine and muscle contraction elements. They can be episodic. Also it is not unusual for a person to have clearly muscle contraction headaches at some times and migraine headaches at other times. The cluster headache is represented by sudden and intense feelings of pain throughout the face and head.

After the headaches described above, particularly the migraine headaches and the cluster headaches, it is not unreasonable for a person to experience a great deal of fatigue and increased irritability. With migraine headaches in particular, there tends to be an increase in the desire to escape it by going to sleep. Depressive reactions are common in all situations. It is rare, however, that the muscle contraction, migraine, or sinus headache leads to incapacitation to do work. Transiently, the cluster headache, however is capable of rendering a person almost useless to do work. In all three situations there can be increased fatigue, irritability, loss of efficiency at work, appetite loss and decreased concentration.

As was stated above, all of these headaches with the exception of the neurological headaches, tend to be relatively common in most people. This is to say that it is not unreasonable for a person to have a migraine headache once or twice a year or a muscle contraction headache two or three times a year. However, there are times when headaches are a concern and should be referred to a clinician for evaluation. These include the times when there is sudden onset and no diminishment of the pain over time. Also when there is a loss of visual or auditory capacity for long periods of time. Also when there is a loss of balance and a passing out or a loss of consciousness. Also critical are unusual tastes or smells such as metallic tastes or a spoiled substances. When these occur it is very important to refer this to a clinician for evaluation. In most cases a regular medical or other reason can be found for these.

In the most common varieties of headache there are some very simple and straight forward measures that can be taken to significantly decrease the headaches. The first is that when symptoms are common, exercise, relaxation, decrease in alcohol intake, decreased stress, and prudent use of occasional over-the-counter medication is very helpful. Often diet changes and lifestyle changes are extremely helpful. Some people develop headaches after drinking substances such as red wine or too much caffeine. Some respond with headaches after ingesting too much monosodium glutamate or other things. There are also other peculiarities that a person’s system may be responsive to. When symptoms are more troublesome and or persistent, consultation with a University Health Services physician or nurse practitioner or nurse may be prudent. After their evaluation they may refer the patient for medication or brief counseling. In certain situations such as migraine headache, muscle contraction headache and mixed headache, the patient may be referred to the behavioral medicine/biofeedback clinic. This is when it is assessed that the headaches are primarily psychogenic in nature, and not medical in that a person can learn to decrease their headache tendencies and their stress level by learning psychophysiological self regulation through biofeedback and behavioral medicine. Usually this can be learned in anywhere from 4 -6 sessions with practice outside of sessions. Occasionally someone may be referred for longer term psychotherapy in conjunction with behavioral medicine. In rare circumstances a person may be referred to a neurologist, a specialist in disorders involving the cerebral area. Also under certain circumstances and MRI or CAT scan may be employed. Primarily however, most headaches are common and respond to treatment relatively easily and quickly without recourse to serious medication.

References
Seymour Diamond, MD and Jose L. Medina, MD, Headaches. Clinical Symposium, Vol. 33, No. 2 (1981)
George D. Fuller, Ph.D., Biofeedback: Methods and Procedures in Clinical Practice, San Francisco, CA

by Edward Bruce Bynum, Ph.D.,A.B.P.P., Director of Behavioral Medicine
Mental Health Department, University Health Services

Often the end of the year or the end of the season is an emotionally intense time for students and family. Many events may be occurring simultaneously. There is pressure associated with the semester’s end. There are concerns about grades. There is stress associated with study. There is especially anxiety about the future for seniors and those in graduate school. This is also the case for first semester students who are wondering if indeed they have what it takes to make it in a demanding academic environment. For others, many family pressures arise. There are anticipated family meetings with the potential for restirring up older, unresolved conflicts with family and siblings. These are intense “reunions” because one is often psychologically trying to establish one’s own separate identity in the world and experiencing real autonomy for the first time. There are anticipated dreaded visits, revisiting old guilts and pressures, etc. There are significant personal and family anniversaries, such as the death of a loved one, to which we have an unpleasant reaction or even a collective reaction to a major cultural event like the attack on the World Trade Towers, which still sends waves of anger, nausea and anxiety through the shared body politic. These can all lead to various kinds of pressures which then eventuate in family and individually oriented crisis around the holidays and around anniversaries.

