Читать книгу Male’s Health in the Objective of Stressology – Beyond the Usual - Армен Мурадян - Страница 9

Stress. For the first time the word “stress” emerged in the English language in 1303 when the poet R. Manning wrote: “The Lord had sent manna of heaven for the people in great stress”.

In the late eighteenth – early nineteenth centuries Goya, whose art was distinguished by passionate emotional and social orientation, created a series of paintings that he called “Desastress”. The series includes paintings reflecting the human grief and suffering, among them: “Unhappy mother” (Sheet 50 of the famous etchings), “I have seen it” (Sh. 44), “They are a different breed” (Sh. 61), “This is the worst” (Sh. 37).

The concept “stress”, introduced into biology and medicine, is associated with the name of H. Selye and it was used to refer to a non-specific response of the body to any harmful and subsequently a harmless effect too. It is a natural genetically programmed normal and necessary response of the body to provide its survival and development. The essence of Selye’s teaching is his discovery of the three-phase general adaptation syndrome (GAS).

The first phase (stage), called by Selye the “phase of combat alert” includes orientation reflex accompanied with restructuring of the whole body. It is mainly implemented by an automatic neurobiological mechanism, by the action of a sympato-parasympatic nervous system BSA and has a bioelectric character.

The second phase is the stage of resistance (strain); it is also figuratively referred to as the “stage of fight or flight”. If during the first stage the situation is assessed as dangerous, and anxiety as the expectation of an uncertain danger becomes a “concrete fear”, then through the activation of the endocrine glands the second stage of the stress reaction develops and stress hormones enter the bloodstream. Spread by blood to organ/systems, they put the body into the state of readiness either to flight from danger or to fight with it (muscles tense, heartbeat vigorous, pressure jumps, etc.). Self-preservation mode is triggered throughout the body.

The whole complex is a normal, necessary effect of self-preservation instinct and similar for both types of behavior. The choice of behavior depends on the impulsivity and genetic program; but in human more often on the acquired experience of response in the deadaptation situation. It is stipulated by activation of three endocrine axes. The effects are caused only biochemical or neurobiochemical mechanism, which activates the appropriate organ/systems by hormones.

The third phase is the stage of asthenization. H. Selye has shown that stress accompanies any life activity and corresponds, in certain sense, to the life intensity. It increases with nervous tension, bodily injuries, muscular work, infections, in the situations of joy or sorrow, even with recollection of tragic events of the past and leads to the shift of the internal state of balance to deadaptation.

Let us denote the process of deadaptation – adaptation by one term – stressogenesis. A person in the course of the whole life gets “stress” injections and acquires stress-resistance in the form of behavioral patterns of overcoming stressful state, learns to comprehend and act in a constructive direction. If it does not occur, destructive characteristics of stress trigger. Using the expression: “Stress is the aroma and the taste of life” we should not forget that they are also different as the favorite aroma and taste in different people are different. The classical version of GAS, its evolutionary core, has a discrete nature and represents a unity of three phases. In this embodiment, the GAS came into use as “stress” and became the property of biology.

Revealed opportunities of studying and understanding what is happening in a person for a long time made their way to medicine with difficulty because of the lack of the concept “man in medicine”. Throughout the twentieth century medicine developed as an aid and health improvement of the diseased body, therefore it would not be a mistake to call it “body medicine”. Human health and disease were regarded as structural injuries of different organ/ systems under the impact of various external factors. The role of mental component was reduced to zero or completely ignored in both the questions of etiology, etiopathogenesis of diseases and those of dynamics, therapy and forecast. Psychological principles and laws acting in man, psychosocial component of man were disregarded due to total ignorance of medical sciences – psychology and sociology.

This was promoted by principle of parallelism dominating in neuroscience. Psychiatry should have been exclusion but it was also biologized. The desire of psychiatrists to find a biological substrate in the brain as a cause of schizophrenia, manic-depressive psychosis is still alive, despite the generally accepted by WHO definition of health. According to the Constitution of WHO, “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. This definition provokes lots of questions, reprimands and critics and it needs serious correction and specification. But it will be possible only with appearance of the concept “man in medicine”, when the issues of mental health and social well-being are considered from the viewpoint of a triad concept: “man” as a unity of biological, mental and social.

