If Life Were Easy They Would Have Asked For Volunteers

Daniel L. Kirsch, PhD, DAAPM, FAISdkirsch@stress.org,     The American Institute of Stress, 6387B Camp Bowie Boulevard, #334 Fort Worth, TX, USA, 76116

Michel A. Woodbury-Fariña, MD, DFAPA, FAISmichel.woodbury@upr.edu,     University of Puerto Rico School of Medicine, 307 Eleanor Roosevelt Street, San Juan, PR, USA 00918-2720

Stress is ubiquitous and follows us everywhere. Since there is simply no avoiding it, the task for psychiatrists has become to further our understanding to improve management in our patients and in ourselves. We see the goal in this is to have a more preventive health care system and consequently a happier and healthier population. We hope to contribute to that end, having made the detailed description of this common occurrence and its impact on the body and mind the focus of this issue.

Dr Daniel L. Kirsch is a neuroscientist who has been in the forefront of pain and stress management for 40 years. He was asked to edit this issue in his role as the President of the American Institute of Stress (AIS), a nonprofit organization founded at the request of the father of the stress concept, Dr Hans Selye, in 1978. Dr Kirsch replaced the legendary stress specialist, Dr Paul J. Rosch, as president of AIS, although Dr Rosch remains with the AIS as Chairman of the Board and continues to write the member-only newsletter, Health and Stress. AIS offers many free resources to practitioners and patients alike at its Web site: www.stress.org. Those resources include the free emagazines Contentment and Combat Stress. Contentment is for everyone, while Combat Stress is devoted to the special needs of military service members and veterans. Since 2005, Dr Kirsch has been actively working with the US military in teaching pain and stress management to uniformed practitioners and working with health care professionals on their own compassion fatigue. He also works with the Army Substance Abuse Program and is a member of the Board of Scientific and Professional Advisors of the Institute for Traumatic Stress.

Coeditor Dr Michel A. Woodbury-Fariña is a Lifetime Distinguished Fellow of the American Psychiatric Association and board-certified Child and Adult Psychiatrist who has been in private practice, academia, and pharmaceutical research for over 30 years. He is also the Chairman of the AIS Daily Life Stress Board. Dr Woodbury-Fariña teaches his residents to use a technique he developed to provide a simple explanation to their patients on how the mind works when under stress. He tells them to hold one fist up and the other hand open next to the fist. The fist represents the primitive (or the unconscious, limbic/brainstem, or immature) brain. The open hand is the adult (or conscious, prefrontal, or mature) brain. He then instructs them to cover the fist with the open hand and say that this is the state of the mind at peace, where the adult brain covers or controls the primitive brain. In this way, we can calmly go about our daily business. The primitive brain will be more active when there is stress, represented by opening the fist and hiding the other hand. The newly opened hand is there to fight or take flight as it takes over. The problem is that the fight/flight response means the primitive brain is under the impression that there is real danger lurking, even the possibility of being killed. The primitive brain sends waves of intense emotions to the adult brain because it does not communicate with words. The adult brain does not know what to do with these intense emotions, so it tries to make sense of them by attributing a real cause to them. Thus, all the distortions described by cognitive psychology come into play, such as, “I failed the exam and my life is over!”

We need to use psychotherapy, relaxation techniques, biofeedback and Alpha-Stim cranial electrotherapy stimulation, supplements or medications, and exercise, among other options, to give enough strength to the adult brain to maintain control of the primitive brain. You can then have the hand representing the primitive brain close to a fist again and have the open hand/adult brain move back over to cover the primitive brain/fist. This simple exercise has helped psychiatric residents communicate the reasons for the interventions used in their therapy sessions. The goal of this issue is to give more explicit details on this subject.

The first article is an overview of how to measure stress. The author of this article has extensive experience with these kinds of measurements as she is a collocated collaborative health behavior provider who has been working in the Primary Care Mental Health Program at the VA Caribbean Healthcare System since 2012. Before this, she completed her APA-accredited internship at the VA Hospital in San Juan Puerto Rico and shortly after began working at the Brief Individual and Family Psychotherapy Clinic. Within the context of her work, Dr Figueroa-Fankhanel has focused on brief interventions that aim toward early detection, disease prevention, and health promotion. At present, her clinical setting affords her the opportunity to work collaboratively with primary care staff in providing consultation for the treatment of stress-related and anxiety-related disorders within the medical settings of the veteran population. In addition, she helps providers effectively engage with their patients and implement motivational interviewing techniques, supportive interventions, and crisis management with veterans who possibly display heightened stress and anxiety states during medical appointments. Aside from her interdisciplinary work, she is a clinical supervisor in the Primary Care Mental Health Fellowship Program and co-leads a health behavior training seminar for psychology trainees focusing on health-related issues such as stress. In addition to staff engagement and education, she provides evidence-based therapies for patients with stress-related and anxiety-related disorders. Cognitive behavioral, acceptance, and commitment therapies, as well as a mindfulness-based stress reduction group are among the treatment modalities she implements. In sum, she has a special interest in measuring how stress affects a person's quality of life, including the documentation of health behaviors, treatment adherence, and treatment outcomes. In her article, she identifies the psycho-immunologic, psychological, and environmental models of stress as being the most influential theories in stress research and proceeds to describe how they are measured. She also includes the advantages and disadvantages of each evaluation modality.

Dr Alexander Bystritsky has been the Director of the Anxiety Related Disorders Program in the Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California at Los Angeles for the last 30 years. He has very broad experience in researching, teaching, and treating stress, anxiety, and related disorders, including treatments using psychopharmacology, behavior therapy, and various types of brain stimulation. Dr Bystritsky developed the ABC dynamical theory of anxiety, which he is using in research, patient education, and practice. For the past 4 years, Dr David Kronemyer has been a researcher at the Anxiety Related Disorders Program. There he specializes in nonlinear dynamical processes associated with belief revision, translational cognitive neuroscience, and phenomenological psychology. In their article, they present the concept that stress and anxiety are so interrelated that the two should be considered on a continuum. This increases the understanding of the brain’s response and helps to delineate intervention strategies as well as provide directions for future research.

The article on the developing brain and the effects of severe stress is written by Dr Ricardo Vela, who has had many years of experience studying this relationship. For 36 years, as a child and adolescent psychiatrist, he has worked with inner-city populations and treated hundreds of children with extensive trauma histories. In fact, during his 9-year tenure at Boston Medical Center/Boston University School of Medicine, he spent more than 4 years at the neuroanatomy lab of Dr Thomas Kemper, a neuroanatomist, neuropathologist, and pediatric neurologist, going at least once a week to study brain anatomy. From this experience and independent study, he organized an advanced neuroscience course for psychiatry residents as well as developed the course/seminar, “Neuroanatomy of Emotions,” at the American Psychiatric Association’s Annual Meeting, which he has taught for the past 9 years. At present, he teaches child psychiatry residents the neuroanatomy of emotions, child abuse/development, autism, schizophrenia, and attentional problems at Massachusetts General Hospital. In his article, he tells us how the neuronal development of the limbic system, which is used to develop emotions and attachment, is extremely vulnerable to abuse and neglect in the first year of life. If such abuse continues, by 3 years of age there will be more negative than positive emotions expressed. The author proposes that we try to understand these effects so that we can present what he has called a psychoanatomical formulation on...