Thanks Dr Bianchi, I think the relationship between these three negative emotional symptoms needs more investigations. In addition to inability to behave effectively,  there are other common cognitive factors such as inability to concentrate. 

You raised a very interesting and complex question, Ahmad. I liked Renzo's perspective.

There are many variables that contribute to the various forms of depression, or anxiety, or both, or none at all. Here are some of these variables:

• The nature, severity, and duration of the chronic stress
• The nature of the person (e.g., his/her genetic predisposition, personality variables, neuropsychology, etc.) and his/her problem-solving, stress management, coping, cognitive, and interpersonal styles, and defense mechanisms, etc.
• Environmental and contextual variables (e.g., predisposing, precipitating, and perpetuating psychosocial stressors such as a death in the family, unemployment, etc.)
• Supportive network/system (e.g., his/her familial, friendly and communal contexts with protective and risk factors, etc.)

 Thak you so much prof Cheung for the the nice and comprehensive answer.  Sorry for the complex question, I like to think mindfuly and deeply in these topics!

Kind regards...

Yes, I agree with your view Dr Bianchi, this makes the person feels hopelessness in most situations.

I like the responses here, to your question, Ahmad.  As an individual who suffers from Major Depressive Disorder, I absolutely agree with predisposition, genetic or environmental, as being key to answering this on-going question.  It has been my experience that when one does not have the proper support team (e.g., network), that only makes things more difficult for the individual.  When we have someone to turn to, rather it be a parent, spouse, friend, etc., that assists in the alleviation of stressors.  Again, this information is from personal experience.  I will put forth the effort to research your question, and let you know what I discover.

Dear Onitra, thank you so much for sharing. your personal experience is very valuable for me, and be sure that it is all right. Yesterday I was discussing the "cognitive errors" as identified by Dr Aaron Beck with a girl who is suffering from depression for a long time. She admitted that she has many cognitive errors and asked me to do cognitive therapy for her. At the end of our meeting which lasted for 90 minutes, she said: "I only now want  a support system", "I need some one to "ventilate" for him".... " "Can I please call you and ventilate when I experience an episode of depression? "   I really appreciate your kind help to answer my question, and impatiently waiting any addition from you.  Hope you the best...

King redards...

Thanks so much for your sharing, Onitra! Yes, there are intra-personal, environmental and interpersonal variables that can affect one's experience of chronic stress, depression, and anxiety.

I really liked your thought-provoking questions that help us examine what we know and investigate what we don't know, Ahmad. Thanks!

I appreciated Renzo's insightful idea that one's chronic sense of helplessness/a lack of self-efficacy and fulfillment can make one feel depressed/demoralized. That can lead to one's hopelessness, as Ahmad suggested.

The knowlege and factors associated with the conditon of personal mental stress may lead to many other health related maladies. Depression within the framework of its clinical etiology may be a factor in which differential impinging issues may associate identifable reasons... leading to greater health disparities.  It is always best to ensure that the advice given would lead to initially having to obain a complete evaluation by a competent, and designated healthcare provider. 

In the matter of having to know what are the exact causes depends on each individual case.  The reoccuring composition of the cycle, and interrelated construcitvely define reasons may include conditons of: personal affect of apathy, emotional contingent application of inate exposure to diffculties of a personal nature, levaing no other option other than to seek credible assistance to provide effective relief.  In the long and continued effort to treat ones' self, may not prove to be clinically applicable to the relative aspect of personal safety.  It is a known and commonly asociated factor that depression of any nature may lead to serious health consequences.  It is always best to allow a fair and productive effort to take place which involves consistent treatment,  avoiding the obvious, and additional clinical difficulties for which may require an effort for an approach to form a modality sigificant to seeking acute treatment.

Realizing the potential for developing greater understanding of ones capacity, driven by authentic discovery to accept taking responsibility, assures the formation enabling efforts to manage a creative process for knowing the ways to take charge of personal health issues, sets the example for others to follow. This empowers the affected person to build a greater bridge for which to sustain the builidng of independence aflame with the knowledge of good self-care for greater future outcomes. 

I liked your ideas and added more discussion.

1- Stress: Everyone feels stressed from time to time as an important part of our life, and rarely a day goes without experiencing a stress in our life. It can simply results from something that imposes demands on us or feel being under pressure, which requires a response such as “fight or flight” response. However, when it is severe or chronic, it may lead to the next symptom:

2- Anxiety: In some situations, although the stressful situation has passed away, we may still having constant feeling of being abnormal !!! feel alarmed!!! It may be due to some fear regarding the previous stressors in life. The feeling becomes constant with no apparent reason, such as in panic attacks (this is the state of anxiety).

3- Depression: After feeling alarmed and fearful for long time, you may start lose meaning in life, feel hopelessness, not wanting to continue, and feel low mood.

No one can deny that there is a biological link between stress, anxiety and depression. Many argues that depressive disorder usually occurs together with anxiety disorder, but the causes for both (anxiety and depression) are strongly linked to having stressful experiences in life

Biological factors may interpret why  stress, anxiety,and depression may not occur at a continuum, the person may feel depressed without clear history of stress and anxiety. However, even if the biological factors are the only cause of anxiety and depression, stressful experiences (negative stressors) can also make the symptoms of anxiety and depression worse.

Dear all,

very interesting discussion.

in reality the association of anxiety and depression is the most frequent mental disorder found in primary care, usually related to chronic stress,  social vulnerability and lack of social support.  It makes the petient´s situation even worse as it lowers the person´s ability  to overcome the stressful situation. It also has negative  influences on other diseases, especially chronic ones, such as hypertension or diabetes and  can be associated with many functional syndromes such as fibromyalgia and with other cases of medically unexplained symptoms. They involve physical ( several types of pain), emotional ( anxiety and depression0 and cognitive symptoms ( lack of concentration).

The concept of allostatic load  and the process of autonomic arousal are interesting ones to help understand this process,

but one of the questions that are being posed nowadays is whether this can be considered an specific pathological process  and if some of the patients with medically unexplained symptoms in reality suffer from  this "chronic stress syndrome", called Bodily Stress Syndrome by the some danish authors.

best wishes

the mecanism of allostatic load

Thanks Dr Fortes, I liked your perspective regarding the "mechanism of allostatic load."

Also, you reminded me with the term "somatoform" which means that the physical symptoms have a psychological origin, and the unconscious defense mechanism of "conversion"

best wishes...

Dear Ahmad, Renzo, Onitra, Stephen and Desmond, 

This is an extremely important topic and I am glad that this is being discussed. I applaud your comments.

I have spent some time working on the concept/construct of chronic stressors and thought I would share my experiences.

"Stress" is an umbrella term that means so many things, it is not terribly useful as a scientific term (e.g. operational definitions). We need to decompose this term into units/elements that are measurable. It has been convenient to label the stimuli (environmental events or bodily stimuli) as ( 1) stressors. Although these are typically environmental, they can also be internal, such as congenital conditions.