As far back as 1861 I. M. Sechenov suggested that a body without environment supporting its existence is impossible. Man thus is the system with two complex components “body + environment”. Since not only man’s body lives in the world, but rather a personality with the soul lives, acts, suffers and overcomes difficulties of life, this concept of I. M. Sechenov can be expressed using the following formula:

Man =

B (body) + P (personality) + S (soul) + E (environment) and referred to as an

INTEGRITY

Within this integrity, these composites interact with each other via bilateral feedback. Environment, including social medium, affects the body through the data flow of signals in the form of:

• positive – eustressors;

• negative – distressors;

• indifferent.

Among stimulants are identified stimulant signals acting without violating the internal balance. This category of customary signals constitutes the background. An unusual signal of the environment produces an orientation reflex aimed at assessing the environment with regard to the body threat.

If a factor is not threatening, the BE system continues functioning in the same mode. If a factor bears a threatening element, anxiety, fear, the deadaptation mechanisms of stressogenesis are triggered introducing the body into the mode of adaptation and it re-adapts. Thus, the factor containing a threat becomes a distressor causing emotional stress.

Emotional stress. The term appeared when the concept “stress” was transferred from biology to psychic (mental) reactions occurring under critical conditions. These reactions were called “emotional stress” which includes emotional reactions to stress (anxiety, fear) and somatovegetative symptoms caused by sympato-parasympatic nervous system. Actually, the emotional stress implied affective experiences separating them from non-specific stressor sympatocomplex of physiological changes in human body. “Intellect or feelings”, “mind or emotions”, “please, no emotions” – that is an incomplete list of common expressions reflecting different attitudes to emotionality and intelligence.

G. Hegel rightly noted that for intellect “…the difficulty is to get rid of the once loosely admitted by it division between the feeling and the thinking spirit and to come to the view that in man there exists only a single intelligence in feeling, will and thinking”.

With the lapse of time the term “emotional stress” has undergone a series of transformations. Thus, the second half of the last century was marked with descriptions of psychosocial models of stress, the models of response not only by the body, but by man as a whole, not only to the changing environment, but also to the psychosocial stressors. It was all about the search for a “medical” model of stress (H. Wolff, 1953), to substantiate the association between social changes and the health of population. This conformity is nowadays considered universal. The social-psychological approach to the medical model of stress is represented by several theories. The theory of loss by P. Marris (1974) assumes that each of us is a holder of some fundamental and universal beginning aimed at sustaining everything that regularly occurs in our environment attaching to it a subjective and personal meaning. Social changes are experienced as losses, disrupting the structure of interpreting the environment, thereby deeply hurting the personality. The traumatic situation (from Latin trauma – injury, wound) mentally traumatizes a person and provokes a storm of emotional experiences often in the form of affects. Therefore, the mental stress is conventionally considered to be the emotional sphere. Such view on its nature is due to the specificity of perception of stressor. At the first moment of perception anxiety and fear come to the fore limiting a judgment about the occurring and the gnostic (from Latin gnosis – cognition) and volitional components are negligible. This link is provided by activation of the autonomous neural axis as bioelectrical effect.

Some medical models of emotional stress development are described: the model of “biosocial resonance” by G. Moos (1973); the formalized model of the effect of social disintegration on health by D. Dodge, W. Martin (1970); the linguo-structuralist theory by R. Totman (1979); the theory of salutogenesis by A. Antonovsky (1979). It can be assumed that researchers of stress pursued one goal: to convince people living in the epicenter of stressful life and professionals in medicine (and they are men in their majority) that there exists the dependence of human health and longevity on the psychosocial structure of life and peculiarities of its perception. As a result emotional experiences have shifted to the category of the causes of developing stress. Thus the term “emotional stress” appeared.

Traumatic stress. It is not just a terminological kaleidoscope around the same phenomenon, but rather an understanding of the difference between diverse emotional, behavioral, somatic reactions of man on different stressors. The knowledge accumulated in the field of stress study has shown that not always the intensity of the stressor is of primary importance.

