lördag 23 juni 2007

Total exhaustion of the system/total utmattning av systemet…

Total exhaustion of the system because of long term hidden (and/or denied) stress in older age... When the defenses are getting weaker and you start to remember things from childhood you haven't remembered earlier (in the middle of life, with a lot around, and/or now you remember in a need to make a summary of your life?) and on top of this you are getting weaker physically too...

Starting to remember when you aren't in the same power or control any longer as aging...

Things you haven't processed... Things you aren't even prepared to at all??

Things made me think on a lot of things, in a lot of threads… About the HPA-axis again, a breakdown in the whole system, about earning love, about the power of narrative…

Anna Luise Kirkengen writes in her book How Abused Children Become Unhealthy Adults” (“Hvordan krenkede barn blir syke voksne” ISBN 82-15-00713-9, which still only exists in Norwegian as far as I know, but there is an excerpts of the book translated to English on the net).

I am going to quote from the chapter Destructive Impactpages 24-27 in the English excerpt (pages 36-39 in the Norwegian book).

Kirkengen writes:

Let us now explore how destructive effect of early negative, silenced and hidden experiences can be understood. The study by Felitti and his collaborators showed a quantifiable correlation between such experience and future health problems which could be demonstrated as much as five decades later. For example, such a connection could be documented regarding heart and vascular diseases. The authors of the latter study write:

We found a dose-response relation of ACEs to IHD and a relation between almost all individual ACEs and IHD. Psychological factors appear to be more important than traditional risk factors in mediating the relation of ACEs to the risk of IHD. These findings provide further insights into the potential pathways by which stressful childhood experiences may increase the risk of IHD in adulthood.

This conclusion is supported by a study of 6000 adults of the correlations among serious illnesses and physical abuse, sexual abuse and overall neglect. The study shows that physical abuse leads to increased risk for lung diseases, gastric ulcer, and rheumatism; neglect leads to increased risk for diabetes and autoimmune diseases; sexual abuse leads to increased risk of heart disease as well. Also, a population study of 1359 women and men at an average age of 75 showed a correlation between childhood sexual assault and diseases of the thyroid gland in men and both arthritis and breast cancer in women.

With that, we are back to my two female patients who died of breast cancer. Both had grown up in so-calledstricthomes. They spoke of abuse, meted out in the name of discipline and parenting, as well as of the adultsuse of alcohol and their socially unacceptable behaviors that had to be kept secret. Already as young girls, both women had taken on the task of concealing the family’s social shame. They were not simply overly responsible but were also powerless to fulfill the impossible assignment they had taken upon themselves. As a consequence of their childhood role as the family’s social worker, both women were in effect predestined to serve as overly responsible rescuers of violent men without ever daring to resist or protest.

I want to link the histories of these two women to general knowledge about neuroimmunological and endocrinological trajectories toward cancer. Throughout many years, both women had been in a state of constant alert fearing the next unpredictable outbreak of violence. Is it fruitful to reason that such a mental condition, enduring the continual experience that one’s life and health may be at risk, nourishes the development of cancer? There exists strong documentation of the negative impact on the immune system of so-called distress, that is, emotional overload. Experimental inquiry into that correlation has taken various forms. In immunological studies, ‘natural killer cellsare central objects for study; in studies of hormones, the role of cortisol holds an important place. Natural killer cells are measurably suppressed in research subjects exposed to stress, for example intense noise, as many as 72 hours afterwards, but only if the subjects believe that they have no control over the noise. The same noise level over the same period of time does not have the same effect, however, if the subjects believe that they can turn the noise off, even when that is not actually the case. In other words, the determining factor is the person’s own perception of either authority and control, or impotence and the feeling of being at the mercy of their circumstances. The person’s subjective experience that his reality is overwhelming and unyielding weakens his natural killer cells. The effect is intensified by repeated experiences of powerlessness, and even more so by chronic powerlessness. This paves the way for pathological cells to take hold in the body’s tissues and organs.

