User:Anthonyhcole/Distress

This is not a Wikipedia article

Suffering
What is it, what does it do to you, what is its role in mental illness?

In 1968 Ronald Melzack and Kenneth Casey re-imagined pain as more than just a sensation, and this model underpins all modern thinking in pain psychology and pain neuroscience. They described three dimensions of pain:
 * 1) sensory-discriminative: sense of the quality, location, duration and intensity of the pain
 * 2) affective-motivational: unpleasantness and urge to escape the unpleasantness
 * 3) cognitive-evaluative: cognitions such as appraisal, cultural values, distraction and hypnotic suggestion.

It is the affective-motivational dimension, the unpleasantness, that harms us. Unpleasantness is also called "suffering", "discomfort", "torment", "anguish", "hurt", "negative affect", "negative valence", "negative hedonic tone", "aversiveness" and "distress". I'll use "suffering" and sometimes "distress" here.

Sufferring is found in three classes of feelings:

1. It is a dimension of unpleasant homeostatic feelings like pain, hunger, fatigue and hyperthermia. Unpleasant homeostatic feelings torment us with suffering until we satisfy them with specific behaviour (in pain: withdrawing and protecting, in hunger: eating, in fatigue: resting, and in hyperthermia: stepping into the shade).

2. Suffering also plays a role in negative emotions like grief, anger and fear, and negative moods like misery, irritability and anxiety.

3. And it is an essential part of some social feelings (e.g., empathy, rejection, shame, loneliness).

Suffering likely evolved first and was enlisted by homeostatic feelings, emotions and social feelings as they emerged later in animal evolution.

It is also likely that just one neural network generates suffering, and every unpleasant homeostatic feeling, emotion and social feeling employs this one suffering network.

What does suffering do to us?

I am studying the effect of suffering on human emotion, cognition and social engagement and I have focussed on three causes of suffering — hunger, sleep deprivation and pain — because each of these has a body of scholarship addressing, to some extent, its affective, cognitive and social impacts.

What I've found is, each of these distressing homeostatic feelings generates in humans the same set of clinically significant symptoms:
 * Increased frequency, intensity and duration of negative mood states (e.g., misery, anxiety and irritability) and negative emotional events (e.g., grief, fear and anger), and heightened negative affect response to negative stimuli (neuroticism): things that hurt, hurt more.
 * Slowed mental processing speed, reduced working memory capacity and impaired attention control, impulse inhibition and emotion regulation.
 * Impaired social feeling/social engagement.

Until someone finds an instance of suffering that does not cause this cluster of symptoms, I shall assume all suffering, regardless of its cause, produces this syndrome.

If suffering is intense, these symptoms are significant and disabling. If you doubt that, reflect for a moment on your own response to intense pain, nausea or sleep deprivation. How's your concentration? Attention to detail?Working memory? Thinking speed? Sociability? Mood? Emotion?

I'm pretty sure no one has described this suffering syndrome before but, if I'm wrong about that, I know no one has applied it to mental illness like I am about to.

This syndrome is found and is a major contributor to disability in all instances of distressing functional mental disorder.

Look, for example, at the extract below from the "associated features" of schizophrenia in DSM-5-TR. Compare the symptoms I have underlined in that text with the symptoms of suffering listed in the bullet points above.

All the symptoms of the distress syndrome, except exaggerated affective response, are found in the DSM associated features of schizophrenia. "Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the absense of an appropriate stimulus); a dysphoric mood that can take the form of depression, anxiety or anger ; a disturbed sleep pattern (e.g., daytime sleeping and nighttime activity); and a lack of interest in eating or food refusal. Depersonalization, derealization and somatic concerns may occur and sometimes reach delusional proportions. Anxieties and phobias are common. Cognitive deficits in schizophrenia are common and are strongly linked to vocational and functional impairments. These deficits can include decrements in declaritive memory, working memory, language function, and other executive functions, as well as slower processing speed . Abnormalities in sensory processing and inhibitory capacity as well as reductions in attention are also found. Some individuals with schizophrenia show social cognition deficits, including deficits in the ability to infer the intentions of other people (theory of mind)."

Eugen Bleuler in 1911 addressed exaggerated affective response in his unmedicated schizophrenic patients:

"Particularly in the beginning of their illness, these patients quite consciously shun any contact with reality because their affects are so powerful that they must avoid everything which might arouse their emotions. The apathy toward the outer world is, then, a secondary one springing from hypertrophied sensitivity." (p. 65)"

Again, this syndrome is found in all the distressing functional mental disorders.

''What is distress doing in functional mental illness? What is its role?''

Recently, a historian of psychiatry told me, "Suffering is central to serious mental illness. Whether it is the cause or the effect, or something of both, is an open question."

I'm sure it is an open question in his mind but the causal relationship between mental disorder and distress is not an open question in psychiatry.

In psychiatry, at least in its bible the DSM, it is always mental disorder that causes distress, never distress that causes mental disorder. Look at this from DSM-5-TR's diagnostic criteria for major depressive disorder:"The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" This formulation occurs throughout DSM-5-TR, and it has been a feature of the DSM since its third edition in 1980 when the lead author laid down new essential criteria for every diagnosis, including: the symptoms must be distressing to the individual or the symptoms must impair the individual's ability to function.

I believe distress, in mental disorder, is causing the same devastating set of symptoms it causes in hunger, sleep deprivation and pain, and psychiatry, if it wants to heal this significant set of cognitive, affective and social impairments common to all distressing mental disorders, should find and treat the source of the patient's suffering.

While social and emotional suffering must, of course, be addressed, the physical, extracerebral body should not be ignored. Look for nutrient deficiencies, hormone imbalances, inflammation, pain, fatigue, any kind of constant or recurring distressing homeostatic imbalance.

Why aren't your patients complaining to you about these terrible distressing feelings? Well, some of them are and you are telling them these feelings don't exist or don't matter and are the product of their mental disorder, rather than real, important and the cause of their mental disorder.

Some of them are inured to the feeling that has been with them for so long it is now just how life feels. Inuring can make consciousness (the sensory dimension) of an unpleasant experience disappear while not diminishing the affective-motivational dimension (the suffering and its concomitants) at all.

You're working in a room with an annoying, loud, grinding, rattling airconditioner. In time, though, you no longer hear it, you forget it's there. Then, when it finally shuts down, you experience relief, your mood instantly lifts, your mind is clearer, you are more convivial. You might even be surprised at just how much distress you had been under due to that stupid airconditioner that, for most of the day, you didn't even hear.

And so it goes with all constant, familiar, unsurprising negative sensory, emotional or social experiences.

So, when a distressed patient reports a distressing feeling, take it seriously. But don't just wait for their report. Seek out distressing homeostatic conditions that they may be partly or completely inured to, look for constant or recurring oppression from others that the patient has normalised. Look for sources of suffering wherever they may be found, and address them.

What about the features that distinguish one DSM entity from another — mania, delusions, hallucinations, obsessions, etc.? They may be summoned by distress from a propensity in the patient's biological inheritance reinforced by life experience and social state (diathesis-stress, an old idea ), so, eliminating ongoing distress may at least to some degree ameliorate these eccentricities, while resolving the seriously disabling affective, cognitive and social harms of suffering.