Lazarus and Folkman while delimiting the field of stress aftermath, considered only moderate stress. Different comprehension of the role of stress “intensity” (that might be light, moderate and traumatic) led researchers to different findings. Furthermore, for a long time, studies of post-stress disorders in human developed independently of stress studies. The whole problem rested on the stereotype approaches that had been adopted as the stress theory developed for the body, while the post-stress disorders were considered responses of the personality involving the body, psyche, consciousness and will. Man responds to environment with his conscious psycho-bodily unity and the aftermath effects are a vector complex systemic response to traumatic events. The generalization of multiple research results of different aspects of traumatic stress described as the structure of self (Laufer); a cognitive model of the world of the individual (Yanov-Boulemane); the affective sphere (Kristal); the neurological mechanisms controlling the processes of learning (Kolb); the memory system (Pittman); emotional learning (LeDoux Romanski) are obvious proofs that the post-stress process involves the entire complex system of man. The leading element is the human ability to attach meaning to any, sometimes even indifferent stimulus (a phone call, the night phone call, a special knock on the door, sleep, crow’s cry). Stress becomes “traumatic” when the meaningful significance of what has taken place results in disorders in the psychosomatic sphere, which is similar to the physical injury – hence is the name (mental injury, mental crash-syndrome). However, in contrast to a physical injury a mental wound can be invisible; it does not impress bystanders with a bloody mash of muscles, vessels and nerves. A spiritual crash-syndrome is a “silent volcano” that can burst at any time, at any place, by any kind of suffering.

In the concept of traumatic grief of Linderman (1944) and “syndrome of stress reaction” of Horowitz (1986) a factor of “time” after trauma during which a person experiences mental discomfort, anxiety, aggression and grief, occupies a special place. As a result the term “chronic stress” appeared alongside with the term “acute stress”. Chronic stress assumes remote aftermaths occurring after disappearance of stressor effect.

Opponents of the concept of a unified mechanism of stress and post-stress disorder, being aware of the affinity of these concepts, suggest using the term “stress” for correctness, to denote the immediate response to stressor and the term “post-traumatic mental disorders” for delayed reactions to the traumatic stress. We think that such “correctness” would adversely affect the understanding of an integral process.As a result, comparison would be done to quite differing conditions, for stress in its classical meaning is a normal response of the body to a stressor, while PTSD is a disease. They are however connected via the integral mechanism of stressogenesis, which changed its function; the function of protection became the function of destruction. It is here that an “impassable” barrier to see the unity of stress and post-stress disorders appears, the emergence of which is connected with the fact that stressogenesis as a normal adaptation reaction becomes a pathogenesis of post-stress disorders. Flashbacks, imagination stipulate transition from acute stress to chronic depriving it from the main peculiarity – discrecity, moving to the category of permanent processes entailing conversion from the norm to pathology.

In her early works (2002–2011) A. Tadevosyan described traumatic stress under the name of APES – Antropogenic Psycho-Emotional Stress thus underlying its specificity already in the name. APES is specific for man and contains both emotional and cognitive components, the proportion of them varying depending on the memory peculiarities of a particular person, his personality, peculiarities of perception, content and duration of the state of grief. Resulting from the interaction between the stressor and the mental vulnerability of man, a state of deadaptation has a number of specific features relevant to man only, which mark its distinction from the emotional stress in general (A. Tadevosyan, 2002, 2003, 2011). An individual, having suffered a mentally traumatic situation himself or as its witness, experiences the emotional stress as an acute state. Actually, this first phase of stressor response as the first step of man’s response to a traumatic event can be easily modeled on animals. When the first emotional outbreak (shock) of traumatic experience somewhat calms down man begins to think over what had happened; memory, comprehension are turned on, the past, present (the cognitive component of the psyche) are assessed often from the standpoint of loss for the person himself. The trauma acquires the category of meaning for a particular man. “The meaningfulness” of injury, its sense results from processing the life entire past, present aimed at the search for “anchors” for the future. Sometimes it takes quite a long time to interpret what happened in detail; during this period “molecules” of emotions of various qualities, various intensities and duration are released. The variety of emotional experience of this period depends on what man remembers about stress, what the content of his traumatic memory is. The emotional palette when alone (stress outprice) can be very dynamic and manifold: from anger, wrath, to the sense of guilt, despondency. The flow of these conditions may be undulating: the emotional tension going up and down. Thus usually the emotional discharge proceeds gradually reducing the destructive activity of the injury – “time heals”. However, there are cases when deliberation of what happened may be accompanied by a growing emotional experience intensified by assuming a personal role in the loss, the rejection of a random set of circumstances, self-blame. This can result in self-generation of an affect with suicide or alcoholization, psychopathology or somatization of the injury. Thus, processing of the event may be accompanied by the second emotional wave, which in a number of cases is much stronger than when it really happened. This stage includes a new phenomenon of the evolution – consciousness and imagination.