Family life is a critical and important aspect of everyone’s life. Indeed, it is the bedrock of our primary emotional and psychological relationships. Many of our later important relationships throughout life are permutations and derivations of these earlier primary relationships. When there is a disruption or a stress in one of these primary relationship configurations, we respond generally with a crisis. Crisis, of course, is both a sign of danger and an opportunity for emotional and even spiritual growth.

These individual and family re-engagements create crises around holidays which can express themselves in a number of ways. One of the more common is an increase in anxieties, especially with one’s roommate. There may be increased frustration and short-temperedness with other people. One of the more subtle changes is a perception of time being shorter and more contracted. Sometimes with this crisis, there is an increased concern about medical and emotional problems. These may have been dormant throughout the year but suddenly take on a greater urgency. For some individuals, there is even a mild kind of reactive depression. This can lead to decreased concentration, more difficulties with sleep or sleeplessness, and an increase in pervasive anxiety. This means that the anxiety is not necessarily associated with a specific person or situation, but rather with the mode or the general atmosphere of one’s life at that time. It should be noted that this is not the same as grief or mourning or bereavement. It is rather a sense of anxiety and the mild depression that may come as a result of all these changes and events.

It is important to notice this in yourself. Generally these situations are more intense than in the high school. In high school one may have been at the top of the class or studying came easily. In a more demanding academic and athletic environment, older skills may not shine as easily as they did in the past. This can be stressful and a shift in the way you see yourself.

In most cases these holiday and anniversary stimulated family crises pass with the passing of the holiday or season. This is quite normal. It is not an indication of pathology or the need for counseling or psychotherapy. At the end of the year most of it ends and the person returns to school or returns home for the summer. However, when situations are persistent, when that mild depression is something that doesn’t seem to be shaken easily, when anxiety begins to disrupt concentration, sleep and the flow of work, then it is perhaps time to go beyond talking with friends and associates and seek out at least a brief professional consultation.

References
Ackerman, N. 1958. The Psychodynamics of Family Life: Diagnosis and Treatment of Family Relationships. New York: Basic Books
Framo, J. L. 1970. Symptoms from a Family Transactional Viewpoint. In N. W. Ackerman, J. Dieb and J. K. Pearce, eds., Family Life in Transition. Boston: Little, Brown & Co.
Whitaker, C., and Napier, A.Y. 1978. The Family Crucible: The Intense Experience of Family Therapy. NY: Harper & Row, Inc.

by Edward Bruce Bynum, Ph.D., A.B.P.P.
Director of Behavioral Medicine

 

Everyone dreams. Some of us remember our dreams and some do not. There are many reasons for remembering dreams and for the content of dreams. One’s cultural background, value system, and interest are particularly important in the remembering of dreams. However, remembering dreams can be a learned and valued phenomenon, and also forgetting dreams is not necessarily a reflection of a problem.

Neurophysiologically speaking, dreams are part of a ninety-minute cycle that occurs in sleep. Dreams actually occur in the “lighter stages” of sleep not in deep sleep, as many people often believe. Sleep and dream research have revealed that dreaming experiences are associated with rapid eye movement, or what is called REM. During these ninety minute phases of the sleep cycle dreams occur. The rest of the time during sleep one has what is referred to as non-REM sleep. Even in non-REM sleep there are patches and fleeting occasions of mental imagery. The situation however with REM is that when one is awakened during a REM cycle, one has the direct recall of having a dream. When people are awakened from a non-REM episode, they occasionally have thoughts, but these are not organized and there is no strong emotion or story-like aspect to it. It is also a curious phenomenon that the duration or length of REM experience extends throughout the night with the longest period of dreamtime occurring near the end of the sleep cycle.