Original research believed these stressors had direct immediate responses because they were based mostly on animal research, but when we humans recognized that there was action between our ears, we began (a la Lazarus) to think about

2) intrapersonal responses (appraisals of threat, harm, control, duration, predictability, novelty, causality and most of all, salience). #1 and #2 together influence

3) immediate/proximal responses such (mood/distress), physiological (sweating), and cognitive and even functional.

Finally, without resolution more benign proximal responses can become

4) more enduring clinical outcomes (DSM depression, chronic illnesses, etc).

Although there is some explanation for why we have ignored appraisals in animal research, many human studies have also ignored appraisals. Indeed, I have studied all of these, but have been remiss in focusing on different processes in different studies. One reason is that it is very complex to do it all and another is the measurement puts too many demands on respondents who are already distressed!!!

We know that depending on one's genetic profile and early environment, epigenetic responses occur to create fairly stable dispositions/early personality. Early trauma (sexual, violent, and verbal abuse, as well as death of loved ones, separation, etc) are key to forming attachments, etc, which all influence responses to stressors as early as adolescence and certainly into old age.

For me, it has been useful to view vulnerabilities as hard-wired factors, such as age, gender, race, and long term physical conditions that develop prenatally or in early development. As a psychologist, I also care about personality and believe it is somewhat stable.

I prefer to use these as vulnerabilities because they usually occur before stressors and this is key if we want to infer causality. My research has focused on interacting vulnerabilities with chronic stress and more mutable resilience/resources.

Although there are variants of the definition of chronic stressors, they are believed to be: enduring, long term, unresolved and without respite. More specifically, chronic stressors are distinct from acute stressors because they are unrelenting, inescapable, long lasting threats and challenges to ones system. These disrupt and influence homeostasis. Depending on the duration of chronic stress and the person's vulnerabilities, these will influence the primary stress hormone, cortisol in terms of responses to stressors, as well as catecolamines, etc.

Philosophically (as psychologists we need to draw on wisdom from philosophy as well as physiology), great minds have discussed vulnerabilities more than 2000 years ago. The Greek word diathesis means vulnerability. The diathesis-stress model was posited as a way to provide better predictions of outcomes than by using stressors in isolation.

In our work, we have defined vulnerabilities as gender, age, dispositions and most of all, comorbidities. In some cases these may have occurred at or near the same time as stressors. So the comorbidities may not be completely causal, but my work has shown that they do interact with chronic stress, such that persons with chronic stress and vulnerabilities have a much higher risk of experiencing physiological disregulation or clinical depression than those who only have one of these.

I began studying chronic stressors using occupational conditions (being a medical student, camp counselor, air traffic controller), but the vast majority of my work has been on persons who are caring for a spouse with Alzheimer's disease. Years ago I labeled caregiving as a "prototypic chronic stressor" for these reasons.

In almost all cases, we can document that caregivers meet criteria for chronic stress. Their experiences tend to be enduring (often as long as 15 years), to require great responsibility, meet physical demands, to cause loss and predict subsequent grieving. In my burden scale, typical responses that are endorsed are: "I have the world on my shoulders", "I do not know when this is going to end.....", "I have no time for myself", and "I feel trapped".

Importantly, many caregivers also derive pleasure from caregiving. In addition to believing it is their duty, they also love to give love.... These are factors that began being researched much later than the first study (1953) on caregiving. We have found interesting relationships between uplifts with physiological measures in the hypothesized direction (yep, it is good to have positive experiences to offset negative ones).

Given this background, we have compared caregivers to non-caregivers who are also married, but who are not full-time caregivers. In some studies we only matched on age and gender, but in our best study, we matched on age, gender, race, income and education. 

I have superimosed actute stress onto chronic stress by performing laboratory experiments that produce acute stress in caregivers and non-caregivers. CGs (caregivers) with Hypertension have much higher blood pressure activity to acute stressors than do NCG (non-caregivers) with Hypertension. These groups were contrasted with CGs and NCGs without hypertension. Hostility and the type of stressor (emotional vs. cognitive) were also important.

I have also done naturalistic studies to assess whether vulnerabilities (gender, dispositions)interact with caregiver status onto physiological and psychological variables.

Given the plight of the world, the massive increase in the older population (especially in Japan, Germany and Italy), especially with comorbidities, my greatest interest has been whether chronic stress influences reactivity to comorbid diseases.

We have found that CGs with coronary disease are much higher on the metabolic syndrome than are NCGs with coronary disease and that CGs with cancer histories are much lower on natural killer cell activity than are NCGs with cancer histories.

And, of most relevant to your discussions here:                                                                  72% of cgs with a history of depression have current depression as cgs, but only 30% of ncgs with a history of depression have current depression in the same time interval as cgs. Of additional importance is that cgs without a history of depression only have a 5% prevalence of clinical depression and ncgs without a history of depression have a 3% prevalence. This is a great example of the diathesis-stress model.

Unfortunately, much research still examines acute and chronic stressors without considering vulnerabilities.

Finally, I totally agree with your comments on the importance of resources.

However, one thing we need to remember about social supports is that money (another resource!!), may influence how valuable social supports are in buffering distress from stressors. Tangible supports may not be as beneficial to physiological well being if a person has lots of money, but emotional supports may always be useful. Of course, all types of social support benefit poor people.

Thank you so much prof Vitaliano for the valuable and interesting presentation of your studies. Vulnerability is very important to be considered. I liked your study very much since I am also studying stress, anxiety, and depression in caregivers (fathers and mothers) of children with autism. I had studied also anxiety, stress and depression in caregivers of patients admitted to ICU. These two studies may provide me with some inferences regarding Chronic Vs acute stress. I am thinking of taking the variable "vulnerability" into consideration in other future studies since it is very important. I also agree with you about emotional vs tangible support. kind regards 

Hi Amad,

This is Peter.

I am happy you are studying caregivers. They do so much for society and families have been the basis for sustaining life in vulnerable people for eons. You should check out the work on caregiving among neandrathals! It is part of our nature. CHeck out the "empathy gene" on 6th chromosome, some call it the empathy gene. It is responsible for producing oxytocin!!

In my long answer, I neglected to mention that I agree with the others that anxious symptoms are a first line reaction to stressors and overtime, depending on the person and the stressors, this can turn to depressed mood, and overtime to clinical depression, but mostly in vulnerable people with low resources.

Differences between cgs and ncgs on anxious symptoms is more pronounced than differences in depressed mood. Indeed, we recently examined the importance of genes in caregiving and showed that after stratifying on dizygotic twinship, differences between caregiver and non-caregiver sisters disappeared for perceived stress, depressed mood, and perceived mental health, but not for state anxiety! However, when we controlled for genetics, we found that monozygotic twinship eliminated anxiety differences in cgs and ncgs as well.

