by Dawn Garisch
How robustly the OFC develops in early life has enormous consequences. Where physical neglect is extreme, as was documented in some state-run Romanian orphanages towards the end of the twentieth century, there was almost no development or electrical activity found in the OFCs of these young children.
Megan Gunnarv47 observed that mothers responded differently to their children's distress. Those who had good rapport with their children had little trouble in calming them when they were confronted with a strange situation. In contrast, mothers with insecure attachments had difficulty in reducing the fear in their children. Gunnar says, ‘They seemed to think it was their job to change the child, to make the child look bold. ’ She notes that secure attachments absorb the anxiety from strange or scary events. Without this buffer, children suffer more stress. Gunnar concludes that ‘The secure children seemed to be saying, “This is scary but I feel safe.” ’
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We can see in animals that have been abused how their fear response has been distorted. A friend took a stray on as company for his dog. It soon became evident that the stray had been viciously and randomly hurt. Whenever there was a loud noise or a sudden movement, the dog would freeze, shaking and trembling, sometimes voiding urine, and on occasion, he would turn on the other dog unprovoked and bite him. Nothing the caring and patient family could do would change his habitual response. His circumstances had changed, but he could only interpret the world in the way he had first experienced it at the time his brain was developing. In response to a perceived threat, all he is able to do is either dissociate or become aggressive himself. The dog is becoming increasingly difficult to live with, and my friend is concerned for his other dog's safety.
People who have been severely traumatised during the first years of life might also behave in extreme and destructive ways. A man in a pub who observes another man looking over at him with a particular expression might punch him. In a similar way that the knee-jerk reflex involves a stimulus followed by an immediate reaction – the leg kicks out – the man in the pub hits out before he stops to consider his perception and his options. Such reflex actions do not allow other information in.
In the knee-jerk this is as it should be; the reflex helps to maintain posture and balance, and allows one to walk without consciously thinking about each step. In the pub scenario, however, the man has his perception of threat hard-wired to memories linked to a habitually aggressive reaction, creating problems for himself and for those around him. If he were able to access the magnificent benefit of the frontal cortex, a network of neurons would be activated where he could reflect on his impressions and assess his options for a nuanced response.
Damasio proposes that consciousness emerges as images rather than words; by images he means patterns established in the brain by any stimulus: emotion, smell, movement, touch, sight. He says, that in any situation, in order for us to choose an appropriate action, we need to be able to refer to a bank of good internal images constellated from previous experiences. We are then able to review a range of images that represent different options, different scenarios, and different outcomes before we act. Good actions, he maintains, need the company of good images.48
Recent findings show that the brain remains capable of change throughout a lifetime. It is possible for someone like the man in the pub to release himself from the terrible bind of poor responses and choices. If he makes meaningful human connection with another who has the capacity – unlike his original caregiver – to provide a relationship which acts as a container of care, the neural circuitry in his brain can reset itself by making new connections.
This is the cornerstone of psychotherapy and is present in the mentoring system offered by twelve step programmes like Alcoholics Anonymous.
A premise of this book is that if we are activated by disturbing events, yet manage to resist the knee-jerk response, engaging in creative acts can assist us to imagine and to think in the pause. It can help us to develop our internal images which might release us from the habits that bind us.
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11. Not Waving, but Drowning
i'm thinking: my nightmare smoking, thinking, smoking
what am i going to do about that, the encroachment of the neighbour's wall the
inbox choking with e-mails everywhere the world tilting towards me the day so
get up at night, four in the morning, get it started so i can push back
Alan Finlay49
The Archives of Neurology50 published a case in 2003 of a man who developed paedophilia at the age of forty. Despite knowing that his obsession was unacceptable, he could not restrain himself from acting on his impulses. This destroyed his marriage and resulted in a prison sentence. Just before going to prison, he developed terrible headaches and went to an emergency room where a tumour of the OFC was discovered and later removed. After surgery, the drive for sexual behaviour towards children disappeared.
This case study of a rare cause of an obsessive-compulsive disorder illustrates both the site and intransigence of defective impulse control. Tension and anxiety builds incrementally until the sufferer acts in order to get relief, even though the consequences of acting might have predictably negative and even disastrous consequences. The sufferer acts, even in the knowledge that the relief will not last, and that the compulsion will repeat itself endlessly. To understand the failure of impulse control in addiction in all its guises – sex, drugs, gambling, alcohol, eating, cutting, smoking, and even shopping – one must recognise that an addict only feels normal for the brief period after he or she has acted on the compulsion.
The hallmarks of addiction, according to the twelve step programme, are deceit, denial, justification and manipulation. An addict has to have access to a regular fix, and his day is organised around this need, using these four tools to get it.