The first mention about the cognitive aspect of mental stress is found in R. Lazarus work. He notes that only an interpretation of the fact or a situation makes the stimulus stressogenic. The evaluation attributed by the individual to a specific factor is the main intermediate variable between the stressor and the response. Defining stress as a situation whereby the requirements to a person are either a trial or something that exceeds his capabilities for adaptation, Lazarus concludes that even if a stimulus affects the individual through some sensorial or metabolic process, this process being stressogenic, the stressor response may fail to appear. A stimulus becomes a traumatic stressor only by virtue of the meaning ascribed to it by man. Therefore, an excessive stress can be initiated by the individual himself, by the one who ascribes sometimes the stressing characteristics even to the neutral stimulus.

This feature was already known to philosophers of the ancient world, who wrote: “People are frustrated not by an event, but rather by how they see it” (Epictetus). And Andre Gide wrote: “How wonderful life would be if we were content with some real disasters, not bowing to the ghosts and chimeras of our mind…”.

Usually three periods are distinguished after an injury:

The acute period can be considered up to 3 months.

Subacute period lasts up to 3–6 years.

Delayed or remote consequences can be extended for years, sometimes for the whole life.

Example from a husband’s story:

“I cannot understand why she did it now. We lost a child 3 years ago, she handled herself well. We have born a girl again. Life began to improve. And suddenly – she commits suicide, leaving a note: “I’m sorry. All this time, I tried to forget … every time embracing our second daughter, I see the face of my daughter, she looks reproachfully at me. I can no longer”… (from the suicider’s note).

Mental trauma is an act of the impact of mentally traumatizing event limited in space and time “there and then”. The traumatic event, having become the content of consciousness, in the course of time can be repeatedly manifested as unprompted flashbacks or initiated by the individual himself anywhere, anytime and in any situation. Its strength and meaningfulness can be amplified by the imagination, which manipulates the traumatic experience, moving it in time, expanding by connecting other people and events. Thus the state of traumatization develops, the core of which is the so-called in psychology and psychoanalysis “trauma body”. At the level of consciousness the “trauma body” (psychoanalytical term) or a traumatic constellation (neuro-physiological term) has a basic quality – the quality of attracting everything that can be tied up into a “single unity” and comprise a traumatic reality.

The latter does not already have clear space-time boundaries. Man “starts to live” not in the objective reality, but rather in the subjective post-traumatic one. Each time when activating that reality, man lives all through again with the whole complexity of the sensory perception of the traumatic injury, the somatovegetative symptomocomplex, supplemented with the affectivity of the moment and the behavior of the traumatized man during the traumatic injury. As a result, the act of “mental trauma” goes over into a “condition of mental traumatization” converting acute stress to chronic. The condition of chronic traumatization is manifested by anxiety, strain or asthenia.

Traumatization is a process, which starts from the sensory triggering factor (a psycho-traumatizing event) and going on when the system generates certain traumatic constellations based upon the A. Ukhtomsky’s dominant (A. Tadevosyan, 2000). The peculiarity of traumatic stress is its ability to retain stressful events in the form of a psychic echo – “echo-stressor” known as flashbacks. “Echo-stressors” can be of different types depending on the mechanism of origin and development (A. Tadevosyan, 2002). A common feature of all varieties of flashbacks is automatism, i.e. they can emerge from the memory anywhere, anytime and in any situation, regardless of the consciousness and desires of man. This category of mental phenomena is caused by the memory capacity to imprint individual sensory perceptions or entire situational events (gestalts).

This category of mental phenomena is conditioned by the activity of mirror neurons and the mechanism of eidethism of the SPA, the ability of memory to imprint individual perceptions or whole situational events, including the feelings, thoughts and behavior of the person himself.

We have singled out several variants of flashbacks – “echo-gestalts”:

• sensory;

• convulsive;

• somatic;

• painful;

• cognitive.