I totally agree that anxiety is the hallmark of acute reactions and while people are still coping somewhat effectively.

This is exactly what I was trying to find between lines in your previous long answer dear Peter, thank you for mentioning it explicitly now!

Kind regards

Ahmad,

To answer your question in an undergraduate manner, when an individual is under constant stress, it can, indeed, lead to anxiety and depression. According to Harding (2014), when a person's body is exposed to the stress hormone, cortisol, on a constant basis, not only can it affect the body, it can also affect one's mental health.

Further, according to Maculaitis (2013), too much stress can cause a plethora of health concerns, including mental health concerns, including panic disorders, anxiety, and depression.

Harding, A. (2014, April). Stress effects: Understanding your body's reaction to tension. Student Health 101, 9(8), 17-18. Retrieved April 23, 2015, from http://readsh101.com/ashfordu.html?id=e88bbc2a&page=17 

Maculaitis, L.. (2013, December). Stress: Head to toe, how stress affects your body. Student Health 101, 9(4), 7-8. Retrieved April 25, 2015, from http://readsh101.com/L/ashfordu.html?id=33cedaa9&page=7

Thank you so much dear Onitra. I am very happy to see your answer, your references are very interesting. Best wishes... 

Very interesting discussion. It's interesting that the literature really does not try to parse out when stressors lead to either depression or anxiety, as they are highly comorbid with each other, and they overlap with multiple symptoms. Even their treatments with CBT and antidepressants are similar, and making determinations if this is anxiety or depression really does not matter much, as it does not inform further clinical treatments. In my clinical experience, stressors are either handled via adaptive coping skills, or they aren't via maladaptive ones. These patients may then start having adjustment problems, and you notice the specifiers for adjustment disorder includes -with anxiety, -with depressed mood, and -with anxiety and depressed mood. If the stressors continue, then either a depressive disorder or an anxiety disorder emerges, and this tends to go back to CBT theory about thoughts and appraisals about the fearful stimuli and stressors, and this seems to be a significant variable which in turn determines which disorder emerges.

It also appears that anxiety and depression share the same neurobiology: it comes down to the interaction of genetic vulnerabilities (family history) with environmental influences (major life stressors), and it is this interaction which leads to abnormal processing circuits in the brain (hyperactivity of the amygdala to fearful stimuli and stressors). This hypothesis has been supported by a recent study which revealed that people with increased reactivity of their amygdala to fearful stimuli (as measured on fMRI), when they also experience a major life stressor, are more at risk to developing either anxiety or depression up to 4 years into the future: http://www.ncbi.nlm.nih.gov/pubmed/25654256. Further research should examine how the differentiation is made between the development into depression or anxiety, following study subjects with high amygdala reactivity to fearful stimuli who have also endured a major life stressor. I hypothesize that it is the thoughts and appraisals of the stressors which differentiates anxiety from depression, as discussed previously by other researchers who have replied to this interesting thread.

I would like to express my gratitude to all scholars who enriched the discussion and clarified these complex relationships. Welcome Dr Carandang, and many thanks for your clarification.

In addition to CBT theory, I think that lazarus and folkman theory of stress appraisal and coping provides appropriate interpretation for what the consequences of stress will be. Individuals who believe that there may be a benefit of still trying, may still try to act anyway (anxiety). while individuals who appraise their situation as an "out of control" may feel hopeless (depression). As the primary and secondary appraisals are continous and dynamic processes, some persons may report experiencing both anxiety and depression symptoms within a specific time interval.

I think it could be quiet interesting to look at the self-efficiency of chronically stressed people, because people who are resilient are often self-efficient and get depressions or anxiety less often. Perhaps we are able to find differences in self-efficiency in people who have depressions and people who have anxieties. 

Given the shared neurobiology, overlapping symptoms, similar treatments, high comorbidity, and increased risk of developing the other disorder when having one of them, the conceptualization of anxiety and depression may be more accurately portrayed as the same disorder, just different subtypes. And the metaphor of stress-strain-load and the capacity to handle that load is very helpful and insightful.

The Lazarus-Folman model is in my view outdated because it relies perhaps too much on cognitive processes. In order to answer your question to my opninion we must look at this from a bio-psycho-social perspective:

1. vulnerability to stress, depression and anxiety varies over gender, is affected by genetic and epigenetic mechanisms (recent research shows that the effects of a stressor are detectable over 3 generations in mice!). This vulnerability is mediated by the settings of the HPA-axis which is affected by psychological coping mechanisms and social climate (Raine, 2012). High stress affects also affects the brain functioning over time as cortisol is neurotoxic, probably enhancing vulnerability for anxiety and depression.

2. psychological resilience and coping mechanisms are not only cognitive but also conative and vary over individual and situation, for instance our own research with incarcerated adolescents found no dominant coping mechanism but a great variability intertwined with anxiety and depression through loss of hope and learned helplessness (Van der Helm, G.H.P, Beunk, L. , Stams, G.J.J.M & van der Laan, P.H. (2014). The relation between detention length, living group climate, coping and treatment motivation among juvenile delinquents in a youth correctional facility. The Prison Journal 2014 (May).

3.  lack of social support is linked to depression and anxiety and directly affects pain centres in the brain causing stress. In our climate research in prisons and psychiatric institutions lack of social support is one of the main predicators for climate quality, anxiety, depression and violence (Van der Helm, G.H.P. & Stams, G.J.J. M. (2012). Conflict and Coping by Clients and Group Workers in Secure Residential Facilities. In: Oei, K & Groenhuizen, M. Progression in Forensic Psychiatry: about Boundaries. Amsterdam: Kluwer).

To my opinion, answering your question requires more than a monocausal explanation or a specific model. Sorry about that.

The biopsychosocial model is a given for psychiatric assessments, and psychiatrists are trained to carry out that formulation when assessing patients. It's like telling a cardiologist that they should follow the biopsychosocial model, when in fact they are well aware of that personality, lifestyle, and resources significantly impact cardiovascular disease. It would be malpractice for a cardiologist to ignor the biopsychosocial model in the treatment plan of their cardiac patients, and the same applies to psychiatrists for theirs. I'm certain that none of the clinicians in this thread uses a monocausal method of formulating cases for the care of their patients with depression and anxiety. As scholars, we brainstorm ideas to enrich the discussion and debate in order to answer complex questions. And monocausal explanations are actually important components of Engel's biopsychosocial model.

The effects of external childhood and adult stress are far more complicated than merely causing one of the forms of clinical anxiety or any of the many forms of clinical depression. Continued overload of the capabilities of the nervous system (stress) causes feelings of inadequacy, personality disorders, selfishness, greed, addictions, and war, among its many other familiar effects.

As a teacher and researcher in the technique of transcending, I see transformations in myself and my clients based on nothing more than the elimination of the effects of stress in the nervous system.