All these features of addiction are present in our contemporary way of life. Our consumer society has trained us to expect immediate gratification, with credit cards forced on us from every direction, with fast foods available day and night without even having to get out of the car, with instant foods and beverages. Nowadays you can buy an instant lawn, or even an instant bonzai, the very symbol of a slow and patient art.
Most of us have some form of compulsion. We live in an addictive, hyperactive, attention-deficit-disordered and entitled society. We are anxious. We want relief, and we want it now, no matter whether we, or the earth, can afford it. We trade temporary, superficial relief of our immediate suffering for permanent disability and disaster.
Addicts are the very last to know that they have a problem, even as their lives fall apart around them. Denial runs deeply in all of us, yet it seems counter-evolutionary. It seems to fly in the face of the life-force itself, which sends out increasingly urgent distress signals in the form of illness, accidents, pollution, plagues, water and food shortages, extinctions and increasingly violent natural disasters.
In my career as a doctor I have seen many people eat, smoke, drug, drink and stress themselves to death. Contrary to logic and the drive towards life, we are capable of killing ourselves through obsessive-compulsive behaviours, anxiety and denial. The consequences of these human tendencies: pollution, destruction of ecosystems, over-exploitation of natural resources and overpopulation, may well be fuelling climate change.
That is something to be anxious about.
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Stress is a normal part of life, part of the call to action and change, but the unrelenting, pervasive nature of stress in the modern world is a serious problem. In physics, stress is the term for a force or system of forces producing deformation or strain. In human life it implies a situation where the individual has to endure something, or is making efforts, beyond the limits of his capacity. Eventually, something has to give.
Many of my patients work too hard and too many hours, whether they are executives or shelf-packers. Often they are doing the work of two people. When ill, many refuse to go off sick; instead they eat a handful o
f pills and go straight back to the workplace. They don't have time to develop other aspects of their lives, from their relationships to their creative pursuits. They default on exercise and on eating nutritious meals. Some of my patients subsist on fast foods. They get bladder infections because they don't have time to go to the toilet. They take their problems to bed with them, and worry into the night. They do not have time to stop and pay attention to what is happening to them.
When we fail to identify this as abuse, we fail ourselves. Collectively, we do not challenge the way that things have been set up. Human beings created this system, so it is possible for human beings to change it.
Anxiety and stress activate the neural and endocrine pathways that prepare the body to resolve the cause of the problem – flight, fight or play dead. The hypothalamus in the brain, working via the pituitary gland and the sympathetic nervous system, stimulates the adrenal glands to release adrenalin, noradrenalin and corticosteroids. These are called either hormones or neurotransmitters, depending on where they are found in the body, but in 1984 the neuroscientist Francis Schmitt suggested that the whole gamut of these agents should instead be called information substances.51 Dozens have been identified that are associated with our emotions and the physiological changes that accompany them.
The information molecules released by fear and stress, heart rate, blood pressure and blood glucose. They divert blood away from the digestive tract and towards the brain and skeletal muscles. Emotionally, we might experience this as a pounding heart, sweaty palms, tense muscles and butterflies in the stomach. We become primed for action to resolve the situation, and to release and move on from this physiological state. In the modern world with its pervasive and layered stressors, the cause of the stress is not so easily dispatched. It is like being all dressed up with nowhere to go, and we end up chronically stimulated for a response that is curtailed.
Persistent stress causes a protracted increase in the information molecules released to resolve the situation. Chronic exposure to these agents results in a decreased sensitivity at the receptor sites, which causes more to be released, with a subsequent build-up of the molecules.
Dr Candace Pert proposes that this situation results in a disruption of the normal fluctuations of other hormones and neurotransmitters in the body;52 consequently the flow of information, processes and emotion necessary for optimal health are jeopardised. We become sick. We lose concentration and have an accident. The body trips us up, asking us to reconsider.
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12. Denial, Deception and Illusion
on the frontlines the mirror the paper the morning news closely shaves off the edges of the real world
Kai Lossgott53
A patient came to see me because she had lost her temper at work and had walked out. She was very upset with herself as she had never done this before.
She identified herself as someone who is good at helping others. She works long hours, often with unpaid overtime, for a demanding employer who hardly ever takes leave herself. This woman is the kind of person who has extreme difficulty saying no to anyone else, although she says no to herself and her body all the time – a body that is increasingly overweight, exhausted and in pain.
Interestingly, she is also unconsciously saying no to her daughter, to whom she does not pay much attention because her job takes up so much space and time. The daughter is exhibiting distress signals too, under-achieving at school and overeating.
On taking a medical history, I discovered that this woman has atrial fibrillation, a condition where the entry chambers of the heart do not contract properly, sending irregular impulses to the ventricles, which in turn cause an irregular heart beat and pulse. This condition is associated with an excess of stress, alcohol, nicotine- and caffeine-containing substances like tea, coffee, colas and some medications. If the normal rhythm of the atria cannot be restored by addressing these aggravating factors, or through medication or electric shock therapy to the heart, then blood clots can form in the atria due to the turbulent blood flow. These can break away and become lodged in the brain, depriving neural tissue of oxygen and causing a stroke, resulting in disability or death. It is therefore essential for such patients to take a blood-thinning medication called coumadin.