When REM is suppressed for one reason or another, on the succeeding nights there is an attempt on the part of the body-mind to rebound from this. This is called rebound REM. One is more likely to sleep and dream for longer periods of time. These are brain or cortically mediated events. REM sleep and REM recall can be suppressed by many factors, including alcohol and various medications.
In the inner landscape of sleep there are three generally accepted “levels” of the unconscious from a psychodynamic point of view. There is the deep unconscious that rarely reaches the surface. This is believed to be the origin of dreams. There is the pre-conscious, that level through which dream experience passes and is transformed and elaborated before it reaches waking consciousness. There is also the range of what is called the subconscious which is another way to view the processes of mental phenomena. The subconscious and the unconscious are related to each other but they are not exactly the same. Phenomena such as repression and suppression, projection, displacement and symbolization occur as unconscious phenomena. Various disorders of sleeping and dreaming can be understood to be processes that occur as a result of psychological repression and various medical phenomena. A “subconscious” view of mental processes does not necessarily embrace these other “psychodynamic” events.

Dreams serve many functions for the higher primates. In particular, however, they serve many emotional and psychological functions for human beings. Dreams are literally biological phenomena rooted in mammals. All mammals dream. We can only speculate however as to the content of their dreams. However, they do have rapid eye movement. If you’ve watched your dog sleeping, you’ve been able to notice that at times his legs will move and he may even bark occasionally. He is having some sort of dream experience.

In human beings, dreams are fragments and reflections of memories, wishes, fears, events, personal and particularly family patterns. On average 30 to 40 percent of the persons in our dreams are family members. This dynamic region of our psychic life is referred to as the Family Unconscious. The actual dreamwork itself involves taking these multiple phenomena from recent times, referred to as “day residue” and memories from long ago. The dreamwork then condenses many of these images in memories and themes, and distorts them, symbolizes them, and often displaces one situation and one image for another. Dreams are often attempts to solve problems. There is also an enormous amount of creativity that occurs in dreams. Many of the greatest works of art, science and religion have their roots in the process of the dream. Also, finally, it should be noted that unusual psychological events that defy our present understanding of space, time, causality and information transfer do occur in dreams and have been documented for many years in laboratories. These include the anomalous phenomena of extra sensory perception, precognitive experience, and related phenomena that as yet is not understood by mainstream psychology and psychiatry but never-the-less are real and persistent human phenomena.

Some of the more common problems however that occur in regular nightly dreams are nightmares and night terrors and sudden awakenings. Nightmares occur in which frightening imagery and stimuli may actually awaken a person. One has a memory of the frightening situation. One’s heart may be racing, there is a perfusion of sweat, and a sense of fear and apprehension. In night terrors however, there is a sudden awakening at night with an intense of fear, anxiety, panic and dread with no memory of the actual content. Sometimes a series of night terrors occur at the beginning of serious psychiatric disorders. It is quite common for children to have night terrors in addition to nightmares as they are learning to live in the world of waking and sleeping cycles. Sudden awakenings also can occur in the middle of the night. These are usually associated with nightmares.

Recurrent dreams are an indication that the dreaming person is attempting to work out various difficulties and episodes of the past, dynamic present or the anticipated present. In some instances recurrent dreams are an expression of a past trauma. Other times recurrent dreams are an expression of the mind attempting to work out solutions for far ranging personal and scientific problems. When one is preoccupied with an issue, be it scientific, medical or interpersonal, the dream life tends to reflect that repetitively.

On occasion dreams are paradoxical as they may seemingly accompany a certain kind of sleeplessness and depression. This is when the person is not sleeping “deeply” but only in the very light sleep. As a consequence there may be experiences of dreams or dream-like phenomena where the person is still tired in the morning. This is referred to as non-restorative sleep. These dreams are usually associated with a great deal of anxiety and depression. These emotional experiences, along with their physical expressions, can plague a person throughout the waking state. One can feel that although one slept a great deal last night one is still tired.

Dreams have an enormous potential for personal, emotional and spiritual growth. Dreams can help one increase intimacy and at the same time differentiation in their relationships. A close and careful study of one’s dream life will reflect one’s own personal mythology and the inner world of symbols, images and dynamic interpersonal and intrapsychic issues.

Dreams have been used in therapy since ancient Egyptian times. In fact, dream analysis as we think of it today began with the ancient Egypto-Nubian cultures and then spread over the millennia throughout the countries and cultures of the Mediterranean basin. Dream therapy and dream interpretation have had a checkered history throughout western civilization. At one time it was actually thought to be a negative thing to be engaged in. However, in the last century many pioneering investigators began to re-look at dream interpretation again. The most notable, of course, in the western tradition are Freud and Carl Jung.