Instead of researching in the dark, wondering what causes what, I am guided by a very simple analysis of how stress, which is a process spanning internal and external effects, can cause almost every problem that perplexes people today. A one-page discussion is available at www.nsrusa.org/about-stress.php . It is a great resource for those who find sweeping claims difficult to accept.

It is so much simpler to fix this problem than to understand it intellectually in terms of its effects on life, because these effects tend to hide their causes. That is the fundamental reason why psychotherapy works well only when there is a good rapport between therapist and patient, and isn't so much a question of how the psychotherapy is done.

Transcending is a simple, natural, and automatic mental process practiced for a few minutes twice a day while sitting in a comfortable chair. It involves no beliefs, religion, or changes in lifestyle, and its dramatic and repeatable effects begin with the first day of instruction. These effects may consist of a sudden and measurable reduction in anxiety, elimination of addictive behavior, increased peace or happiness, increased harmony in personal relationships, or other continuing benefits, depending on the individual and his or her problems.

In the form of Natural Stress Relief (NSR), instruction in transcending is delivered to the client in the form of a 50-page manual sent through the mail. Thus, it reaches anyone in the world without undue expense or need for travel. Several medical doctors, psychiatrists, and psychologists regularly refer selected patients for instruction, and have given their testimony of the rapid help that transcending provides in the clinical experience.

In summary, it is no longer necessary to feel around in the dark to understand the commonly-seen detrimental effects of  stress. We now can offer patients and also the healthy general public an efficient and natural method for dissolving the effects of stress in the nervous system, leaving body and mind clear, fresh, peaceful, and happy.

No psychological problem can last long in the face of these remarkable effects. It fits in well with Abraham Maslow's analysis of peak experiences and theory of self-actualization, as well as many other theories of psychological growth and health.

For those who have read this far, but are very skeptical, here are some additional helpful facts:

First, I did not invent this technique. It is the same pure technique of self-development that has been taught in India for thousands of years, freed of the layers of mysticism and religion that obscured its simplicity and naturalness as a necessary fourth state of the physiology.

Second, I am not in this for money. In fact, our business model is to distribute quality instruction in transcending for the lowest possible price, consistent with the psychological need to avoid the devaluation that occurs when a teaching is offered for free. Natural Stress Relief, Inc. is a 501(c)(3) educational and research charity registered as nonprofit and granted tax exempt status by the USA Internal Revenue Service. I take no salary for this work; I am amply repaid by the successful transformations enjoyed by my many clients, even those with "difficult problems" that remained unsolved for many years. All of our operations, in several countries, are conducted by volunteers and succeed without the slightest bit of advertising.

I agree that this discussion is highly useful.

When we think about the content validity of psychological distress, it  is typically measured (say, anxiety) via symptoms that are physiological, psychological, emotional and cognitive. Depending on the measure, these can be considered in terms of frequency, intensity and duration. In psychiatry (DSM), we tend to put emphasis on duration, which speaks more to chronic than acute stressors, although all are important.

I had the great privilege of knowing Richard Lazarus. I admire him for many things. He was not only brilliant, but kind!

To me, one of his greatest contributions was that he did not shrink from tackling difficult concepts.

In this regard, Baba, Ahmad and Renzo have all touched on important issues in this very complex issue.

What I enjoy so much about this forum is that there is communication with like-minded and intelligent researchers around the world.

Thanks for giving me more ideas to work on.

Here is one of them.

In previous work, my colleagues and I superimposed acute stressors onto persons with and without chronic stress to observe whether physiological reactions to acute stressors would be different in those with and without chronic stress.

Although we looked at state anxiety and anger in these participants, we did not analyze appraisals. Lazarus would say that appraisals are not only influenced by the stressor, but also by person factors. Yes, he focused on the stressor, he did not abandon the person!! 

Based on our discussions here, I will test to see if the appraisal of control (that was done on the same people with regard to their major stressor and their completion of the Revised Ways of Coping Checklist), is related to blood pressure reactivity to an emotional stressor.

The stressor we used was to ask caregivers and non-caregivers to talk about their spouses and the kinds of persons they are for 5 mins without interruption. The vast majority of the caregivers in the study had previously listed caring for their spouse with Alzheimer's disease, as their major stressor. Hence, their appraisal of this stressor (in terms of control, salience) should be related to their taped and coded statements (e.g. critical, emotional) about their spouse in the reactivity experiment. We would predict that those who express lots of negative expressed emotion and/or greater blood pressure activity, should also have appraised their stressor as less controllable and less predictable.

If Lazarus were alive, I know he would appraise such analyses having good potential.

This summer I do less teaching and would like to do these analyses and keep in touch.

Thank you for giving me this idea! If you have any thoughts I would appreciate them.

  the there no clear line to splitting between  anxiety and depression due to a lot of etiological and epistimological views , so the response towards chronic steers will be different from each other based genetic , Vulnerability and the personal perception to stress , it is a complex response due to a lot of factors

Both!

Chronic stress creates cell oxigen deficiency. This could lead to multiple problems that are determined by one's genetic vulnerability, as well as enviromental exposure factors.  Anxiety and Depression are some of the adverse mental health responses to the above.

very good discussion.

It is especially  interesting to note how often the subject of the difference between anxiety and depression arises. For us in primary care, this distinction is not very clear.

if we observe patients in primary care, where they will probably be seen at the beginning of this pathological process, we notice that anxious-depression is the most common presentation of emotional distress, usually  associated with physical symptoms and diseases (hypertension and diabetes) which beginning can be traced to  stress producing events.

Many other factors interfere ( it is of course a multidetermined process) in its course and the evolution may include different types of anxiety and depressive disorders AND also several physical and functional ones such as diabetes and fibromyalgia.

several factors and mechanisms involved in these pathological processes are being discussed here. Understanding and treating these people certainly is a multidisciplinary task that need integrated models.

Take a look at:

Collaborative Care: Models for Treatment of Patients with Complex Medical-Psychiatric Conditions

Gabriel O. Ivbijaro & Yaccub Enum & Anwar Ali Khan & Simon Sai-Kei Lam & Andrei Gabzdyl

Curr Psychiatry Rep (2014) 16:506 DOI 10.1007/s11920-014-0506-4

Obversely, judging from our primary care practices - chronic stress, anxiety and depression may seemingly be seen as co-morbid, yet they are truly separate entities.

While chronic stress like PTSD is considered lifetime and life threatening disorder with no hope of leaving the mental institution, the adjustment disorder or stress response syndrome is usually dismissed after 6 months period of psychotherapy.

For anxiety, it is best left alone but more are getting help from CBT sessions.

When talking about depression, it is a no-no mess-up issue. The person undergoing depression is most likely to be put under ECT in not once but daily therapy. It could stretch up to 1 month or more depending on the patients' suicidal ideation.

It is not much about the caregiver issues but the patients' crumbling emotions resulting from scores of failures which sometimes do not exist at all.

