User:Anthonyhcole/Distress

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Distress

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,^[1] and their new model now underpins all thinking in pain psychology and pain neuroscience. They described three dimensions of pain:

sensory-discriminative: sense of the quality,^[2] location, duration and intensity of the pain
affective-motivational: unpleasantness and urge to escape the unpleasantness
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 "distress" here.

Distress 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 distress 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. Distress 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).

Distress likely evolved first and was enlisted by homeostatic feelings, emotions and social feelings as they emerged later in animal evolution.^[3]

It is likely that just one neural network generates distress, and every unpleasant feeling employs this one distress network.^[4]

What does distress do to us?

I am studying the effect of distress on human emotion, cognition and social engagement and I have focussed on three causes of distress — 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 affective 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 distress that does not cause this cluster of symptoms, I shall assume all distress, regardless of its cause, produces this syndrome.

If distress is intense, these symptoms are disabling.

This syndrome is found and is a major contributor to disability in all instances of distressing functional mental disorder. Some functional mental disorders don't necessarily come with distress. Certain tic disorders and personality disorders, for example, only qualify as mental illness because they may interfere with the person's functioning, but not necessarily with their happiness. This cluster of affective, cognitive and social symptoms I call the distress syndrome is not usually found in these non-distressing disorders but it is a feature of all distressing functional mental illnesses.

Look, for example, at the extract below from the "associated features" of schizophrenia (a mental disorder strongly associated with distress) 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)^[5]

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 the symptoms of mental disorder that cause distress, never distress that causes the symptoms of 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,^[6] 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 functional mental disorders, should find and treat the source of the patient's distress. Begin by scouring the body for distressing homeostatic conditions.

But the diverse cluster of cognitive, affective and social symptoms that comprise the distress syndrome are not the only features of distressing mental illness. What about the symptoms that distinguish one DSM entity from another — mania, delusions, hallucinations, obsessions, etc.? Well, they may be summoned by distress from a propensity in the patient's biological inheritance, modified by life experience and social state (diathesis-stress, an old idea^[7]), 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.

"Some researchers [claim] that a single dimension similar to the g factor in intelligence, that provides a summary measure of general mental ability, accounts for all types of psychopathology accross the lifecourse. 'Today's patient with schizophrenia was yesterday's boy with conduct disorder or girl with social phobia and tomorrow's elderly person with severe depression', psychologists Avshalom Caspi and Terry E. Moffitt assert." — Allan V. Horowitz, DSM: A history of psychiatry's bible (2021), chapter 6.

Caspi's and Moffitt's proposal is in this 2018 American Journal of Psychiatry article. They discuss "the new idea that there may be one underlying factor that summarizes individuals’ propensity to develop any and all forms of common psychopathologies," which they call p.

This p factor is, of course, distress.

Notes and citations

^ Melzack, Ronald; Casey, Kenneth (1968). "Sensory, Motivational, and Central Control Determinants of Pain". In Kenshalo, Dan (ed.). The Skin Senses. Springfield, Illinois: Charles C Thomas. p. 432.
^ "Quality" in pain science means the unique sensation that distinguishes pain from other feelings like itch, nausea and thirst, or the characteristic that distinguishes one pain from another, e.g., tingling pain vs. burning pain.
^ Antonio Damasio in his 2021 book, Feeling and Knowing, puts the appearance of basic discomfort and wellbeing before the emergence of homeostatic feelings in evolution.
^ Damasio, ibid, says, "But we often overlook the fact that our psychological and sociocultural situations also gain access to the machinery of homeostasis in such a way that they too result in pain or pleasure, malaise or well-being. In its unerring push for economy, nature did not bother to create new devices to handle the goodness or badness of our personal psychology or social condition." P.127.
^ Bleuler, Eugen (1911). Dementia Praecox. Translated by Joseph Zinkin in 1950. New York: International Universities Press.{{cite book}}: CS1 maint: numeric names: translators list (link)
^ From page 23 of DSM-5-TR: "In the absence of clear biological markers or clinically useful measurements of severity for many mental disorders, it has not been possible to completely separate normal from pathological symptom expressions contained in diagnostic criteria. This gap in information is particularly problematic in clinical situations in which the individual's symptom presentation by itself (particularly in mild forms) is not inherently pathological and may be encountered in those for whom a diagnosis of 'mental disorder' would be inappropriate. Therefore, a generic diagnostic criterion requiring distress or disability has been used to establish disorder thresholds, usually worded 'the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.'"
^ Kendler, Kenneth S. (July 2020). "A Prehistory of the Diathesis-Stress Model: Predisposing and Exciting Causes of Insanity in the 19th Century". American Journal of Psychiatry. 177 (7): 576–588. doi:10.1176/appi.ajp.2020.19111213. ISSN 0002-953X.

[1] Melzack, Ronald; Casey, Kenneth (1968). "Sensory, Motivational, and Central Control Determinants of Pain". In Kenshalo, Dan (ed.). The Skin Senses. Springfield, Illinois: Charles C Thomas. p. 432.

[2] "Quality" in pain science means the unique sensation that distinguishes pain from other feelings like itch, nausea and thirst, or the characteristic that distinguishes one pain from another, e.g., tingling pain vs. burning pain.

[3] Antonio Damasio in his 2021 book, Feeling and Knowing, puts the appearance of basic discomfort and wellbeing before the emergence of homeostatic feelings in evolution.

[4] Damasio, ibid, says, "But we often overlook the fact that our psychological and sociocultural situations also gain access to the machinery of homeostasis in such a way that they too result in pain or pleasure, malaise or well-being. In its unerring push for economy, nature did not bother to create new devices to handle the goodness or badness of our personal psychology or social condition." P.127.

[5] Bleuler, Eugen (1911). Dementia Praecox. Translated by Joseph Zinkin in 1950. New York: International Universities Press.{{cite book}}: CS1 maint: numeric names: translators list (link)

[6] From page 23 of DSM-5-TR: "In the absence of clear biological markers or clinically useful measurements of severity for many mental disorders, it has not been possible to completely separate normal from pathological symptom expressions contained in diagnostic criteria. This gap in information is particularly problematic in clinical situations in which the individual's symptom presentation by itself (particularly in mild forms) is not inherently pathological and may be encountered in those for whom a diagnosis of 'mental disorder' would be inappropriate. Therefore, a generic diagnostic criterion requiring distress or disability has been used to establish disorder thresholds, usually worded 'the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.'"

[7] Kendler, Kenneth S. (July 2020). "A Prehistory of the Diathesis-Stress Model: Predisposing and Exciting Causes of Insanity in the 19th Century". American Journal of Psychiatry. 177 (7): 576–588. doi:10.1176/appi.ajp.2020.19111213. ISSN 0002-953X.

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