Taking coumadin itself can be hazardous: if you take too much, you can haemorrhage, and if you take too little it won't be effective. To ensure that the patient is taking the correct dose, her blood must be tested every three to four weeks. Even though this patient knew why it was essential to have her blood checked, she told me she had been too busy to do so for over six months.
Many physical difficulties we see in the consulting rooms are self-inflicted. People usually have the means to keep themselves healthy and to help themselves to heal, yet curiously we often choose lifestyles that run counter to health and healing, and which make enormous demands on the restorative capabilities of the body.
A doctor is a consultant in the field of health and healing, and must advise a client concerning matters of wellbeing. This includes trying to help a patient break through self-deception. Most of the time this is an unbelievably difficult and dispiriting task. Many people persist with denial even in the face of crippling illness. As an intern I was impressed by the attitude of an obese woman who was admitted for a diabetic complication. After receiving life-saving and costly interventions, her blood sugar was restored to normal. As I was doing the paperwork at her bedside to discharge her, she admitted that she could not wait to get home for a lovely white bread sandwich with peanut butter and syrup.
On another occasion I was on duty in the obstetric ward when the flying squad arrived, sirens blaring. They brought in a large woman who had started haemorrhaging six months into her pregnancy. This can happen if the placenta starts to come away from the uterine wall. The likelihood of losing the baby in this situation is high. It was her first pregnancy, and she was understandably distressed. She said she could no longer feel foetal movements. The drip was up and running, and we immediately sent blood off for cross-matching. When we could not find a foetal heartbeat on the monitor, we feared the worst. But the ultrasound showed no pregnancy. The woman was having a normal period. In her desire for a child, she had stopped menstruating for six months, had put on weight, and had felt foetal movements.
As a doctor I deal with denial every day, and I need to understand it better. As a writer, it is a fascinating aspect of the human condition. And as a human being, I have had to face my own capacity for not seeing things that were staring me in the face.
Denial prevents us from having the insights necessary to fuel appropriate action, such as acknowledging evidence that a revered leader has turned out not to be an honourable man and is instead a poor role model, or that a loaf in the supermarket labelled ‘health bread’ contains artificial ingredients and has a token coating of whole wheat.
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My in-tray today contained a glossy pamphlet advertising a conference for medical professionals entitled ‘Medical Aesthetics’. On the cover was a soft-porn shot of the face of a young blonde model picked for her child-like features. Her full and perfect lips were suggestively parted. Held vertically up to her mouth, the tip of a needle attached to a syringe was about to penetrate her lacquered upper lip. The subliminal associations were: oral sex, paedophilia, abuse, addiction, and fixing something that is not broken.
Which is about right. The underbelly of plastic surgery is about retaining the illusion of youth, sexual appeal and availability through abusive and addictive attitudes to the body, which is deemed never good enough.
This meeting is not a couple of hours after work. It is a four-day extravaganza, with four international speakers and a long line-up of local practitioners. Topics include:
• Treatments to improve the external genitalia's aesthetic appearance
• The difficult lip
• Non-surgical options for nose reshaping and African nose treatments
• Peels and other resurfacings
• Rejuvenating neglected areas
• Home devices
• The ageing athlete
• The exploding male aesthetic market
We all have something about our bodies that we do not like. Whatever it is, if you have the money, you will be able to find a doctor who will be prepared to alter it for you.
As I am growing older, my body is changing. It comes as a shock to see evidence of the passing of time etched into my own tissues. And it appears to have arrived overnight. I glance at my thighs and notice small red veins sprouting under my skin. In the mirror I see sags around my eyes, and a slackening around my jaw.
My first impulse is surgery. Cut it off, take it out, laser it away, whatever. Restore me to myself, whatever that is.
I rein myself in, caught between the shame of ageing and the shame of feeling ashamed of ageing. I decide that I will only go for plastic surgery when I am completely comfortable with the way my body is as she grows older. Of course, when I am comfortable with how I look there is no way I will let anyone near my face with a knife.
I have a sense that, when we side with an idea of perfection and try to rid ourselves of everything that hints at imperfection, we become increasingly lopsided, alienated from the totality of who we are. As a writer, I know how much character matters. The idiosyncrasies of my physical shape and facial contour are important to who I am. These attributes are accentuated and given more definition by time.
An hypothesis: Coming to terms with my face is coming to terms with my life.
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Professor Loyal Rue in his book By The Grace of Guile points out that our understanding of ourselves and of the world is a construct based on perception, and the meaning we attach to that which we perceive. We are perpetually flooded with information about our inner state and that of the exterior world, and often the information is in conflict.