The stressors could simply being mere disappointments over issues like not getting ideal jobs, over a one-sided relationship, an accident that could be preventable and so forth.

Yet the lamenting period exceed that of the mental space which makes the questions at hand seem more bigger than the brain itself.

Also, the way the chronic stress, anxiety and depressions are handled do separate the issues that we thought we could bind them altogether.

Thus, chronic stress could result in anxiety co-morbid depressions or found in combinations but the patients' emotional aspects, the ambiguous stressors and different treatment plan sure differentiate the triad interpretation altogether.

Mariam Ahmad, while I agree with your conclusion, some of your statements are in error, and readers should not accept them as fact.

"While chronic stress like PTSD is considered lifetime and life threatening disorder with no hope of leaving the mental institution,"

This is most certainly incorrect. Current research in PTSD is showing dramatic benefit, both for outpatient maintenance and for actual cure, by the mental technique known as transcending, specifically as taught by the Transcendental Meditation organization (I have no relationship with TM). CBT, which you also mention, has had some (but limited) success in treating PTSD. Also, peer support groups are helpful in maintenance of PTSD. This is not a disorder that necessarily requires a lifetime of incarceration in a mental institution.

"The person undergoing depression is most likely to be put under ECT in not once but daily therapy."

This statement, also, is completely incorrect. ECT is only one of many effective interventions for the various forms of depression. It is most effective for drug-resistant depressions, where it frequently provides rapid and lasting relief. For most patients, it is more appropriate to start with a mix of psychotherapy and antidepressant medication. This is well-known information, so your mistakes are really not excusable. I say this with respect, but with deep concern that your statements might be taken by some readers as authoritative.

I  appreciate the latest set of comments on here that have focused on psychopathology.

Just to clarify, my comments on here have been exclusively about distress/mood and not about psychiatric diagnoses. Although I have seen MDD in about 10% of 280 caregivers and 3% of 200 demographically-similar  non-caregivers, most of my interest has been in depressed mood and anxiety as distress and not clinical disorders.

We know that the brains of persons who have suffered from clinical disorders are different from persons without such disorders. This and the "measurements used" in non-patients and patients are enough to suggest differences in relationships of stressors with anxiety/depression in persons with and without clinical disorders.

Psychiatric patients experience a mismatch between appraisal and coping and mismatches are related to anxiety and depression. If a person appraises a stressor as being unchangeable and still continues to use problem-focused coping, is that a good or a bad thing? I and others have found that such people have greater depressed mood than persons whose coping matches their appraisal. Likewise, avoidance in situations where change is possible, is characteristic of higher levels of depression.

One of the hallmarks of mental disorder is that there is a poorer  fit between  appraisal and coping in  patients than in non-patients; and, one consequence is greater distress in patients.

Please, just  keep in mind that PTSD is considered a type of anxiety disorders.

Hi David Spector,

Honestly, I agree that your statement is somewhat true.

Unfortunately, I find no error in my statements and it is up to the readers to accept them as facts or fictions. Please note that as specified clearly, I am writing in my country context and not as universally accepted.

Truly, I do not tolerate the same treatment too as that is proven too harsh.

Yet  I have to stress that my findings are based on true personal observation in my country and the hospital that I was attached to.

I have seen how the patients are being worked up for the 3 mental disorders. Though PTSD is never a "lifetime incarceration", it is a practise in my country to "contain" them safely through medication and CBT then to allow them to be unattended outside the mental institution's premise.

With concerns to the ECT issues, it happens in front of my very own eyes how the patients were wheeled for their daily therapy. I was flabbergasted that I even checked with the primary doctors as to why the need to do so.

I was told that for as long as the suicidal ideation remains the topic of the day, the ECT therapy will continue.

You may have profound knowledge on all the treatment plans and their executions, unfortunately, not all countries, mine included, is opened to your esteemed suggestions.

Therefore, research or otherwise, we are dealing with real people and there have always been the dilemma of applying basic as compared to research method of treating patients.

The hospital's choice is more on the basic immediate and practical approach. It is not bent on research excuses of adopting one approach as compared to others - subjectively.

For your information, these group of people is not one but several. It is therefore not easy to just concentrate on one and do mind that we are professionals resource-limited.

To adopt your plan is easy but the responsibilities are divided.

I have never emphasised that my statements are authoritative. Rather, it is just mere discussions at country level as to what your people are doing against what we are adopting over the same issues that we are facing.

I do respect your courtesy but my personal observation facts and findings are unmistakably final, authoritative or otherwise.

Best regards - Mariam Ahmad

Dear Mariam Ahmad,

I must apologize that I fell into a bad habit of generalizing the clinical experience as it happens in my country (USA). I did not even think that perhaps another country could possibly be so dramatically different in how patients are treated. But now that I have read your response, I realize how ignorant I was, which is why I apologize for making assumptions.

I can understand how limitations of budget and of personnel could make a big difference in patient treatment options.

But I wonder if the difference here is more in history, belief, and institutional politics rather than in economics. I say this because the cost to cure or manage a PTSD patient by putting them into inpatient care is enormous as compared with the very low cost of teaching them transcending, which is a simple and natural mental technique, and enrolling them in a peer-support or similar supportive situation.

The USA Veteran's Administration is currently investigating whether transcending (using Transcendental Meditation in this case) can serve as an effective therapeutic intervention for the management or cure of PTSD. If the government of our country can pay attention in this way to research results and economics, why cannot the government of your country likewise consider this low-cost alternative?

Similarly, the cost of several rounds of ECT is much higher than outpatient procedures common in our country, such as medication, psychotherapy, and, again, inexpensive alternatives such as learning the practice of transcending.

I teach transcending to a variety of clients around the world as a nonprofit organization for less than fifty dollars per client. This is a truly cost-effective intervention. Several doctors and mental health professionals in my country send some of their patients to me for instruction in transcending, and they testify to the effectiveness of this technique for directly dissolving stored stresses.

If you are correct, and economics is the guiding principle in your country for the very specific treatment practices you have described, then questions and concerns arise that would not arise if the reasons for these choices are determined instead by history, beliefs, and politics.

In any case, I find it interesting that treatment approaches are so different in different parts of the world, and I hope that the patient and his or her recovery come first in your medical system's list of priorities. People and their recovery should come first, in my opinion. I apologize for my expressing my opinion so openly and readily, and hope again that you will accept my apology for my behavior and my passion for patients.

A very informative discussion. 

I am wondering where in the spectrum would you place the concept of 'Burnout'? If I may elaborate a bit: 

The pace of life arising from the influences of technology and mechanisation has increased rapidly in Ireland and I notice an increase in the degrees of exhaustion being experienced by deifferent age profiles.

My clients seem to be hyper-aroused, with verey high levels of expectation and demands of themselves.

They are   often being diagnosed as suffering from anxiety, stress or depression but I suspect it is neither. In my view it is 'running on empty' both emotionally and physically.