Sensory echo-stressor (sensory flashback). Traumatic dominant (constellation) occurs immediately, without a period of formation. A traumatic event is retained in memory in the form of pictures, situations or fragments of those situations that took place in reality. This phenomenon comes up unprompted. Considering the holographic concept of the memory and psyche, it is clear that “a fragment of man’s life” reflecting a traumatic event retains the spatial and temporal characteristics of the trauma moment and the whole complex of sensations and emotions. Most probably all this happens through the mechanisms of eidetic memory. Neuro-Linguistic Programming (NLP) makes it possible to determine which information channel is preferable for this or that person.

Based on NLP data it is possible to pre-determine the kinds of flashbacks that can develop in a particular individual in cases of traumatic stress. This “mould” (gestalt) of reality has a capacity to break into the current everyday life, pushing aside the current moment, and so a person starts to live, go through and act in accordance with the echo-reality. Having come up through the mechanism of association, this flashback possesses strength of the real event changing the clarity of consciousness into a psychogenic fuzzy consciousness, making a person lose his bearings in the real situation. This is the analog of hallucinatory illusory experience of epileptic twilight disorder of consciousness (mental equivalent). The individual can hear, see, smell the traumatic “echo-reality” in all variations of features, which is manifested in the common stressor response. As distinct from epileptic twilight, the content of traumatic twilight disorder of consciousness is stereotypic, it repeats in every detail the traumatic reality. The psychic equivalent involuntarily emerging from the memory, can change the mood, behavior that become inadequate to the reality, but adequate to the content of traumatic experience.

Examples.

1. Patient K. used to drop to the floor and crawl to a wall every time she heard a buzz of a flying plane. Squeezing herself in a corner or under a table she stayed there until the buzz ended. Her face showed fear; she was trembling, sometimes grappling her head and lamenting: “Again bombing, again bombing…”

These conditions emerged six months after the fears experienced during “Grad” bombings in Karabakh and moving to Yerevan.

2. Patient M., a survivor of the Spitak earthquake, each time during high wind used to run out of her apartment down the stairs screaming: “Earthquake!!!”. She lived on the 9^th floor. In this state no one could stop her or make her change her mind.

3. Patient T. lost his 9-yearold son in the earthquake. 12 months later he applied to the Center “Stress” on account of his condition that scared him and made him think he was going mad. He said that almost every day he heard his dead son talk to him. Walking along the street, “… clearly saw the son either walking or playing in the street or running to meet me”.

The described phenomenon is not merely a symptom. Its appearance makes it possible to understand the mechanism of transformation of the external signal into an act of consciousness, the mental phenomenon. Flashback is a reflection of the event or its fragment by mirror neurons. The parameter of a physical object – seen, heard, having become the content of consciousness, is transformed into a mental phenomenon. Echo-phenomenon is an intermediate link between the world of physical phenomena and mental world (between physics and psyche, matter and consciousness). It is a key to understanding the transformation of the external world energy into the internal one. Mirror neurons perform this first level.

Picture 1. Flashbacks as described by one of the patients.

Picture 2. Flashbacks as described by the patient.

Picture 3. Flashbacks as described by the patient.

Convulsive “flashback”. An epileptiform convulsive fit may occur in a psychotraumatic situation, especially if it is accompanied with oxygen deficit. Actually, the fit results from hypoxia. The state of “asphyxia” is accompanied with a characteristic facial expression and a specific pantomimic mask. A man who lacks air starts to “grab” air with hands, face is strained, neck reaches out, mouth opened, breathing outwardly reminds breathing of a fish thrown out on the shore and strenuously grabbing the air with the mouth open. Epileptoform “echo-stressor”, if it happens in situations with air deficiency, is accompanied by similar movements.

Examples:

4. Once the Epileptological Center sent a young man to the “Stress Center. He complained of epileptiform convulsive fits occurring once in 2–3 months for over 8 years. A careful examination in the Epileptological Center failed to yield any objective paraclinical data. Since the fits were rare and over time the tendency of their frequency was not observed, and the clinical picture did not change, the parents decided not to give the boy anticonvulsant drugs, for fear of their undesirable side effects. No epileptic symptoms were discovered. The father was a witness of fits and was able to describe in detail the onset of the fit, focusing my attention on the grasping movements of the hands, “as if lacking air” – added he. Some leading questions helped father to remember the occasion that happened with his son when he was taught swimming in the pool. On the second day of swimming lessons, not knowing how to swim, the child was dipped head and ears into water. The boy experienced strong fear and refused to attend the pool. Several months passed between that event and subsequent fits. The relatives forgot about it. The patient himself confirmed that the fit usually occurred in stuffy rooms. It happened twice in a vehicle packed with people, once it recurred when he saw the sea for the first time.