Finally, dreams are extraordinarily powerful in the exploration of levels or dimensions of consciousness. Dreams may help one skillfully explore their own intrapsychic unconscious. However, there is a deep and unfathomable collective unconscious in which particular symbols of a universal nature called archetypes emerge in the dream life. Also the dynamic family unconscious contribution to dreams reflects one’s intimate and deep, abiding relationships with one’s family of origin that are then evolved out and played out in our emotional life with others. Last, but not least, dreams can reflect the transpersonal or spiritual dimension of one’s life and consciousness. All of these interpenetrate and dynamically reflect each other.

There are times however, when difficulties with dreams warrant a consultation with other than friends and associates. When recurrent stressful dreams occur where one is tired or a sense of dread and fearfulness occur, that is a time to consult a counselor about one’s experience. Also repeated sudden awakenings with panic and/or night terrors are another occasion to seek a consultation concerning one’s life situation. Recurrent nightmares and a sense of foreboding are an indication of possible difficulties that are associated with trauma phenomena. When dreams are normal they reflect the regular stresses and strains of family and interpersonal relationships simply because they are very intimate and it is a biological necessity to dream. It is only when the dreams are unsettling, persistent, and physically and emotionally disturbing that we should seek a professional consultation.

References

Bynum, E. B. 1993. Families and the Interpretation of Dreams. Ithaca, NY: Haworth Press.
Hartmann, E. L. 1984. The Nightmare: The Psychology and Biology of Terrifying Dreams. New York: Basic Books.
Hauri, P., Ph.D. The Sleep Disorders. A Scope Publication, Upjohn.
Hobson, J. A. 1988. The Dreaming Brain. New York: Basic Books.
Sullivan, H. S. 1953. The Interpersonal Theory of Psychiatry. New York: W. W. Norton & Co., New York.
The information provided in this column is for educational/information purposes only. The intention is not to provide medical advice or replace the services of a trained healthcare professional. Please take specific issues or medical concern to your healthcare provider.
Visit us at our website at www.umass.edu/uhs/mentalhealth.

by Edward Bruce Bynum, Ph.D., Director of Behavioral Medicine

 

There is a great difference between sadness, brief unhappiness, and depression. Sadness occurs when one is disappointed or unhappy with a situation. Brief periods of unhappiness occur after losses. Depression, however, is another matter all together.

Depression has many forms. There is a brief or normal and reactive depression. When we have lost a job or a position or a relationship, we can often respond with a brief and reactive and appropriate depression. During this time we are upset, there may be some changes in our general habits, but most people pass through this and pull themselves back together. Mild symptoms are often associated with depression. These may be a mild decrease in appetite, loss in weight, slight lowering of self esteem, an uneven sleep pattern for a while, increased rumination, and low energy level. Again with the vast majority of individuals, these pass without serious repercussions.

However, there are times when the depression posses a greater and more serious threat to the integrity in the life of an individual. When the depression is significant and appears to last for more than at least two weeks, this is something that should be taken note of. Sometimes with a significant depression there is a serious sleep interruption. This might be that the person experiences difficulty falling asleep for more than an hour at a time. There may be mini awakenings at night. There is sometimes difficulty getting out of bed in the morning and getting to classes. In some individuals there is the phenomenon of hypersomnia, which is excessive sleep. This would be gauged by the need for more than ten hours of sleep. When there is an appetite loss of ten or more pounds, this is also a significant factor. In cases of significant depression these is a decrease in concentration and periods of time in which a person can feel unfocussed. There is often associated this a loss of motivation for school work or other forms of work. This is associated with a sense of fatigue and heaviness. Others may a notice a sense of social withdrawal and isolation by the individual accompanied by sometimes increased irritability. In some extreme cases there is even what is referred to as “psychomotor retardation”. This is when the person literally begins to physically move slower and seems to be experiencing a significant decrease in their capacity to move and conduct themselves through the day. Also with depression that is significant there are increased feelings of guilt, sense of uselessness, and loss of pleasure or anhedonia. These are all signs that the depression has moved beyond a mild or moderate stage into something more serious and deserves the attention of those around them.

