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Psychological trauma in Parkinson's disease It
is dangerous to suppress emotions. People who continuously
suppress their feelings will break (
Parkinson's personality The first idea I had after receiving the definite diagnosis of Parkinson's disease was about fear or anxiety and I saw the symptoms of the disease as expression of such (repressed) emotion. The pre-morbid personality structure of the Parkinson’s patient is characterized by obsessive-compulsive behavior, which is controversial but however widely recognized in medical literature. Such personality structure is an expression of defense and a psychological mode to process anxiety and depression, which are much more frequent in Parkinson's disease than in other diseases. In addition, it has been observed that Parkinson’s patients exhibit a comparatively greater number of traumatic life incidents in childhood and that a shock or psychological trauma is more often reported in connection with the onset of the disease. The marked behavior of social withdrawal, finally, completes the psychological image of Parkinson's personality. Based on these clinical observations and my own experience of the disease I concluded that psychological trauma, fear, shame and helplessness play a major role and that dissociation and the rigid suppression of emotions are the keys to the understanding of Parkinson’s disease.
Defense strategies In animals three possible reactions can be observed in threatening situations: fight or flight and when motor behavior is not successful anymore as a defense strategy, motionlessness (freezing). If in an overwhelming event there is no room anymore for fight or flight motor energy is completely blocked. Such tremendous defense energy remains blocked as long as the danger is not over and balancing of energies is not possible. But what is a very natural process in animals to release energy is inhibited in man by cortical functions. However, the fight-flight response is not the only defense mechanism. The evolutionary inheritance includes on top of that other defense systems that are instrumental in survival. The emotion of shame protects as such the integrity of the self and supports social adaptation and submission. Shame is besides fear also an emotional trigger of "alert immobility", a protective motor block. Psychological dissociation, finally, is in men the most common protection. It is a primitive defense when emotions are overwhelming and becomes somatic when "mental escape" is not possible or not enough anymore and feelings get too strong. Such healthy defense normally resolves immediately, when danger is over and blocked energy is released. However, it becomes chronic, when the emotion is internalized. It comes up with (learned) helplessness and hyper-vigilance. When the frozen defense energy cannot be released and the equilibrium re-established, a highly over-aroused nervous system is permanently blocked on the vegetative, psycho- and finally loco-motor level.
Psychological trauma In men key elements in the traumatizing process are loss of control and dissociation. In this process are mainly structures of the limbic system and the basal ganglia involved as well as the parasympathetic nervous system. In the traumatic event the victim gets helpless and paralyzed. This is the case in shock trauma but helplessness arises also in developmental trauma with repeated experience of not having control. In reality helplessness can develop without attracting so much attention and the crucial traumatic event does not need to be a great deal. Not the event is the trauma but the response of the nervous system. Once the nervous system is traumatized, at the least sensory input from the cortex the amygdala sounds the alarm. Endogenous opiates deaden sensations and emotions and shut the prefrontal cortex down with its capacities of communication, orientation, memory processing and control. Therefore the hypothalamus becomes hyperactive and alerts the autonomic nervous system to an emergency. The stress response of the major parasympathetic nerve, the vagus, comes about with a most primitive reaction. In the absence of cortical and emotional mechanisms there is basically only one bodily response, again and again the blocking of motor capacities.
Post-traumatic stress reaction The traumatic event eases but the system does not return to normal state. The traumatized person’s nervous system is stuck in the immobilization and remains on constant alert for rapid mobilization via sympathetic-adrenal activation at the slightest provocation. With persistent helplessness noradrenalin output is high and therefore serotonin levels are low what is probably the cause of depression in Parkinson’s disease. Under the influence of endorphins however dopamine synthesis is strongly enhanced. With such neurochemical imbalance the traumatized person remains in a state we know as posttraumatic stress reaction (posttraumatic stress disorder PTSD). But even though there is a similarity in symptoms, it is not PTSD what experiences a person during life before she or he develops Parkinson’s disease. The effects of psychological trauma are masked. On one hand the nervous system is over-aroused and on the other hand the immunization by (structural) dissociation and vigorous mental resistance fakes normal state. In comparison with a car, gas pedal and brake are operated in the same time. The Parkinson’s personality splits completely off from all sensations and emotions in order not to suffer from PTSD.