Subjective interpretations also affect the hormonal interplay between the hypothalamus, the pituitary gland and the adrenal glands, the so-called HPA-axis. There now exists a considerable body of documentation regarding these hormones, particularly as to their effect on the naturally fluctuating daily production of cortisol. The concept ofallostasiscomes in here. Allostasis means stability through change and it includes all the internal systems that make possible a flexible accommodation to both routine and shifting daily life. An allostaticloadingarises during repeated experiences of danger. It has been measured during long-term strain as in social crises such as war and emergencies, during school examinations, when experiencing grief, loss of livelihood, and divorce – as well as during the ongoing suppression of strong feelings such as while providing long-term care to a partner with Alzheimer’s disease.

The loading is reflected in continually hyperactive cortisol production. This brings with it all of the known consequences accompanying raised levels of cortisol: weight gain, elevated blood pressure levels, disturbances to blood sugar regulation, loss of skeletal minerals, just to name the most central effects.

In short, people subjected to a sense of chronic powerlessness develop such conditions as osteoporosis because of chronically elevated levels of cortisol. It is very tempting to place this hormonal causal relationship into a more. complex system of potentially convergent phenomena. It could be, for example, that rather than considering osteoporosis, and many other conditions, an epidemic it ought to seen as part of a syndemic. The concept of a syndemic was introduced by anthropologist Merrill Singer in a study of three interacting, mutually impacting, and mutually intensifyingepidemics”: narcotics abuse, violence against women, and AIDS.”

Self destructive behaviors and life styles, social problems… If it isn’t directed at others in destructive behaviors of different severity (even to the worse criminals, such as Pincus has described)…

Kirkengen also writes in Intensions and Introductionthat she with this book about how violations of integrity leads to sickness and want to address all those which

“…come in contact with people, old and young, who are being hurt or have been hurt in the past by other people’s lack of respect for their personal integrity.” *)

The initiatives must have as their goal the prevention of humiliation, violation, injury or abuse, particularly of people who are young and dependent. They must also aim to insure that all people, regardless of where they are or where they go, can trust that they will be valued and treated with respect. Laws must have as their aim that all people, especially those who are small and dependent, who have already been humiliated, violated, injured or abused receive the help they need, and in abundance. They must also aim to insure that all people who have been treated with disrespect or contempt can regain their sense of self-worth and self-respect.

*) Where every persons personal integrity isn’t only about the sexual or physical integrity, but also the emotional. Not violating any of those boundaries. To show deep respect, not least against children and the ones that are still growing… I came to think about what Jennifer Freyd writes about CSDM. About the difficulty to estimate other people’s boundaries sometimes… Adults between, where there doesn’t exist a power differential…

Lack of respect for personal integrity, which comprises sexual, physical and emotional integrity.
Also see about the ACE-reporter number one.

And I think a coming blog post will be about the topicguilt”… Paralyzing guilt?

Something personal: When I sat here writing I came to think about something that occurred a couple of days ago when I had friends here an evening... I use to put books and writing away I don't want them to look in... And in my books I use to write, sometimes fairly a lot, very personal notes... Which I don't want anyone to read!!

I have learnt with those that I shall do this (and I probably do other things because I don't want them to come with comments about things...

But this time, when I and one of the friends was occupied with other things one of them took books from my book cases and read... I suddenly saw it and in fact asked/begged him not read what I had written!!! And this I really view as a boundray violations, not least as I have told these that I write a lot in my books and therefore can't lend them to other people usually (maybe if it novels; then I don't write so much and sometimes nothing).

If you have been exposed to boundary violations you easily get violated in a similar manner??

Came to think about other forms of violations, such as telling others what they shall wear, how they shall live, how they shall have it at home etc. Grown ups between this is a little different then if a child is exposed to this... But it can be very irritating for grown ups too...

And the more "well behaved" you are because of your upbringing (with high demands for instance) it can be really disturbing and maybe something you just can't push away!!??