Would burnout fit in this discussion?

Dear Mr Bianchi, do you have any literature undermining your post. Thank you in advance.

From the perspective of a teacher of transcending, burnout is just another dysfunction resulting from the accumulation of stresses in the nervous system. If you are interested, you can read about our definition of stress and the processes of stress accumulation and stress release at www.nsrusa.org/about-stress.php .

While I find distinctions between different kinds of pathological processes interesting, being able to repair these processes gives me a very different perspective. The knowledge that I use to eliminate burnout, depression, panic attacks, chronic anger, and all the other pathological processes so common in society today has nothing to do with these various distinctions, and does not require analysis of a particular patient's problems, other than to evaluate whether they need traditional psychiatric intervention in addition to their learning the practice of transcending, which is the key to the natural elimination of stress from the nervous system.

I see nothing abnormal about a busy life, one filled with interesting and satisfying challenges, whether in Ireland or Israel or Iran. Stress is independent of challenge. Conversely, being free from stress gives one the flexibility and strength to take on any challenges free from the further accumulation of stress.

In other words, once a person is free from stress, that is the end of all pathological processes. Anxiety, depression, burnout, they are all gone, and gone for good.

I recognize as I write this that such a concept seems crazy, in a world where crazy is taken as being normal.

Yet everyone either knows or has heard of extraordinary individuals, Maslow's "self-actualized" people, who seem to take on great challenges without falling into depression, anxiety, or antisocial or self-injurious behaviors. These are people with less stress, people free of the pathological processes that seem so difficult to reverse.

The fact is that self-actualization is not only a random phenomenon. It can be cultivated in any individual through adoption of the fourth state of consciousness, the practice of transcending.

This is a solution to many of the problems faced by clinicians every day, just waiting for them to discover it, a solution, not a field of knowledge or an intellectual exploration, a goal already reached, not yet another wish or hope for the future.

We have the published research, we have the practitioners' own experiences and successes. What else is needed before transcending is recognized and adopted as an important part of the clinical treatment tools?

check out the concept of Adrenal Fatigue (Robert Wilson's book). It is similar to earlier concepts, but it is not buried in medical jargon. Many people believe that Alzheimer's is the Disease of the 21st Century, but Adrenal Fatigue is a very strong candidate. Check out Wilson's discussion of "cortisol steal". Depending on where people are in "burnout", "chronic stress", etc., cortisol steal provides a nice explanation of how long term stress can evolve into disease.

This is an interesting and complex question.Chronic stress leads to burnout phase of HPA axis. Anxiety and depression are overlapping syndromes that DSM artificially divided in two groups but it is known that anxiuos symptoms and melancholia are often together since classical period but we can remember anxious or reactive depression and endogenic melanchonic depression more prone to psychotic symptoms in Ey's psychiatry manual. Vulnerability to anxious and depressive diseases  are probably due to cognitive misrepresentation (see  Beck ) and genetic hypereactivity of HPA. Most probably anxious and depressed behavior were  vantagious for  evolution of the human kind but in our societies they became maladaptative behaviors (theory of  Cavalli- Sforza's selective balancing).  I hope my answer may be useful.

Remove the stress or reduce the stress. This should have a knock effect on anxiety by reducing or removing. I believe that depression occurs at a later stage, after stress and anxiety have been manifest for a long time. Can severe depression induce anxiety, again stress may be involved.  There is a complex interplay between the three, and mental health is not static but fluid and will move through an array of emotions and feelings that impact the mind, mood and physical state of the body. To improve the situation we are required to remove or reduce the stress. 

I agree with your view Abdulla, and like to add more. In most situations, not all stress can be avoided. you may need to focus more on reducing the stress rather than removing the stress. Also, we can talk about decreasing the consequences of stress by improving coping strategies and resilience especially when stress is chronic. 

The stress-vulnerability (stress-diathesis) model is a really useful and deceptively simple framework for understanding some of the factors relating to risks for onset and recovery from mental health disorders such as depression and anxiety. It adds nothing to the depression vs anxiety discussion, but does help provide a conceptual model for understanding the relationship between the most important contributing and mediating factors. 

Thanks, Ilaria and Renzo. Anxiety and depression- different sides of the same coin.

Of course, we do not want to make life less interesting by reducing its challenge. We want to increase the strength and flexibility of the nervous system, so that challenge makes us happy rather than depressed, anxious, or miserable. There is only one way to dissolve and eliminate the dysfunctions that weaken the nervous system.

Hi David,

There is an optimal level of stress in life, but the optimum level varies greatly between individuals. Some people are highly robust, some are very vulnerable or chronically unwell. Most of us are somewhere in the middle. However, if you place enough stress on anyone, no matter how robust they are, they will exhibit symptoms of mental illness.

http://www.bhevolution.org/public/stress-vulnerability.page

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Sometimes we can't improve the coping skills or eliminate all dysfunction. And sometimes otherwise healthy people are experiencing these symptoms in response to serious trauma or intolerable environments.

There is more than one way to approach these issues.

Professor Peter Tyrer, editor of the British Journal of Psychiatry, argues that his profession practises "mental colonialism" on people with long-term, chronic mental illness that's resistant to treatment. His alternative approach is called Nidotherapy - (Nido meaning 'nest') - focused on changing a person's environment not their personality.

"Nidotherapy is named after the Latin word nidus, or nest, and of course it describes a natural form of environment, the nest, which actually accommodates to anything which fits inside it, whether it's a round thing or sharp thing, or pointed, or parametal, it doesn't matter what shape it is it will fit into a nest. And so the idea behind Nidotherapy is that we say look, we accept that things aren't entirely right with you but rather than force you to fit into the environments we have around us what we'd like to do is, it's a form of reverse Darwinism really, instead of all fighting to be in the same environment therefore we've got to try and make you like everybody else, we actually create an environment for you; in all its forms, not just a physical environment, where you feel at home and free of distress and this may not involve changing you at all. The important thing is to realise that we all practise Nidotherapy in many ways in our own lives, we are organising our environments in various ways to suit our ability to fit in"

http://www.abc.net.au/radionational/programs/allinthemind/nido-nest-therapy-top-psychiatrist-issues-strong/2960628

.

See;

Nidotherapy: making the environment do the therapeutic work

Peter Tyrer, Priya Bajaj

Advances in Psychiatric Treatment Apr 2005, 11 (3) 232-238; DOI: 10.1192/apt.11.3.232

http://apt.rcpsych.org/content/11/3/232 

.

Regards,

Paul.

Paul, Thank you for the information about Nidotherapy, which appears to modify the environment to suit the illness, at least at the start.

When I wrote, "There is only one way to dissolve and eliminate the dysfunctions that weaken the nervous system," I meant that literally and specifically. I wasn't saying that there are no alternatives to standard therapies for mental illness. There are many.