5. Three years after the earthquake, mother of a 12-year-old girl consulted the “Stress” Center on the occasion of convulsive fits in her daughter. Mother said that she and her daughter remained under the ruins for 10 hours. It was there that the first convulsive fit occurred to the girl. The subsequent examination revealed no data in favor of the organic origin of the fits. A fit starts with short breath, the girl grasps her throat, trying to catch her breath. The girl herself said she always felt short of breath before the fit.

Both examples mentioned are similar in their stereotype clinic, lack of dynamics and mechanisms of occurrence. In both cases, the parents decided not to give the anticonvulsants thus retaining their original form not burdening the clinic with side-effects of medications.

Somatic “flashback”. The memory retains not only “a piece of the objective-emotional world” in the form of a sensory “echo-stressor”, in the same way it can register any bodily symptom or syndrome accompanied by a strong emotional response – “somatic echo-stressor”.

“Somatic echo-stressors” can be exemplified by various somatic conversions well known to psychiatrists, neuropathologists, psychotherapists. It is common knowledge that in contrast to the somatoform manifestations, conversions never give way to organic changes. Functional disorders never convert to the structural ones, even when frequently repeated. Probably, the somatic conversions are stipulated only by the first level of the stress process or the autonomous nervous axis providing only a bioelectrical effect, without involvement of endocrinal axes or hormones.

Pain “flashback”. The most common is somatic-pain syndrome of various localizations. Phantom pains also relate to this category.

Example: Five years ago, a patient having fallen on the stairs experienced a terrible pain in her back, which then gradually ceased. She did not pay much attention to this since there was clearly no fracture. However, after a while, about a week, the pain resumed and did not pass. X-ray and other examinations did not reveal any abnormalities, but the pain became chronic despite the ongoing therapeutic measures. The pain occurred even when she accidentally touched the furniture. “As if I fell down the stairs again”,– the patient said. The pain recurred many times. Sometimes the pain appeared all of a sudden when she was watching TV: “I did not touch anything, but the pain is there! I cannot walk; I hardly do something around the house. But what is really strange is that a sharp sound, sometimes even an ordinary conversation or a draft cause attacks of the same pain”. Gradually she began to limit herself in mobility, ceased going out, bought crutches, became disabled. The pain sharpened with physical or mental loads”.

An example is well-known to orthopedists phantom pains when a person experiences severe pain in the amputated part of the leg. Analgesics do not bring relief from this suffering and the pain remains there for several years. Both phantom and chronic pains in the back are not related to the current external injuries. The pain effect had a real cause but it happened in the past, once and in a specific place – “Then and There”. Now the pain appears anywhere, anytime. As the patient describes, “appears when it wants to appear. It does not change, does not increase or does not fade with time, as if it is stuck in me and under some conditions makes itself felt: “I’m here, I’m in you”. Indeed, pain has become part of human body and life.

Example: “Two years have elapsed since I suffered herpes in the waist (lumbar region) and chest. All the external signs have long since passed; there are no changes on the skin. But it is hard to imagine what pains I am experiencing. As soon as I come home, and now I live alone, itching and pains seem to be waiting for me at home. Nothing helps. I was examined – no deviations. But the pain does not leave me, and it is always the same – with itch”.

A person experiences pain in the absence of bodily injuries and moreover, such pain is as real for a person as a physiological one. It is not “imaginary”. As distinct from the primary pain, chronic does not calm down with time, its appearance does not have spatial and time boundaries, analgesics do not help, antidepressants give a temporary relief. In neurology, such pain is known as neuropathic. In psychiatry – as a “chronic pain syndrome”, which is treated as psychalgia (mental pain), equated with it and included into the group of somatoform disorders (ISD–10/F–45).

Anxiety and pain are signals of danger but of different levels: pain is a signal of danger to the body, and anxiety – for the psyche of an individual. These protective reactions, similar in their discreteness, are due only to the autonomous bioelectric mechanism of the first phase of stress reaction. If there is a fixation of pain sensory stimulation, then it becomes obsessive and can be attributed to a bodily flashback symptom.