So it has been with those friend too, or at least the woman... (she does this with the man she lives with too!! :-) As maybe many women do!??). "You should..." with how I dress!!! How low my lamp in the kitchen was, because they didn't think they could see people round the table... But I am raised not to mention such things even if as in this case you maybe see the person in front of you till his/her edge of the scalp!!! If we at least have eye-contact, what's the problem???

And she has even had opinions on how I have it at home... A sigh...

With age I have started to dress more personal than I have done earlier... And i guess (yes, I really GUESS!!!) I have some sense for artist-things... It means a lot how I have it around me at home at least!!! That it is personal and things I like... Preferably things made by living human beings... But not only that... Because it isn't that rigid. I hope not so very rigid at all.

And I haven't bought anything to the household I haven't been able to pay immediately, except for maybe technical things such as the last stereo... But that I paid in one or two months...

If I don't have money to buy a new chair or small table, then I have an old one in the meantime... And even many years...

Drawing this sort of people to me - have I?? A little at least? And what they have said has been very irritating to be really honest!!! As if to say I have a bad taste or need help!!?? (Maybe I do?? In fact a little ironical... I have it as I want - almost!).

The ones that maybe violated such boundaries, as reading things that was private was maybe dad... And the one having opinion about how to think, feel etc... has been mom I think.

Another human beings thinks, feels as he/she does... To say what others shall feel/ think is humiliating, and disrespectful and probably also violations of boundaries (and integrity)... But I shall not say that I never can say: "Oh, but you shall not think so..."

Both my maternal grandmother and dad checked mom's purse as if it was their right!! Grandma stopped with it though (but she did this when mom already had maybe three or four children; I think I remember it, to see if dad gave her money!!!). But dad did this his whole life!! I wouldn't have allowed this, I think! But mom did. At least with dad... Why??? How about boundaries and integrity?? No matter if you are married or not!!??

And by the way I think one shouldn't have to put things away when people are going to visit you!!! That it shouldn't be a temptation for people to read what one has written for instance... But sometimes it is, and then I try to remember to take those books etc. away.

And really a side-track: I managed to burn music, a CD, yesterday on my new computer, too, through trial-and-error-method!! Fun!! (my situation some years ago was of that kind I couldn't afford a computer at all, so I bought my first computer in my whole life less than five years ago... My economy had been ruined during a period of a little more than six years when I tried almost entirely on my own to recover from an exhaustion... I had no savings left after it. And from working only 80 % after that for three years before I was back on full time work, which I am since four years now. And these four years have meant a lot for my economy, in recovery of that too on top of trying to recover in other areas and ways of my life, because of very bad work place conditions and a "40-years crisis" in advance? Why 40-years crisis? I have my ideas...).


Total utmattning av systemet på grund av långtidseffekt av dold (och/eller förnekad) stress hos äldre.

Saker fick mig att fundera… Om ett sammanbrott av hela systemet. Och kom att tänka på vad Anna Luise Kirkengen skriver.

Jag kommer att citera sidorna 36-39 i hennes bok Hvordan krenkede barn blir syke voksne” ISBN 82-15-00713-9, ur kapitlet ”Den destruktive virkningen” sidorna 36-39, vilket finns i ett utdrag på engelska på nätet How Abused Children Become Unhealthy Adults” i kapitlet ”Destructive Impact” sidorna 24-26 i det utdraget.

Kirkengen skriver:

”Låt oss nu undersöka vilken destruktiv effekt tidigare negativa, tystade och dolda erfarenheter kan tänkas ha på senare hälsa. Studien av Felitti och hans medarbetare visar ett kvantifierbart samband mellan sådana erfarenheter och senare hälsoproblem som kan påvisas upp till fem årtionden senare [dvs. alltså i övre 50-årsåldern och senare]. Sammanhangen kan till exempel påvisas för hjärt- och kärlsjukdomar. Författarna till den sistnämnda studien skriver:

’Vi fann både en dos-responsrelation mellan negativa barndomserfarenheter och hjärtkärlsjukdomar och ett samband mellan nästan alla enskilda ACE-faktorer och hjärtkärlsjukdomar. Psykologiska faktorer ser ut att ha större betydelse än de traditionella riksfaktorerna i förbindelsen mellan negativa barndomserfarenheter och hjärtkärlsjukdom. Våra fynd ger vidare insikt i hur belastande barndomsupplevelser kan öka risken för hjärtkärlsjukdom bland vuxna (Kirkengens översättning).’ [dessa fynd förser oss/utrustar oss med vidare insikter om de potentiella vägar genom vilka stressfyllda barndomserfarenheter kan öka risken för hjärtkärlsjukdom som vuxna, min översättning av den engelska texten].

