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		Stress and Stressors Professor Beverley Raphael, RMA Member Paper prepared from edited transcripts of the RMA Forum March 2004 Stress and Stressors Even though my topic was psychiatric conditions and stress, the core issue which comes before the RMA repeatedly relates to the whole issue of stressors, stress and the relationship to health. I think it's very fitting that this follows on from the discussion of both the strengths and the barriers to how the RMA functions, because in the area of stress, the confusions that exist in the scientific literature and the advances that come progressively through a scientific expansion in this field, have to inform what we do. Yet this has still left us with things that may appear nebulous and difficult when we try to relate them to the real life experience of veterans for matching against SOPs. Now, stress is a broad concept. In the English language and probably in many other languages there are similar or different concepts related to cultural perceptions. However, in the scientific literature it is often very poorly defined and variably measured. That has to be on the table from the beginning because, as indicated in the earlier presentation, we have to base our decisions for the SOPs on the scientific and medical literature. We think it is useful to consider separately the stressors, the things that happen, events or ongoing circumstances, and stress, the reaction. The reaction may have psychological, physiological, biological, social or cultural components. When we think about stress and its effects, stress may range from something like being in a motor vehicle accident to the fact that stress is part of everyday life. From the moment a baby is born and indeed from the moment a baby is conceived, there are stressor effects which may impact on development either biologically, psychologically or socially. The adaptations made, the coping strategies evolved and the psycho-physiological mechanisms of response may be linked to genetic pre-dispositions as well as to learning processes. These are all part of the fact that stress is part of life. In our earlier conference on stress we also looked at stress as challenge because it is quite clear that without adequate stimulus, which may be stressful at times, there is an inadequate process of development. The response to the challenge component of stressor exposures is often a critical aspect of development and, as has been suggested increasingly by some research, it's necessary for personal growth. There are now questionnaires that are looking at personal growth as a consequence of what might be called psychologically traumatic stress. Stress exposures, stress and individual reactivity can be influenced by genetic factors and there's a body of research which has looked at behavioural genetics and the relationships between reactivity to stress and patterns of genetic connection. Learning can also affect the response to stressors. If you grow up in a very anxious environment; say for example you have a parent who is worried and anxious about how some threat may hurt you, you may learn to be more reactive to external stressor exposures. We know from a range of studies in the literature that people are variously exposed to stressful exposures. When we look at the end of the spectrum of what might be seen as potentially psychologically traumatic exposures, we know that while everybody gets some exposures in those circumstances, certain groups in the population may have excessive exposures. The question that then arises is what part of that individual or that group might seek or be vulnerable to greater exposures to stressors for a variety of potential reasons. There are social and cultural factors which affect the responses to stressors. We would define something as bad for example if someone attacked you savagely as you walked out of a social venue. On the other hand, if you were tackled the same way on the football field everyone would be saying, "This is great." Whether or not you ended up with the same wounds, you might perceive it differently and its cultural and social context would be quite different. You would be seen, if your team won, as a victorious person and the significance of the stressors and the stress effects would be seen as a great contribution to your team's positive achievements. In the other situation you might be seen as a victim. People's perceptions of stressors come up in the discussions about criterion A in post-traumatic stress disorder (PTSD). Perception is frequently part of what we try to take into account if we can measure the impact it might have as reported in the scientific literature. We also know that it is critical, if we are being fair to science, to bear in mind protective influences, resilience and personal strengths. These factors might also influence how we respond to stress. Studies of children and others in very adverse and highly stressful environments have shown that there are personal and other characteristics that favour resilience so that there is not a negative outcome from the exposure. Positive support from the environment both before, during and after an exposure, may influence outcome as may learning and training. For example, in my work in the field of disaster (which also relates to the military) we have found that people who are prepared and exercised in handling certain stressors or exposures are likely to have better outcomes in terms of their mental health. Much