Oxidative stress The force that is needed to hold back the enormous energy of the frustrated defense reaction, is immense. When the immobilization fades, the energy is still there and causes a re-activation of emotions and memories. In addition there are feelings of rage or terror as a consequence of the frustration of the defense. The cognitive and emotional frame does not allow any processing of traumatic energy and the response is therefore again immobilization. With each new experience of freezing, fear is also increasing. Therefore the amount of energy that is necessary to cope with the situation gets more too. The rigid inhibition prevents from experiencing pain, tension, anxiety or fright and finally relief. Instead more endorphins flood the body anesthetizing body sensations, further dissociating memory, inhibiting the expression of emotions, numbing the autonomic nervous system, splitting up body sensations, blocking the motor energy and masking thereby the traumatic state. In addition dopamine synthesis in the substantia nigra is further enhanced, far over the needs of normal motor behavior and in the same time endogenous opiates block dopamine receptors in the mesolimbic system further inhibiting emotions. Excess dopamine in the motor system is broken down by monoamine oxidase what results in oxidative and nitric stress and together with other toxic effects in degeneration of dopaminergic neurons in the substantia nigra. Profound changes in the neuro-chemical processes generate free radicals, induce DNA mutations and cause permanent changes in dopamine receptor functions. Such process can last unnoticed decades until dopamine decreases become significant enough that Parkinson’s symptoms begin to appear.
Dissociation Defense or survival mechanisms are innate biological operating or action systems. The processes are complex and there are usually several systems and subsystems involved. Frustration of defense includes the subsystems of fight, flight, fear, terror, rage, freeze, hyper-vigilance, anesthesia-analgesia, energy management and submission. The failure of any of this systems can cause a malfunction of the whole organism. Psychological dissociation is a mechanism that protects the systems from falling apart by splitting off self and reality temporarily. However, when it does not stabilize timely again emotions and sensations cannot develop their adaptive function and dissociation becomes somatoform. (Structural) dissociation seems to be very strong in Parkinson's personality. In its primary form it dissociates between two mental systems, the defensive system on one hand, and the systems that involve managing daily life on the other hand. The emotional part struggles with the effects of trauma splitting off parts of memory and perception in order to escape intolerable emotions. The professional or so called "(apparently) normal" part avoids traumatic memories extremely and allows to function at a high level of adaptation, e.g. mainly as successful professionals for years or decades. But when the systems cannot integrate the dissociated parts split further up. Certain inescapable aspects of daily life may become associated with past trauma. Somatoform structural dissociation eliminates the perception of such elements from the functioning part of the personality. Such apparent loss weakens the functioning part and is particularly strong when not only helplessness but also internalized shame are the driving forces of avoidance. However, when dissociation between pieces of the so far functioning part starts it is not PTSD that comes up. As there is no connection to emotions and sensations there are only the (negative dissociative) symptoms of the repressed emotions. Fear, shame and helplessness mark the main symptoms of Parkinson's disease, tremor, rigidity and immobility. In addition, postural instability results from a dysfunction of the proprioceptive system, which is common in trauma. Eventually cognitive physiological systems deteriorate and the non-motor symptoms of Parkinson's disease develop. However, negative dissociative symptoms refer only to apparent losses. The motor skills that are not available to one of the dissociative parts of the Parkinson's personality my be accessible to another part. As under certain circumstances dissociated parts become operative again, the Parkinson's patients may be able to use (motor) skills that are normally not at his disposal ("paradox kinesia").