The forms of serious depression however are many. Some of these are reactive to a situation. This includes a major depressive episode. A person may require to be removed briefly from the life context in order to overcome this depression. Some depression, however, appear to be cyclical to the persons personality style. In other words, there is a condition called cyclothymic disorder. This is where a person literally has significant ups and downs in their personality during the year. Another condition is referred to as bipolar disorder. There are two forms of this. It is essentially where a person’s moods are significantly altered that it requires attention. There are several other mood disorders that are associated with depression. There is a form of depression also associated with personality “style” that is deferred to as dysthemia. This refers to a person who may feel themselves to be low in energy and mildly depressed for long periods of time without any clearly stimulating factors. A variation on this is SAD or seasonal affective disorder. However, seasonal affective disorder occurs primarily on the wintertime and is significantly altered by the change of seasons. Seasonal affective disorder is also know to respond to different forms of light therapy. Many forms of depression also respond well to brief medication.

A form of depression that is unique to women is referred to as post-partum depression. Sometimes after the birth of a child, there is a significant depression on the part of the woman for several months. This is related to biological and hormonal changes as opposed to primarily psychological factors. Clearly psychological factors are involved, but it is primarily a medical disturbance.
Another form of serious depression that is normal is the bereavement response. This is when someone very close to us, usually in our family relationships, but also in our other intimate circumstances dies. We have a painful but normal and prolonged grieving process. In most individuals this generally lasts about a year. Many cultures and societies naturally address this with various rituals and patterns of response to help the individual move through these difficult times. This again is a normal response. When it moves beyond a normal response to one that is a clinical response, it is referred to as melancholia.

There are forms of depression that are brief and reactive that are initiated not by the personality but by substances. These substance induced mood disorders are many. Also occasionally there is an intense form of depression referred to as psychotic depression. These can occur with intense manic episodes and with other major depressive episodes.

It is important to know when to seek help for one’s self and others. When the depression occurs for more than a month, it is important to address that depression. Also when the depression appears to be continuous, it is important to address it in yourself or to others. If significant changes in habits such as sleep, appetite, concentration, mood, subjective negativity and isolation are all signs that the depression should be taken seriously. In extreme situations suicidal ideation, whether it be recurrent or fleeting, can attend depressive episodes. These brief suicidal thoughts can occur in one’s self and sometimes be observed in others. When they are fleeting, they may occur to a person for the first time and actually be quite frightening for an individual. Others however, have experienced suicidal ideation off and on many times and are not as frightened by them. However in either case they should be taken seriously. When there is a sense of finality and a sense of severing of ties, of unrelenting guilt, remorse and feeling of worthlessness, this is when depression is associated with suicidal ideation that should and must be taken seriously. Verbalized statements of self injury to self or others are also to be taken quite seriously. When messages are left to others in various ways symbolic or other, this is a sign that the person’s behavior should be taken quite seriously. This is not the time to abandon a friend. It is better in circumstances like this to be nosy and intrusive with someone that to abandon them. Also when there is an increased fixation on (exit) options, this is sign that the person is entertaining destructive thoughts beyond the fleeting level.
It is extremely important to take such subjective and behavioral signs seriously. When this occurs to one’s self, even if it’s for the first time, one should seek help or if it occurs with someone else, one should gently urge the others to seek help. One should be aware of the emergencies operation. Here at the university, you have available the University Health Services Mental Health Division, which is a 24 hour on-call service. There is also Emergency Services in Northampton. There is also the police and other agencies.

Help for someone with a significant depression that may be associated with a suicidal ideation can take many forms. Sometimes brief counseling or even longer term therapy is important after there is an assessment by an appropriate clinician. Sometimes brief counseling may be associated with appropriate medication. There are a number of very effective medications that significantly decrease the pressure that is created subjectively with depression and suicidal ideation. Sometimes leaving school or one’s job can actually be a positive step in decreasing one’s immediate life stresses. Under certain circumstances hospitalization, voluntary or involuntary, is the path of choice. Again it is more important to be persistent and even nag the person rather than to isolate them and leave them alone. Better safe than sorry. Compassion is significantly less expensive than grief.

References
Diagnostic and Statistical Manual of Mental Disorders (DSM IV), 4th edition, American Psychiatric Association
Alfred Friedman, MD, Harold Kaplan, MD, & Benjamin Sadock, MD, Modern Synopsis of Psychiatry II

by Edward Bruce Bynum, Ph.D., A.B.P.P.