of this may relate to the degree to which we perceive or learn or develop control over the potential stressor, our capacity to have some control in our reaction to it, and the skills and a sense of mastery which may come from past experience. Past experience may make you vulnerable but it may also give you skills and strengths in handling the next exposure. Another important factor in stressor reactions is that when we look back we often attribute things to particular life experiences. How we separate real causes from that attribution is a difficult thing in science, as it is clinically. We know, for example, that significant events in our lives are often remembered very clearly. Whether that memory is on a spectrum with the traumatic memories of a psychologically traumatising experience often remains to be identified in the process of assessing its impact as well as the relationship of the memories to it. Recent research has suggested that even with wartime experiences, which may seem to be quite clear cut, there may be change over time in the memory of what actually happened. So, what actually happened, one's perception of the event and the impact of memory progressively changing and dealing with it in different ways, may mean that in retrospect the event takes on a greater or a lesser significance as a potential causative factor. We know there are often quite significant differences between an acute exposure to a one-off, major, horrendous life event and more chronic stressors which may seem to be at a lower level and yet nevertheless may seem to impact in a range of ways on health and mental health. These differentiations are often not clearly distinguished in the literature and yet the science may point to one or other of these components as being critical in aetiology. How many, how frequently and how often we are exposed as well as how sudden, unexpected and uncontrollable stressor exposures are, may contribute to their impact. However we know that we may actually attribute something to a life experience as a cause when it may or may not be a cause. Some years ago, some researchers looking at people who had a range of psychiatric illnesses asked them what they thought were the causes. Most people attributed their illnesses to stressor exposures. It is a strong, social attribution that we believe ourselves, if we've been stressed, that it may make us sick. It may certainly make us psychiatrically unwell but we may believe that stress might have contributed to our illness, very often without the science that can support our contention. There is nobody in this room, including myself, who would not agree that war is stressful for all involved and all who watch and all who know anything about it. I started my life as a young general practitioner in a veterans' practice. The principal in the practice had survived Changi so I grew up as a doctor working with veterans and I ended up a psychiatrist, I am sure, because I kept saying, "What happened to them in the war?". Nobody else seemed to be asking those questions. Dr Lars Weisæth, who is a Professor of Disaster and Military Psychiatry at the University of Oslo and a consultant to NATO, suggested that there are three forms of war stress: shock traumas of brief duration, repetitive or serial trauma and prolonged exposure to danger characterised by varying degrees of predictability and control. Marshall, another researcher in this field, again talks about a range of low intensity events which people might see as coming into play in what is sometimes called the malevolent environment. This consists of the more chronic type of events as opposed to high magnitude events and conditions where people's lives are threatened. So, even when people have tried to look at stress and war, operational definitions of what stress might be have varied between researchers who are extensively experienced in looking at this field. Not all stressor exposures lead to problems of illness and we know now from a large number of studies of soldiers and many other exposed populations that even with severe exposures to horrendous traumas, not everybody is likely to either develop PTSD or to have a psychiatric condition as a consequence. For example, in a US study of Vietnam veterans, 15% were reported to have PTSD. In the general community in Australia the level of post-traumatic stress disorder found by a national epidemiological study was 3.5%, which is quite high. It is linked to a range of exposures to trauma in the community. We know too that while combat exposure might be one of the high risk factors for developing an illness like post-traumatic stress disorder, military service also has positive effects. There are a range of studies which suggest that these might be to do with learning, development of personal strengths, being part of a team, coping skills and a sense of independence and maturity. Many young men and now young women come in to the services at a time of personal maturation- late adolescence and young adult life. It is a time of development and growth, where there are particular vulnerabilities but opportunities for strength. Social cohesion, mastering the experience, personal characteristics, training, experience, and recognition and response from others, are critical factors for coping with an exposure. If other people respond to you by saying, "It was nothing" or "It's your fault", it tends to make it more likely that this will be a difficult issue for you. When I was a general practitioner working with