Studies of recent years make it possible to understand why the amputated limb hurts; why symptoms of herpes persist after the disappearance of all objective manifestations; why a pain syndrome persists in some people when there is not even a scar left from an injury or wound, not to mention some internal injuries. A differential sign that distinguishes the pain “flashback” from other numerous manifestations of the pain syndrome is its paroxysmal character independent of place and time and not changing its qualitative characteristics: localization, the character of pain over a long time.

As far back as 1894, the German neuropathologist and psychiatrist Franz Kisel showed that nerve injury led to significant changes in glia cells in the area of nerve fiber switching in the spinal cord. At the same time the number of microglia cells increased, astrocytes became denser, and thick bundles of fibers that strengthen cytoskeleton appeared in them. A hundred years later, in 1994, Stephen Meller from the University of Iowa proved the participation of glia astrocytes in the formation of chronic pain. Further studies shed light on the mechanism of this phenomenon. Glia cells secrete various substances capable of increasing the excitability of neurons of spinal ganglia and spinal cord responsible for the transmission of pain sensitivity. Such substances include also growth factors. It has been found that glia cells perceive enhanced impulse from neurons as a sign of their functional tension. With these data, a real opportunity appeared to explain one of the mechanisms of obsession (involuntary repeatability). According to them, with bodily injury, the pain “excitability” in the glia of the spinal cord can persist for too long and then the neurons of spinal ganglia continue to send pain impulses in the absence of external irritants. These effects resemble mental flashbacks in PTSD. It can be assumed that the glia of the brain as a memory carrier and its cells or groups of cells retain enhanced excitability. The latter is considered as the main cause of neuropathic pain in neurology. The injured body, when confluence of some factors, is able to preserve the memory of trauma at different levels of pain formation, using different links of the same process – the process of feeling pain. The aftereffect of traumatic injury in the form of a trace pain “echo-stressor” can become stuck in glia cells of the spinal cord, astrocytes and microglia cells. The glia cells themselves are not capable of impulses, but they are capable of capturing neurotransmitters – substances released by the endings of nerve fibers and providing signal transmission from one neuron to another.

Example: All my life, as long as I can remember, I have been sensitive to the pain of others at the bodily level. Someone fell – I have pain and feel creepy all over, got wounded – synchronously with him I feel pain in the body. Once in the third year of the Medical Institute during a practical lesson in surgery we were taught spinal puncture. As soon as the needle entered the spinal canal of the patient – I reacted: having experienced pain, I was covered with cold sweat and fell into a subconscious state. Becoming a professional, I began to analyze the events of childhood, life, memories. Looking back at everything that happened in my childhood, I recall my first experience of feeling pain in the body, the experience of curiosity and pain. It was the first year after the war. My father was awarded a sanatorium trip. I was 9 years old then, and father took me to Georgia, to the Black Sea. It was a fairy world where I was amazed at everything: palm trees, salt water in the sea, huge white flowers on the trees – magnolia, in the air the aroma of oleander, roses, flourishing lemons and oranges. And I touched everything, picked flowers, leaves; I ate melons and watermelons for the first time in my life. One evening guests came to us and while they were sitting at the table I went out into the garden. The sun had already set, twilight came and the shape of the surrounding trees and bushes became vague. I stopped at the plant which I had never seen before, it was very strange, and at the top there was a flower of marvelous beauty and some other fruits. I grabbed the plant with both hands, pressed it to me and the same moment screamed, screamed in pain in the whole body, incomprehensible, sharp and stabbing. Hundreds of needles pierced me. It was cactus. I screamed, but I could not get rid of the pain and the plant. The dog ran from me to the house and barked loudly. I screamed in pain, it barked until the adults heard. My memory did not keep everything, I remember only that I was given cognac and all amicably began to pull out bundles of thorns that pierced my body. Even the next day my grandmother still found needles. Since then, I hate cacti and synchronously feel pain when someone nearby feels it. Even when I watch a TV program about “black humor” I am pierced with pain or shiver all over if suddenly someone fell or got injured.

The examples cited above unveil the mysteries of intracerebral activity and make it possible to look at facts differently. If a person encounters the event that traumatizes his psyche for the first time, the mechanism of repression (the psychoanalytical term and mechanism) is triggered. Repression (suppression) is one of the mechanisms of psychological defense. It is triggered as an active, motivated elimination of something from consciousness into the unconscious, usually manifesting itself in the form of unmotivated forgetting or ignoring some moments of a traumatic situation due to protective inhibition (neurophysiological mechanism). Clinically these “forgettings” are described as various amnesias (A. Tadevosyan, 2011).