There is a mounting crisis in one of the residence halls. A professor has been aware for several weeks now of a student’s conflicts, communicated in vaguely suicidal and sometimes bizarre written statements to the professor. The roommates have noticed a change, especially in the last three or four days. There has been a shift in eating and sleeping patterns. Everyone has noticed his ability to concentrate has really gone down. One evening, inexplicably, the student seems to explode after the smallest provocation. After that, the student withdraws into his room, prompting a resident assistant to contact the University Health Services and the UMass police. After a confrontation and a contact with University Health Services, the student is transported to a local hospital. Everyone in the residence hall knows about this. Then after four days, the student is back in the dormitory and not a word is said. Everyone is bewildered and anxious. What are we to do?

Often in the university community there is a perceived conflict of interest between the rights of privacy and confidentiality and the right, and perhaps the need, of the wider community to be aware of a difficult and sometimes serious stress to the health and safety of the community. This can occur not only in the above situation, but in many others. For instance, a family’s concern about their son or daughter whom they have not spoken to for months. The student is actually a patient at the University Health Services’ Division of Mental Health and actively does not wish to speak with their family. Also, in the situation described in the hospitalization case, the student may not want the parents to know about this at all and does not want the bills to go to the parents’ home. Another is a situation in which there are legal ramifications brewing after an incident in the community. The persons involved wish to keep this very private until the situation is clarified, yet all the time the community, newspapers, and the administration are very concerned and want information because of potentially negative effects on other staff, faculty, and students. The University Health Services’ Division of Mental Health may see a student, faculty, or staff member whose child is considered at risk or involved in some other complicated situation, and there needs to be privacy for the family while simultaneously addressing the community’s concerns, both clinically and legally.

More often than you might imagine, the University Health Services Division of Mental Health has been in these complicated situations and must “sit on” sensitive information that is critical to all concerned. Of course, the “identified” patient always has the right to share their information with other professionals, physicians, psychologists, and clinical social workers. Permission for a mental health professional to release information is secured only by written permission. Forms are easily gotten for this at the University Health Services. Most often, however, individuals wish to keep such intimate situations confidential and to themselves and therefore invoke statutory laws of confidentiality on their side.

All the situations described above bring to light subtle and complicated legal, ethical, and clinical issues around confidentiality. After all, confidentiality is one of the cornerstones of effective psychotherapy. Assurances of confidentiality communicate respect, dignity and autonomy to the patient by both the psychotherapist and the larger community of which the institution is a part. Without confidential communication, there can be no trust nor the sustained empathy necessary for work and exploration of intimate material in the person’s life. The right to confidentiality and privacy of records extends even beyond the death of the patient!

The United States Supreme Court has even taken note of the importance of confidentiality specifically in the psychotherapeutic context. They have stated that

“Effective psychotherapy . . . depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories,
and fears. Because of the sensitive nature of the problems for which individuals consult psychotherapists, disclosure of confidential communications made during counseling sessions may cause embarrassment or disgrace. For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment.” (Jaffee vs. Redmond, 518 U.S.1.)

Indeed, it is a cornerstone of the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 1992) and laws of the state of Massachusetts. Psychiatry and clinical social work have similar ethical and professional requirements. In the case of the clinical psychologist, the ethical principles clearly state that “Psychologists have a primary obligation to take reasonable precautions to respect the confidentiality rights with whom they work or consult, recognizing that confidentiality must be established by law, institutional rules, or professional or scientific relationships.”
(Standard 5.02) The statutory laws of the state of Massachusetts indicate that “all communications between a licensed psychologist and the individual with whom the psychologist engages in the practice of psychology are confidential.” (Massachusetts General Law, Chapter 112, Section 129A)

In general, then, the guidelines are the following. A clinician has both an ethical and a legal obligation to keep information confidential unless a patient consents in writing to reveal this information. A student, faculty, or staff who receives treatment at the University Health Services is, in addition to being a faculty, student, or staff, is also a patient. It is this legal status of being a patient that gives rise to the mental health provider’s duty to protect confidentiality. The clinician is free to attempt to persuade the patient to release information if it appears to be in the patient’s best interest. However, even in circumstances like these, the patient may at times elect not to do so.