veterans I could never understand why their entitlement cards were labelled, "Inadequate Personality Disorder," because it seemed to me going to war meant you were adequate in the first place. There was a sense that people often felt they were blamed for what had happened to them, or that it was some reflection on them as people. We know that better recognition is critical. We are well aware that the RMA have a range of definitions of severe stressors. These have evolved in different ways because of the literature relevant to the particular conditions and the science that was available at the time that the SOPs were being prepared. We understand this does not make things easy, and indeed in some instances we may not have adequately clarified some of these things because the literature was uncertain. This will lead us to look much more closely in a review of these stressor exposures. This links to the work that's been done for DSM-IV, and before it DSM-III, in trying to define better what a stressor exposure is. Encompassed in the DSM-IV definition of an acute stressor is the reaction to the stressor: "Which event or events might evoke intense fear, helplessness or horror" The need for a reaction in the definition has been debated frequently. Some scientific literature suggests that there can be a dissociation from reactions in which it's as though you weren't there. This dissociation may be indicative of heightened risk of developing a condition later. So, sometimes the definition includes the response and sometimes it doesn't. Where there has been exposure to catastrophic stress a consequence may be enduring personality change. This may reflect part of a spectrum of PTSD. The term "psychosocial stressors" refers to a different level of stress, and can be related to the broader range of conditions than the very specific type of stressor identified for post-traumatic stress disorder. Here we look at the range of things that could occur that would be extremely distressing for us. In our own attempt to be more scientific, there is often a complexity between describing the exposure and the reaction to it. In the scientific literature there is often no clear separation of the exposure and the reaction to it and there is a broad, ill defined use of the word "stress". The confusion in the literature makes it difficult for the RMA to make conclusions which can be applied in a SOP. Some of the questions that have arisen from ESOs, from veterans and from the courts are included here. I'm putting these up, not because there are sound scientific answers to these, but because they are common questions that come up across the spectrum. The first question is, does the stressor component for PTSD have to be an actual threat of death or serious injury? Does it have to be a threat which anyone could objectively judge, or is it really to do with perceptions? What do we mean when we say the person was confronted by an event? If you're rung up and told about an event, is this stressful? What about your individual perceptions? If you thought it meant you or a loved one were going to die, is that objective or is that a perception? What if you found out later that there wasn't really a basis for the perception of threat? Another question is what types of events might constitute stressors, and how severe might they be? People have made many attempts over the years to grade life event stressors. In the early work of Holmes and Rahe the death of a spouse rated the highest on the scale and we have to go from this to trying to identify the rating corresponding to being exposed to a terrorist threat, or indeed to any other horrific life threatening experience. It's interesting to note in the aftermath of September 11 there have been a very large number of studies in the US looking at the rates of PTSD in the population. New York hotels were booked out as soon as September 11 happened with people coming in to do trauma counselling for everybody. As it turns out, the better literature is highlighting the fact that resilience was strong and early high levels have settled down to quite low levels in the general population. We have to be very careful that in our understanding of stressor exposure we are both appropriately recognising the potential impacts as perceived by members of the armed services and veterans, as well as protecting people from developing a disabling view of the experience. The RMA is committed to understanding and supporting the reality of the nature of the conditions described, and veterans' experiences, but also making sure that we do this properly. To do it properly we have to provide the scientific basis and in our ongoing review we have to answer some of the questions that have arisen and been put to us by veterans or the courts. We have to take into account what evidence there is about subjective and objective realities. The question of the malevolent environment as a more profound and ongoing stressor has come up but is still in the early stages of study in the scientific literature. Other questions being studied are the nature of the different stressor exposures and experiences, how memory may alter and change these in adaptive and non-adaptive ways, and how exposures may lead to different outcomes and disorders. Our work, of course, then has to be picked up in the clinical side for the assessment and diagnosis of individual veterans. Thank you. Previous | Contents | Next This page last updated 22 March 2005.

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