Stressors and the fine line between normal and psychopathology.

The terrorist attacks of September 11, 2001, were a sudden and extreme stressor that affected many people. (1,2) We all responded to this high level of trauma in different ways. In extreme circumstances, the otherwise adaptive defenses that we use no longer provide us the means to "make sense" of our experiences. As a result, more primitive defenses (eg, denial, projection identification) are used as "failsafe" mechanisms to allow the necessary time for adjustments to a defamiliarized world. Even when gathering all the pertinent information about an individual, it is difficult to accurately predict the impact of stressors on that person's psychopathology. (3) It is also known that the presence of emerging psychiatric illness leads to impaired tolerance to even normal stress. (4) Therefore, a comprehensive psychiatric history, with emphasis on dynamics of commonly-used defenses, is essential to understand the development of emerging delusional systems.

In this issue of the Southern Medical Journal, Reeves and Beddington (5) present a novel look at the impact of a particular type of stressor, the terrorist attack, on psychopathology. The discussion synthesizes nicely the possible ramifications of this encounter. The patient presented here had an acute presentation. Beginning several days after the terrorist attack, he experienced anxiety, decreased sleep, was hyper-vigilant, and developed paranoia, all in the course of less than a month. This led the patient to psychiatric evaluation and eventually to hospitalization. In time, despite treatment, the delusions continued to develop and crystallize. Once delusions crystallize, interventions have limited usefulness. The incipient delusional phase before crystallization theoretically offers more opportunity to correct the specific dysfunctions and to reduce the decalage between levels of cognition and perception.

What determined the acute development of psychosis in this individual? Is it the nature of the stressor or the combination with one's particular mode of perception and processing of information? The experiential aspect of perception is obtained from processing primitive awareness through working memory and referenced through the association areas. It might be difficult to find a reference to such a stressor (terrorist attack) as a result of our limited exposure to such events. Considering this theory, it is possible that for this patient, the response to novel trauma would be similar for all catastrophic events of such magnitude. However, this information is further processed and stored. Through repetition, the perceptions will be transformed in meanings and then in beliefs. Beliefs are the fundament of our understanding of the world. As in this patient, they create a powerful reference system that colors the world as a hostile place and we ought to be prepared.

Lopez-Ibor, (6) discussing response to stress, highlights the following possible psychological mechanisms: preimpact, alarm, impact, recoil, postimpact and reconciliation. Resulting symptoms can range from avoidance to obsessive ruminations. Bracha et al (7) suggest the importance of understanding from an evolutionary perspective, the development of the human fear circuitry. From that perspective, the patient's reaction may seem adaptive for preservation.

Fortunately, there is a recognized need to increase individual and national preparedness for terrorism threats. (8) We begin to understand more and more the importance of early psychiatric interventions to decrease the sequels of such stressors and, as a result, great efforts are made to have the infrastructure for quick response in place.

References

1. Hoven CW, Duarte CS, Lucas CP, et al. Psychopathology among New York City public school children 6 months after September 11. Arch Gen Psychiatry 2005;62:545-552.

2. Nandi A, Galea S, Tracy M, et al. Job loss, unemployment, work stress, job satisfaction, and the persistence of posttraumatic stress disorder one year after the September 11 attacks. J Occup Environ Med 2004;46:1057-1064.

3. Pine DS, Costello J. Trauma, proximity, and develop mental psychopathology; the effects of war and terrorism on children. Neuropsychophurmacology 2005;30:1781-1792.

4. Klosterkotter J, Ebel H, Schultze-Lutter F, Steinmeyer EM. Diagnostic validity of basic symptoms. Eur Arch Psychiatry Clin Neurosci 1996;246:147-154.

5. Reeves RR, Beddington JJ. Persistent paranoid delusions following the September 11 terrorist attacks in a man with no preexisting mental illness. South Med J 2006;99:303-305.

6. Lopez-Ibor JJ. Psychopathology of disasters. An R Acad Nac Med (Madr) 2002;119:489-505.

7. Bracha HS, Yoshioka DT, Masukawa NK, Stockman DJ. Evolution of the human fear-circuitry and acute sociogenic pseudoneurological symptoms: the Neolithic balanced-polymorphism hypothesis. J Affect Disord 2005;88:119-129.

8. Polatin PB, Young M, Mayer M, et al. Bioterrorism, stress, and pain: the importance of an anticipatory community preparedness interventions. J Psychosom Res 2005;58:311-316.

M. C. Davila, MD, and R. G. Bota, MD

From the University of Missouri Kansas City, Kansas City, MO.

Reprint requests to Cristina Davila, MD, University of Missouri, Kansas City, MO 64110. Emal: [e-mail]

Accepted December 21, 2005.