There are, however, a few legal, clinical, and ethical situations that do recognize the limits of individual confidentiality and the greater need of the community to know. These situations generally focus on some imminent threat to health or safety. Disclosure of confidential information without or over the consent of the patient can occur in the following limited circumstances. All health care professionals are mandated to report suspected abuse or neglect of a child, elderly adult or disabled person. This is a situation in which confidentiality rights are trumped by the need to protect those who are more vulnerable. Second is a court order when the court has decided the data held in confidence sheds significant light on the “truth finding mission” of the judicious proceedings. The third situation is when there is an imminent threat to seriously harm an identified individual in a community, together with means and intent to carry out the threat. This is the Tarasoff duty to warn principle. Each state has a subtle variation on this duty to warn an individual of impending danger.

The last is rather new and involves the insurance industry and their requirment to gather information for acute or longer term care, based on criteria for “clinical necessity”. Generally, managed care plans will provide up to 8 outpatient mental hath sessions without review. However, when there is a request for insurance payment beyond 8 sessions, or for more acute care such as inpatient treatment, there generally is a requirement for your mental health provider to provide clinical data that would establish clinical necessity. While the managed care insurer is obliged to keep this information confidential within its organization structure, if that organization structure changes, such as may occur in a corporate acquisition, that information may then be accessed by other health care systems within the new structure. Some feel uncomfortable with this release. It generally is a good idea to discuss this with the provider and/or your insurer.

It is important to repeat that because a parent or faculty or staff may wish to know about a student or other significant other’s psychological or emotional state when that person is not deemed at imminent risk, suicidal or psychotic or at risk of injury to themselves or to others does not therefore free the mental health clinician from the legal and ethical duty to protect confidentiality. This at times can feel quite absurd to the family or staff member of the person involved, since they are aware this person is actually seeing the clinician. In such situations, a delicate negotiation may ensue. However, the guiding principle is the right to confidentiality, except in those narrowly prescribed circumstances, as outlined by Federal Law, Massachusetts Law and Professional Codes of Ethics. Without this as assurance of confidentiality, psychotherapy cannot proceed.

REFERENCES

Behnke, S.H. Year 2000, Confidentiality at Student Health Services: Private Rights, Community Interests. Published by Massachusetts Psychological Association
Quarterly, Volume 44, Number 2 – 3, Pp. 33- 36

“The Ethical Principles of Psychologists and Code of Conduct,” American Psychological
Association, Washington, D.C., 1992.

by Edward Bruce Bynum, Ph.D., A.B.P.P.
Director of Behavioral Medicine

From time to time everyone experiences that nervousness and apprehension that we call anxiety. Sometimes it’s very brief but occasionally it lasts longer and we feel uncomfortable. This kind of anxiety usually occurs after a crisis, be it an interpersonal or familial crisis. Anxiety also occurs before an uncomfortable situation such as test anxiety, a new relationship and intimacy, or even an examination. Anxiety often occurs during an acute period of stress. This can be around a tragic circumstance. It can also be in the case of an argument with someone else. Anxiety is generally a warning to ourselves that there is some danger, or some perceived danger, to our situation. There are some positive aspects to anxiety however. That warning to be on alert when it is appropriate is a good one. Most often anxiety is a very transient experience.
When anxiety lasts for more than a few weeks, it is perhaps more of a serious concern. Too much anxiety can lead to decreased concentration and increased irritability. It can lead to sleep onset delay problems, a not very satisfying or non-restorative sleep, even interrupted sleep or one of several forms of insomnia. In some situations it has been known to effect and create stressful dreams which then affect our body, energy level and moods. Prolonged anxiety can exacerbate mild to strong rumination or worry or preoccupation with things. Anxiety can cause increased concern about medical or physical health issues. It can also lead to an exaggeration of usually mild or vague social or family concerns. In some cases anxiety can lead to depressed appetite and weight loss or even an excess weight gain through increased eating in an attempt modulate one’s mood. In a certain percent of cases, anxiety can lead to serious depression. This will include loss of motivation, lethargy and other signs associated with significant depression. Anxiety has been well known to lead to the avoidance of certain situations, be they interpersonal or social in nature. Isolation can result from extensive anxiety. This withdrawal is apparent to others and to one’s self.
The causes or origins of anxiety that are persistent are many. Periodically it is a largely medical condition. Thyroid difficulties, be they hyperthyroidism or hypo-thyroidism, are two of the more well known medical reasons. However acute stress reactions to actual events can also lead to persistent anxiety, even after the initial frightening episode. Dysfunctional coping styles also exacerbate anxiety. The well know fight-flight response will sometimes be exaggerated and extended far beyond its appropriate expression. Muscle tension with diminished or few recreational expressions may lead to persistent anxiety.