Denna konklusion/slutsats stöttas av en studie bland 6 000 vuxna om sammanhangen mellan allvarliga sjukdomar och fysisk misshandel, sexuellt missbruk och generell vanskötsel [Bosch och Jenson refererar till Pia Mellodys koncept om medberoende och vad kränkningar faktiskt är; att de inte bara är fysiska eller sexuella, utan också kan handla om vanskötsel och vanskötsel som ganska många av oss inte uppfattar som vanskötsel, och ökar dessa faktorer så får denna sorts vanskötsel svårare följder än om barnet utsätts för få faktorer]. Studien visar att misshandel medför ökad risk för lungsjukdomar, magsår och ledsjukdomar, att vanskötsel medför ökad risk för diabetes och autoimmuna sjukdomar och att missbruk medför ökad risk för hjärtsjukdom. Och en befolkningsstudie bland 1 359 kvinnor och män med en genomsnittsålder på 75 år visar på ett sammanhang mellan sexuella övergrepp i barndomen och sjukdomar i sköldkörteln hos männen och både artrit och bröstcancer hos kvinnorna [men hur många kommer ihåg sådana här övergrepp?].

Därmed är vi tillbaka hos mina två kvinnliga patienter som dog av bröstcancer *). Bägge hade vuxit upp i så kallade ’stränga’ hem. De talade om misshandel i namn av straff och uppfostran och om de vuxnas alkoholbruk och socialt oacceptabelt uppförande som måste hållas dolt. Bägge kvinnorna hade redan som små flickor tagit på sig uppgiften att dölja familjen sociala skam. De blev inte bara överdrivet ansvarstagande, de var också hjälplösa inför den omöjliga uppgiften de tagit på sig själva. Som följd av sin barndomsroll som familjens socialarbetare hade de nästintill blivit förutbestämda att bli överansvariga räddare av våldsamma män, utan att någon gång våga gå till motvärn eller protest.

[*) två kvinnor som Kirkengen tidigare skrivit om, vilka dog av bröstcancer och vilka visade sig ha blivit misshandlade av sina män ända till de blev sjuka vilket de teg om till Kirkengen av en slump fick veta det, men för sent för att kunna lasta av dem den stress som gjorde att de slutligen dog i sin bröstcancer.]

Dessa två kvinnors historier knyter jag nu till generell kunskap om neuroimmunologiska och endokrina vägar mot cancer. Bägge kvinnor befann sig i många år i konstant alarmberedskap och rädsla för det nästa, oförutsägbara utbrottet av våld. Är det fruktbart att tänka att ett dylikt mentalt tillstånd, det vill säga en konstant upplevelse av latent fara för liv och hälsa, när utvecklandet av cancer? Det negativa inflytandet på immunsystemet av så kallad distress, det vill säga emotionell överbelastning, är starkt/övertygande dokumenterat. Experimentell utforskning av sammanhangen har förankrats på flera sätt. I immunologiska studier är ’natural murder cells’, på svenska mördarceller, centrala studieobjekt, i hormonstudier har kortisol en betydande plats. Mördarceller undertrycks mätbart hos försökspersoner som utsätts för stress, till exempel intensivt oljud upp till 72 timmar efteråt, men bara om försökspersonerna inte tror att de kan kontrollera oljudet. Samma nivå av oljud över lika lång tid har dock inte samma effekt om försökspersonerna tror att de kan slå av ljudet, även om det inte är sant. Med andra ord: Personens egen upplevelse av antingen auktoritet/makt och kontroll – eller vanmakt/impotens – bestämmer verkan. Personens subjektiva upplevelse av verkligheten som överväldigande och opåverkbar försvagar mördarcellerna. Effekten blir förstärkt av upprepade upplevelser av maktlöshet och ytterligare vid kronisk vanmakt. På så sätt öppnas vägen för patologiska celler i kroppens vävnader och organ.

