Sex, Drugs and CBT
Freud believed that neurosis, anxiety and depression, were caused by sex. A whole industry grew up around this idea and there are many people who still believe that anxiety and depression are caused by unresolved unconscious conflicts. Sufferers of anxiety and depression could spend years and thousands of pounds on therapy trying to resolve these conflicts, often with not much of a result apart from for the bank balance of the therapist, cynics may say. More recently the trend has been to attribute anxiety and depression to faulty thinking, otherwise known as CBT – the cognitive behavioural approach. I am postulating that rather than unconscious conflicts or faulty thinking being the main cause of anxiety and depression, the real causes lie in either acute or chronic trauma combined with underlying risk factors. If this is the case then the field of sports injury may offer insights into the treatment of some mental health problems because sports science offers a model for understanding and treating pathology caused by trauma and risk factors.
Five reasons why I think that some mental health problems may be a kind of overuse injury
1. The similarity between physical overuse injuries and some mental health problems.
Overuse injuries are the culmination of repeated minor traumas, often with an exacerbating trigger event that precedes the onset of symptoms. Some mental conditions such as anxiety do involve a kind of mental cumulative trauma where symptoms manifest themselves after a trigger event. For example, a child that experiences chronic low levels of insecurity is being exposed to repeated microtraumas which may evolve into an anxiety disorder after a stressful event in their teenage years. So in the same way that repeated physical stress/trauma can cause physical injury, it seems reasonable to assume that repeated psychological stress/trauma can cause mental injury. In the same way that physical overuse can cause a period of health problems it seems likely that mental overuse could cause a range of different mental health problems. However, I think that anxiety and depression other most likely consequences of mental overuse injury. This is because it is easy to see how the repeated experience of insecurity and sadness as a baby and child could lead to a generalised feeling of anxiety and depression later in life.
2. The lack of awareness of cumulative trauma
It has taken a long time for physical overuse injuries to be recognised because they take a while to appear and the cause and effect are not as closely connected in time as in acute injuries. The diagnosis and treatment of physical overuse injuries is not joined up. Books or web articles about Repetitive Strain Injury of the hands from typing never connect it to vocal overuse injuries or the other myriad of overuse injuries that can effect any part of the body.
So it is not surprising that mental health problems – the Cinderella of health – are not recognised as being caused by cumulative trauma because not only are the symptoms and causes separated in time but mental health issues are invisible and shrouded still in stigma and denial so the connection between overuse injuries as a whole and mental health issues that have been caused by mental trauma/overuse does not come naturally.
3. The false distinction between mental and physical illness
I think that the division of mental and physical illnesses into completely separate categories is arbitrary, our minds are in our brains which reside within our bodies so the same principles that cause physical illness can also cause mental illness. If the body can be affected by overuse injury then why not the mind?
4. If there is a PTSD then there must be a CTSD
There is great awareness now about Post Traumatic Stress Disorder (PTSD). PTSD is the psychological equivalent to an acute injury. It follows that there must be the psychological equivalent to an overuse injury where somebody is repeatedly exposed to low levels of stress over a long period of time. It is strange that that even though there is an awareness that issues such as psychological neglect can cause harm that there is no aware about what could be called CTSD, i.e. Cumulative Trauma Stress Disorder. I think that the reason for this is that in the same way that physical overuse injury can easily be overlooked because of the distance between the cause and the injury, it is very easy to see the connection between an acute psychologically traumatic event and the ensuing distress but the connection between the levels of chronic psychologically less traumatic events over a long period of time is not quite as obvious or dramatic but the consequences could be the same, if not worse.
5. My experience.
For many years as a child I had experienced minor traumas related to feeling neglected and worry related to Catholicism, then as a teenager I experienced a combination of stresses following a road accident where I was hospitalised, school exams, and a piece about me in a national newspaper. I think this combination of stresses combined with genetic risk factors, such as increased sensitivity, then led to an anxiety disorder. The symptoms of anxiety themselves generate stress and this perpetuates the disorder.
The following illustrates an example of how anxiety can be an overuse injury. In my previous job I had opportunities to just work by myself or have a change of environment by going to meetings outside of the building where I was based. When I changed jobs I was suddenly around people all day long and I developed a problem with constant hyperventilation (previously I had just experienced hyperventilation intermittently). I think that in the previous jobs the time by myself and the opportunities to leave the building gave me some recovery time. Also in the new job on my very first day I was presented with a very stressful incident. I think that this incident was the trigger but that the reduction in recovery time, and incidentally an increase in stress because of a house move, led to the hyperventilation problem. This process of reducing recovery time and cumulative and sudden increases in stresses, plus a triggering stressful event that precede the onset of symptoms is exactly the same process that occurs in physical overuse injuries.
At the same time as developing the mental overuse injury I also developed a physical overuse injury with my knee. I think this was connected to carrying my bicycle up three flights of steep stairs almost everyday and running up and down stairs at lunchtime. In both cases the mental and physical overuse injury were related to stresses associated with a change in environment and routine.
My experience of working in mental health has also shown me through surveys that I conducted that about two thirds of the people who used the services where I have worked have been sexually, physically or emotionally abused or neglected when they were young i.e. they experienced mental trauma/overuse. However, the link between this abuse and neglect in my experience is less strong in people who have schizophrenia or bipolar disorder than with anxiety, depression and personality disorder. Though I would not rule out mental overuse injury as being a factor in schizophrenia and bipolar disorder. There are also people who have not experienced a significant level of mental trauma but who nevertheless still develop mental health issues which indicates that in these cases the cause may be more biological, so it is important not to overgeneralise the amount of ‘mental overuse injury’ but I think that is substantial.
The Stress Vulnerability Model
The Cumulative Trauma model I am offering here is similar but different to the well known ‘stress vulnerability model’ because the latter does not make any connections with or apply any lessons from the parallel process operating with physical stress and disease and it does not highlight the role of repeated minor trauma. The stress vulnerability model also does not offer a systematic and logical approach to avoiding and reducing the effects of mental trauma through avoiding misuse and overuse of the mind and emotions.
The Cumulative Trauma Model in a nutshell
- There are a range of risk factors that can predispose somebody to a mental overuse injury. These risk factors include a range of psychological, behavioural, social, biological (particularly neurological) factors that reduce the individual’s resilience to stress.
- If enough of these risk factors come together and if the individual is subject to a period of intense stress then the psychological disorder will manifest itself. This intense stress is usually caused by experiencing ‘too much, too hard, too soon’ i.e. the amount, the intensity and frequency and duration of stress have passed beyond a threshold that is enough to cause a ‘breakdown’ i.e. the onset of symptoms.
- Treatment involves identifying the risk factors and seeking to modify or remove them, where this is possible and as long as this does not involve making things worse.
- Undertaking psychological and behavioural rehabilitation.
- Preventing and minimising further trauma by applying the principle of injury prevention taken from sports medicine, i.e. to avoid doing ‘too much, too hard, too soon’. More specifically this involves seeking to control the amount, the intensity and frequency and duration of stress.