In transcending, which I have discussed elsewhere in this forum in some detail, the environment is not usually investigated or changed. Life is not made easier for the patient.

Avoiding external challenge, which you call stress, is not at all a good thing. It only encourages the disorder, whether it manifests as anxiety, depression, jealousy, phobias, etc. As soon as the triggering external situation arises again, the patient is again unable to cope, or overwhelmed by their particular disorder.

Instead, using transcending, the patient is gradually strengthened starting from their current state to a stronger state, and this is done not just through any alternative method having anecdotal results, but one that has received considerable scientific research. The results I claim have been measured using instruments such as STAI Form Y, confirmed reliable ways to measure psychological and physical states of the nervous system and body.

As a teacher and distributor of the NSR course I see people of all backgrounds (normal, mentally ill, and mentally ill with treatment resistance of various kinds) showing immediate improvement through this effortless, natural, and automatic mental technique.

I continue to see improvements throughout the months and years, generated specifically by 15 minutes of effortless practice morning and evening. This is not only the only way to truly eliminate internal stress, it is affordable and pleasant as well.

I am the only provider of support for most NSR clients, who number in the thousands. I could never provide adequate support to these thousands without the phenomenal effectiveness of NSR as an individual practice. The fact is that most clients never need any support; individual practice is enough to gradually improve their quality of life over the years, based on the clear and specific instructions provided to them in the NSR course.

I am not trying to create a conflict situation between transcending and other treatments for mental illness. When the difference in effectiveness is this great, there is no conflict.  I am only trying here to show its basic difference, which is in actually eliminating the internal stresses, dysfunctions of the nervous system that cause suffering in the life of the patient.

When I say "internal stresses", don't think of the challenges of life, such as a car accident or a boss criticizing an employee. These are not the immediate or root causes of the patient's current disorder. A fully healthy and autonomous human being can easily endure a car accident or a dramatic interaction with a boss. A healthy human being is creative, intelligent, peaceful, happy, flexible, and fulfilled, regardless of their environment.

My definition of stress is given in the short article at www.nsrusa.org/about-stress.php . It is a definition of what happens in the nervous system when it is continually overloaded or abused for years. It also admits of reversal: of the possibility of eliminating the stored internal stresses through a unique state of deep rest known in the Indian spiritual tradition as samadhi or turiya and produced by encouraging the natural tendency of the mind to move in the direction of greater peace and happiness, greater internal satisfaction.

Thank you for this opportunity to clarify my brief comment on the value of transcending in the context of psychological disorders. As I have said here, this is the reason that psychologists and other mental health professionals refer some of their patients to the NSR course.

Hi David,

Please do not take my comments (below) as oppositional or combative. I would like to tease out some of your statements (above). I'd like to continue this conversation.

I have been a martial artist for more than 35 years, and was introduced to zazen and mindfulness meditation exercises by my teachers at an early age. Mindfulness is a very useful tool for regulating stress. If I feel anxious I will "belly breathe" for a few seconds and the sensation passes very quickly. I don't think this is due to redirecting my ki (chi), nor is it magic or due to any spiritual powers. I believe it is because several years of mediation has conditioned my nervous system. If I breathe deeply and consciously my pulse immediately slows, and I suspect that my brain down-regulates cortisol and other stress hormones. It's just a learned, conditioned  response. 

If they are suffering anxiety I do encourage my clients to at least try mindfulness exercises (including mediation), when appropriate for the individual. I do not encourage them to join a transcendental meditation group, as I have met a number of fraudulent and exploitative practitioners of TM.

Your definition of stress (in the second last paragraph above) is rather eccentric. People may experience episodes of acute stress (such as the car accident or argument you mentioned in your reply), and they may also be subjected to chronic stress. Chronic stress can activate the same cascade of hormones and neurotransmitters that acute stress triggers, and these chemicals modify brain activity and the body's metabolism. If this is unresolved it causes the symptoms we identify as anxiety and depression.

For example, the acute stress response causes your body to reduce protein synthesis, reduce digestion, increase sweating, down-regulate immune responses, increase blood sugar levels and blood clotting factors, restrict peripheral blood flow in the extremities whilst raising core blood pressure and pulse rate. These are adaptive responses to episodes of acute physical stress; your body is temporarily redistributing physiological resources to help you fight or flee as efficiently as possible, and to limit your bleeding if you are injured.

However these responses are not adaptive when the acute stress is something you can't fight or run away from. When someone who is nervous about public speaking is put "on the spot", it is the same cascade of cortisol, adrenalin, and other chemicals that makes their mouth dry, makes them tremble, blush and break out in a sweat.

And these same physiological responses can lead to serious problems with physical health if they are activated chronically.

In a similar fashion, depression and anxiety are adaptive, in that they cause an organism to modify it's environment, or to modify it's own behaviour, to avoid threats. They are maladaptive if the threat is a stressor that cannot be avoided and especially if it is chronically present. The symptoms of PTSD (sleeping lightly, hyper-reactivity, suspicion of the motive of others etc) are highly adaptive to some life circumstances, (such as being a combat soldier, a refugee in a war zone, a vciitm of domestic violence etc). These behaviours are only symptoms of a disorder when they persist after the sufferer has left the traumatic environment.

You wrote; "Avoiding external challenge, which you call stress, is not at all a good thing". I tend to agree with this generalization, within certain limits. However there are many  stressors (external challenges) in life that you would be well advised to avoid, if you want to preserve life and limb.

You also wrote; "A fully healthy and autonomous human being can easily endure a car accident or a dramatic interaction with a boss. A healthy human being is creative, intelligent, peaceful, happy, flexible, and fulfilled, regardless of their environment." and I find this last sentence simplistic and somewhat naive.

By "serious stress" I don't mean a car accident or an argument. I work with people who suffers co-occurring problems with mental health and substance use.

Some of my clients have suffered chronic homelessness and social and economic disadvantage their entire lives.Many come from backgrounds of child abuse or domestic violence. Some are refugees from wars or from ethnic cleansing and persecution.

So, try the following thought exercise;

Try to imagine growing up in Burundi or Rwanda and seeing your family killed with machetes, being forced by the people who massacred your village to fight as a boy-soldier, then spending your teens in a refugee camp in Tanzania, and finally finding asylum in a country with a completely different language and culture to your own, where you had no income and no social supports at all. I suspect given such life circumstances, you might have arrived at a different view of the relevance of an individual's social and physical environment to their mental well being.

Now try a different thought experiment. Imagine you are exactly who you are now. Do you really think that nothing in your external world could adversely affect your mental well being? You obviously derive pleasure and self worth from your work. Helping other people is deeply and intrinsically rewarding. Imagine losing all of that. Imagine loosing your home, family, social supports, and anything that is rewarding engaging and worthwhile. Imagine being subjected to powerlessness and severe trauma. As an extreme example, imagine you are falsely suspected of involvement in terrorism, "disappear-ed" and you end up somewhere like Guantanamo Bay.