Subjektiv tolkning påverkar också det hormonella samspelet mellan hypotalamus, hypofys och binjurebarken, i engelsk kortform HPA-axeln. Nu finns en omfattande mängd dokumentation rörande dessa hormoner, särskilt avseende deras effekt på den naturliga fluktuationen i den dagliga produktionen av kortisol. Begreppet ’allostas’ kan här introduceras. Allostas betyder stabilitet med hjälp av ändring och omfattar alla interna system som möjliggör flexibel anpassning till både rutin och skiftande vardag. Allostatisk ’uppladdning’ sker vid upprepad upplevelse av fara. Den har mätts vid långtidsbelastning som samhällskriser, krig och nöd, vid examen, sorg, förlust av uppehälle och skilsmässa – och vid långvarigt undertryckande av starka känslor som under långtidsskötsel av partner som har Alzheimers sjukdom. Uppladdningen kommer till uttryck i ständig hyperaktivitet i kortisolproduktionen. Detta har alla de följder som förhöjt kortisol ger, alltså viktökning, blodtrycksstegring, fel i blodsockerregleringen och förlust av mineraler i skelettet, för att nämna de mest centrala.

Personer i kronisk vanmakt får alltså till exempel osteoporos på grund av kroniskt förhöjt kortisol. Det är mycket frestande att sätta detta hormonella orsakssammanhang in i ett mer komplext system av möjliga sammanlöpande fenomen. Det kan nämligen tänkas att osteoporos, som många andra sjukdomstillstånd, inte bör förstås som en epidemi, men som en del av en syndemi. Begreppet syndemi blev introducerat av antropologen Merill Singer i studien av tre interagerande, ömsesidigt påverkande och ömsesidigt förstärkande ’epidemier’, nämligen narkotikamissbruk, våld mot kvinnor och AIDS”.

Kirkengen skriver också i Innledning og veiledning att hon med denna bok om hur kränkningar av integritet leder till sjukdom och hon vänder sig till alla dem som ”…kommer i kontakt med människor, stora och små, som skadas eller har blivit skadade på grund av andra människors bristande respekt för deras [personliga] integritet.” *)

Att alla dessa (i sjukvård, socialtjänst, inom psykiatri, i skolan, advokater, politiker, de som stiftar lagar, medmänniskor i allmänhet troligen också)

”…ska ha som mål att förhindra att människor, och särskilt de som är små och beroende, blir förödmjukade, kränkta, skadade och missbrukade /…/ De bör ha som mål att sörja för att alla människor, oavsett var de är eller färdas, kan veta att de blir respekterade och aktade. Lagarna bör ha som mål att sikta mot att alla människor som har upplevt andras respektlöshet och förakt får riktig och riklig hjälp och kan återfår sin självaktning och självrespekt.”

*) Där varje individs personliga integritet inte bara rör den sexuella eller fysiska utan också känslomässiga och emotionella integriteten. Att inte kränka dessa gränser. Att visa djup respekt, inte minst mot små barn och det växande släktet… Tänker på vad Jennifer Freyd har skrivit om CDSM… Om svårigheten att bedöma andras gränser ibland… När det gäller vuxna emellan… Som inte står i olika maktposition…

Avsaknad av respekt för personlig integritet, vilken omfattar sexuell, fysisk och känslomässig/emotionell integritet. Se också blogginlägg om ACE-studiens första nyhetsbrev.

Och jag tror att ett kommande blogginlägg kommer att bli om ämnet ”skuld”. Förlamande skuld?

See also Ingeborg Bosch on burn out.

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