Shame Clinical experience shows that strong resistances are mainly motivated by shame. Shame has been shown to inhibit the expression of any emotion and to block motor capacities. The origin of shame is dyadic and external, but when it is internalized it does not require the presence of an external person anymore. Then, shame is triggered when self-image and behavior don't match. A major opportunity for malformation of the function of shame is the sexual development of the child. But there are many other opportunities to develop shame when the response of the caretaker is inadequate. One of the possibilities is the misuse of the disapproval-inhibition transaction as an instrument for limiting the child's aliveness. The mental and physical immobility seen in shame is due to a shift in balance in the autonomic nervous system, with an offset of sympathetic activity and an onset of vagal activity. This represents an offset of endorphinergic activity of the ventral tegmental and mesocortical dopamine system resulting in a reduction of dopamine synthesis. Furthermore it activates the noradrenergic lateral tegmental circuit that is inhibitory. Such conditions produce "a shame state of 'frozen inactivity', an overwhelming, paralyzed state in which the mind goes blank, the head goes down, the social smile disappears and the capacity for speech is lost". Clinical experience shows that the prognosis in Parkinson's disease is better when the (shame induced) resistance can be softened. In addition, clinical experience demonstrates that the decrease of inhibition threshold is beneficial for the Parkinson's patient. It seems therefore that the treatment of shame is a possible therapeutic approach to the disease.
Disapproval-inhibition transaction "Alert immobility" is a protective mechanism that can be triggered by shame. It is mediated by the disapproval-inhibition transaction and is a simple loco-motor halt. It blocks only temporarily gross movements in order not to attract threat by motion or not to move into a dangerous zone. It does not block defense energy and does not necessarily involve a great amount of energy. The disapproval-inhibition reflex is called also parental disapproval transaction or disapproval-shame transaction. The disapproval-Inhibition reflex is triggered by an external source that is not the threat. It is typically the emergency brake of the caregiver that prevents the toddler from doing some potentially self-threatening action. The infant immediately freezes loco-motion when the mother shouts "no" or shows another disapproving expression. The impulse is set by the emotion of shame. The function of disapproval-inhibition develops in a moment of motor awakening of the preverbal toddler. It is a developmental period full of expansion by the child and the emergency brake might be used by the caregiver in an extensive and inadequate way. What was designed as a simple trigger of a motor reflex takes over, gets internalized and causes the mechanism to become chronic. The trigger becomes permanent and the individual gets hyper-vigilant. The threat does not go away anymore, produces (learned) helplessness and finally immobility. In order to avoid that, the toddler may try to run away from the caregiver's influence but tight control prevents from getting relief what might be traumatizing. The frustration of flight produces terror and more helplessness. Structural dissociation prevents from losing control and PTSD at the time being, but causes immobility in the long run.
Impulse deficiency syndrome Emotions and sensations have a signaling function that trigger adaptive reactions or adequate motor responses. Cutting-off sensations from experiencing them prevents Parkinson's patients pre-morbidely from losing control, but denudes the individual of the subtle psycho-motor impulses that initiate and accompany emotions and that are the intuitive mechanisms for motivation and natural behavior of a person. It makes him helpless. Parkinson's personality, however, does not remain helpless (immobile) but dissociates further repressing all emotions. But on a long run, without e-motion there is no motion. The Parkinson’s patient is typically lacking in impulses that start movements and keeps them going. Clinical studies and observation show, however, that the previously learned motor programs, the sequential motor plans, are still available. But suffering from Parkinson’s disease, some of them are structurally dissociated and not accessible by the functioning part of the personality. External “triggers” help to connect with the motor plans and the improvement that can be achieved using such stimuli is well documented in medical literature. In everyday life there are cues that help, like lines on the floor, music, lights and other stimuli. But the phenomenon of impulse deficiency is not limited to the motor capacities. Due to the profound dissociation of emotions and sensations, Parkinson's personality shows an important deficit in motivation and in natural reward. Therefore he is in general prone to addiction to artficial external stimulation. Posttraumatic, professional and social stress are the main artificial stimuli. Dissociation and stress, addiction to endogenous dopamine and finally withdrawal from behavior and substance affect the physiological systems and cause non-motor dysfunctions in autonomous, cardiac, proprioceptive and cognitive system(s).
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| Last modification: 06.10.2006 |