Since memory lapses violate the integrity of the inner mental world of a traumatized person, in everyday life, specialists have the expression “holey memory”. Repressed experiences, let’s conditionally call them “lost memory puzzle” are in a “semi-active state”, in all probability, making up operative memory. The stored information as operative memory is between the consciousness and unconscious (in the pre-consciousness, according to Freud) and systematically breaks into the sphere of consciousness through nightmares, flashbacks that are described as symptoms of PTSD. We view these mental paradigms not as psychopathology but as a normal functioning of the mental apparatus in a state of post-trauma, which has a threefold meaning.

1. The appearance of nightmares, flashbacks makes it possible for the consciousness to “fill in the gaps in the memory”, to restore the integrity of the mental world torn by amnesias. Cognitive processing of them, spontaneous or in the office of a psychoanalyst, is the therapy of the trauma itself.

2. At the same time recurring memories together with the work of consciousness form a leading reflection as a person’s readiness for repeated traumas, thereby reducing their destructive impact on the psyche; and this is an increase in stress resistance.

3. If cognitive processing of the obtained traumatic experience does not occur timely (within 6 months on the average) and in the right direction, the appearing phenomena are fixed and can acquire an obsessive character (the mechanism of the mental apparatus) becoming symptoms of post-stress disorder.

Cognitive echo-stressor. This type of traumatic event memorizing is of a conscious nature. A traumatic event can be retained in the form of memories or images that the individual randomly recalls in memory. When alone, he can mentally “play back” the events, and by active use of his imagination, man can distort reality. Imagination and fantasies can reduce a pathogenic effect of a stressor using one of the mechanisms of psychological defense; however they can also amplify a traumatic event, resulting eventually in affectivity growing like a snowball. Having been processed by consciousness, recollections acquire a personally significant meaning and can entirely devour a person. A constructed subjective mental reality replaces the objective reality, forcing a person to adapt within the framework of its new priorities. This kind of mental “echo” has an arbitrary character and results from man’s evolution.

The state of stress outprice (when alone) produces self-generation of “echo-stress”. A thought is a stressor to which the brain responds by one of the components: anxiety, strain, or exhaustion. Each time recollections of events again trigger a stressor response, stressogenesis with some of its links dropping out, e.g., the orientation reflex, the anxiety stage. The psychophysiological response can be stipulated by one of the neuro-endocrinal axes of the anxiety phase, while as the stressor in this case can appear the cognitive senses (thoughts) of man. Since the end organs permanently receive the stress hormones, somatoform disorders acquire an organic basis. So, it is the presence of cognitive “echo stressor” that converts acute stress into chronic. The peculiarities of the brain and psyche based upon their rules and mechanisms make it possible to generate the interiorized (internal) distress (neurophysiological term) or intrapersonal conflict (psychoanalytical term) keeping man under condition of prolonged stress.

A stressor response, having a discrete nature, is manifested by functional disorders. Stressogenesis, due to the frequency of conscious flashback to the experienced trauma, actually becomes non-stop, resulting in increase of the degree of disrupting the homeostasis that in turn can lead to transition of functional disorders into the structural ones. As shown by clinical experience, if “echo-stressors” exist due to the bioelectric mechanism, functional disorders, regardless of the duration of symptoms, practically do not pass into the organic. However, if the “echo-process” involves the endocrine system, and the stimulation of the end organ is done through hormones in the blood system, then the development of organic disorders becomes more probable.

Availability of different varieties of “echo-stressors” explains the commonly known fact that a traumatic event affects man years later, manifesting itself by one of the varieties of a delayed post-stress disorder or behavioral disorders. The appearance of delayed effects is a peculiarity of APES.

The total response is a vector of complex internal processes that manifest themselves as a personal experience of trauma. The complexity of this response requires an integrated approach due to the peculiarities of APES, its multisensory nature, complexity and ability to produce the whole range of health and behavior disorders manifesting itself as one of variants of the stress- phase-oriented model of the mentioned disorders.

“Boring, oh, how boring, it’s horribly boring… And you do it”

Patient’s drawing.