No matter how autonomous and healthy an individual is, if your life circumstances changed abruptly and for the worst it would have an adverse impact on your state of mind.

I hope these points are enlightening or provoke some thought and reflection,

Yours sincerely,

Paul.

Actually, I can resonate because although I did not experience such horrible circumstances, I certainly did not come from privilege. I am a contrast to the vast majority of American professors who do come from privileged backgrounds. The people whom Paul has described make people such as myself look like we are royalty in terms of life circumstances and life development. 

Another message here is that "you can read all you want about how to ride a bike, but unless you get on the bike, you will never know how it feels......." I have met so many good hearted and well-meaning professors who have no idea how it feels to grow up in an American family and have a parent who can not read English or a parent who does not do work that is considered to be prestigious.

What is really important about Paul's comment is that resilience is very difficult in the face of great vulnerability........I mean vulnerabilities that are hard to change (genes, womb environment, first few years of life, trauma in the home such as sexual and physical and psychological abuse, oppressive and dangerous environments throughout life). I do not know the circumstances of the person he "imagined from Burundi or Rwanda, but the vast majority of those citizens are not in safe environments. People who can overcome these obstacles are saints in my book.

I recently attended a presentation at my university where the so-called Stanford Resilience Project told 1000 students that they wanted them to understand resilience using the exemplars who were on the podium. Everyone on the podium was a white professor who  came from privileged backgrounds, save for one African-American who experienced great hardship and overcame it. I thought that the examples the others gave of their resilience were ridiculous. One of the people was a former student/ basketball player from Stanford who said that "it was so difficult for her to be resilient and overcome the fact that she could not play in the Women's Basketball Association." Wow, she had to overcome such great obstacles....I really feel her pain...........what a great example of resilience!?!  She managed to graduate from Stanford, is white, healthy, has a degree in computer science ...........

The description by Paul Dessaur above really speaks to resilience in the face of great vulnerability. It is people such as those that he described, whom I really respect and admire.

Paul, Thank you so much for your thoughtful and sometimes unexpected responses to my points. It was fascinating to read, and I can see clearly how differences in our backgrounds have shaped differing points of view. I wish that you and I could sit down for an hour or two and really communicate deeply. Unfortunately, we cannot spend the time here in this research forum to really explore our differences in the depth they deserve. If you are sufficiently interested in continuing the discussion to take it off line, I would love to spend more time with it, and with you. You can reach me by email in private by using the Contact Us form at www.nsrusa.org to initiate contact. I'd love the chance to respond in depth to each of your comments. I feel we both could learn from an extended discussion.

Hi Peter,

The story about growing up in Rwanda is not really imaginary, it is a genuine case history. I've worked with people from other African nations, and from ethnic minorities in Burma and Sri Lanka, with similar life stories. Some of my work here in Australia is with Aboriginal people from remote communities who suffer the compounding effects of inter-generational and ongoing trauma and disadvantage.

Many lifestyle factors impact upon people's mental health or ill-health.

Some readers may be interested in the attached article by my colleague Rob Donovan. His public health work applies the principles of physical health promotion campaigns to mental health, and is informed by the understanding that mental health is more than simply the absence of mental illness.

Regards,

Paul.

Hi Paul,

I very much appreciate the work you are doing in Rwanda.

Perhaps we could talk some time about my interest in working with grandmoms in Subsaharan Africa who are caring for grandchildren whose parents have died of AIDS.

Talk about resilience!! They have not only lost their children, but now have to be parents, yet again. And, they do not have great resources. What is truly mind boggling is that there are approximately 450K of them in Subsaharan Africa.

Thanks Peter, but just to be clear, I have not worked in Africa. I have worked briefly in Myanmar (Burma) and in Yunnan Province in China.

I work in Western Australia, but much of my work is with people who come from backgrounds of serious economic and social disadvantage and trauma. And some of them are refugees from war-torn countries, or who are escaping from persecution due to their ethnicity or religion.

I am very interested in the factors that increase resiliency in the face of such forces.

Thanks to you too, David, for your reply.

As you pointed out, we are straying from Ahmad's question. If either of you would like to continue chatting, just message me privately via RG.

Regards,

Paul.

Chronic low resilience is a consequence, as is anxiety, of pre-existent, unrecognized depression and not the cause.

The problem lies mainly in the lack of any precise and stable definition of depression. Failure of any sensitivity's study of various test precludes any statement about lack of pre-existent depression. This notion is, however, basic for considering causality.

Bernard Maroy, Thank you for this clarification. It sounds right to me.

There is a theory of stress (www.nsrusa.org/about-stress.php) that explains how and why stress builds up in the nervous system over time.

This fundamental concept then leads to an elegant and predictive explanation for much of abnormal psychology, including anxiety, fears, phobias, drug-seeking behavior, some forms of depression, criminality, and a major factor in most other prevalent negative issues such as poor self-worth, poor anger control, mental distraction, poor work and school performance, and many stress-based disease processes, such as anorexia, bulimia, obesity, BPD, ADD, BDD, etc.

Understanding the likely basis of abnormal psychology is valuable in guiding both preventive and therapeutic interventions, suggesting that effective and easily learned mental techniques for permanently, easily, and naturally dissolving stored stresses, such as transcending (through existing courses in Transcendental Meditation, Natural Stress Relief, and others), which have been shown to have direct and indirect benefits in many aspects of life, deserve wider acknowledgement and use in society.

Dear David I am far from thinking that stress is always pathological.

However, if you mistake causes and consequences, you can't thick clearly.

I suggest you 2 papers.

Bernard Maroy, Thank you for the papers.

You give many more symptoms for depression than the DSM, which shows your good observation. (Of course, the DSM is designed for use only for research categorization, but is often misused as a source of disease definitions.)  You only recommend the standard treatment for depression, ignoring transcending entirely as most clinicians do.

Your definition of stress is very different from mine, so take care not to compare apples and oranges. You appear to focus on external challenges, whereas our definition focuses on the resulting dysfunctions of the nervous system, which tend to last the rest of one's life, far beyond the time of the original overload of experience.

It is not external challenge that causes problems, disorders, and disease. The proof is that certain people with very strong nervous systems can tolerate very high levels of external challenge with no adverse effects.

If you would only read www.nsrusa.org/about-stress.php you would understand the difference in our approaches.

Your agreement with the usual definition of stress is why you caution that stress is not always pathological. Technically, our definition should be of distress not stress. But 'distress' is already a common English word with its own meaning.

One key characteristic with our definition of stress is that stress is always pathological. This is why our definition is so helpful and predictive.

I think I have given you a good response, but I don't want to get into an argument, so let's leave it at that.

If our definition of stress is as useful as we find it to be with our thousands of clients, it will prove itself over time with no effort on our part to push it against the prevailing theories. I only hope that my well-worded overview here is of help to someone.