Many of you are well aware that in high school, or at other times when there was a great deal of pressure and anxiety, sports and athletics or other physical activities were an outlet for this anxiety. Becoming involved in serious academic work along with continued stress without that traditional athletic expression of dynamic muscle tension release can lead to increased anxiety and emotional tension. This is rather common on college campuses. Ongoing psychological conflicts with one’s self or others can lead to prolonged instances of anxiety. Here the dynamics of anger and resentment, sometimes shame, and even trauma and other unexpressed powerful emotions are at work. In some individuals there is a pervasive, what we call “free floating anxiety” associated with one’s personality style. You may have heard in this context of the type A personality. In some cases poor diet and lack of regulated life patterns that are crucial can lead to prolonged anxiety. Certain situations where there is an excessive use of medications or drugs such as caffeine or nicotine or alcohol or the mixture of these can lead to persistent and pervasive anxiety.

It is of course important to know what to do under these circumstances. The first and easiest thing to do is to talk with others, including friends and other relationships about this. This is to decrease one’s anxiety and sense of isolation. Also it is extremely helpful to regulate one’s diet, get moderate exercise, and a good amount of healthy sleep. Mini relaxations during the day are also extremely helpful in bringing down pervasive and unwanted anxiety. The use of meditation, prayer, and sitting quietly are exceedingly helpful in modulating most normal anxiety.

There are certain circumstances however in which anxiety, be it pervasive and persistent or sometimes extremely acute, warrant a consultation with a professional. Here are twelve such occasions.

1.) When anxiety interrupts your concentration for a week or more.

2.) When sleep and appetite are disturbed for more than a week.

3.) When physical illness or somatic preoccupations significantly decreases work, study, or social and interpersonal and family functions.

4.) When you are aware of an increasing isolation from others, increased irritability, and a sense of depression.

5.) When your mood seems to swing from one extreme to the other. This is not necessarily an indication of a psychiatric condition, but it is a situation that warrants a brief consultation.

6.) When you have noticed an increasing fear of going outside, of traveling, or other phenomena such as this arise. In some cases this is a beginning episode of agoraphobia.

7.) It is extremely important when episodes of “unreality” occur to seek an outside consultation. This is referred to as depersonalization or derealization experience.

8.) When a prolonged depression of over a month or so arises which one cannot seem to shake, this is an opportunity and a time to seek an outside consultation.

9.) When there is obsessive preoccupation with ideas or behaviors which are difficult to get rid of or dismiss.

10.) When an anxiety or panic attack occurs at least two or three times. It is not unusual to have an anxiety attack or panic attack once. This is not an indication of a psychiatric disorder.

11.) When bulimia and/or anorexia or other eating disorder behaviors dawn.

12.) When persistent and/or recurrent thoughts of suicide or homicide occur with strong emotional force. Fleeting self-destructive images occur to many people. It is when they are strong, occur within a specific plan or are unsettling that you must consult someone else.

When any of the above seem to occur and can be identified, a simple phone call to the University Health Services or other counseling agency is warranted. At that point one would talk with a mental health professional who may consult with you or refer you directly to a physician or a therapist for a more appropriate exploration of the situation.

References
American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC.
Menninger, K. 1963. The Vital Balance: The Life Process in Mental Health and Illness. New York: Viking Press.
Shapiro, D. 1965. Neurotic Styles. New York: Basic Books, Inc.
The information provided in this column is for educational/information purposes only. The intention is not to provide medical advice or replace the services of a trained healthcare professional. Please take specific issues or medical concern to your healthcare provider.
For more information please visit us at our website at www.umass.edu/uhs/mentalhealth.