As the 19th century mathematician physicist Lord Kelvin emphasized, "To
Measure Is To Know", but there are numerous ways to measure
"stress". You can measure hormone levels in body fluids,
cardiovascular and electrodermal responses to stimuli, other changes in
sympathetic and parasympathetic balance that affect blood flow in the
extremities, face or speech, and by using sophisticated EEG and imaging
techniques that show specific changes in the brain. The most
cost
effective and therefore the most commonly used measures are self report
questionnaires, many of which have been designed to measure stressful
states and traits such as anger, anxiety, depression and Type A
coronary behavior. The gold standard in questionnaires to
measure
stress is generally called the Holmes-Rahe scale, first published 40
years ago, and which has subsequently been revised and updated several
times by Dr. Rahe. Before discussing the evolution of this
rating
scale, it is important to explain some of the difficulties encountered
in this undertaking and to provide some historical background.
A major problem is that stress is difficult to define in objective
terms that scientists can agree on because it differs for each of
us. Things like a steep roller coaster ride, bungee jumping
or
sky diving that would be very distressful for many people are
exhilarating and highly pleasurable for others. We also
respond
differently to stress. Some people blush but others become
pale. Hans Selye, who coined the term "stress" as it is
currently
used, struggled unsuccessfully all his life to find a satisfactory
definition. As he frequently complained to me, "Everyone
knows
what stress is, but nobody really knows." So, if
you can't define
stress, how can you possibly measure it? As Lord
Kelvin also
noted, "You can't improve anything if you can’t measure
it". And the same applies if you want to reduce anything, and
this is especially true for stress.
Although these hurdles make it difficult to prove that stress can cause
or contribute to illness, evidence for such a relationship has been
recognized and widely accepted in all cultures since
antiquity.
Over 2000 years ago, Galen not only emphasized the need for equilibrium
in the four humors to preserve health, but also what he called the
"non-naturals", among which he included the “passions or
perturbations of the soul.” It was equally
important to
help patients keep their emotions in balance to preserve mental as well
as physical health. This belief in the influence of strong
emotions on health and illness grew progressively stronger in the
Medieval period and was championed by Moses Maimonides, the 12th
century physician, philosopher and rabbi, who was the leading medical
figure of his day. He was so celebrated, that despite being
Jewish, he was physician to Saladin, the Sultan of Egypt, whose huge
empire at the time of the Crusades included Syria, Iraq, Mesopotamia,
Jordan, Jerusalem and Mecca. Maimonides wrote, “It
is known
... that passions of the psyche produce changes in the body that are
great, evident and manifest to all. On this account ... the
movements of the psyche ... should be kept in balance ... and no other
regimen should be given precedence.”
As a result,
"The
physician should make every effort that all the sick, and all the
healthy, should be most cheerful of soul at all times, and that they
should be relieved of the passions of the psyche that cause anxiety."
The importance of emotional balance and mind-body relationships was
increasingly recognized during the Renaissance when fears about the
influence of the "imagination" were intense. It was widely
believed that vivid thoughts and ideas could cause serious problems,
especially during pregnancy, where the effects were sometimes bizarre.
Frog
Baby
Ambroise
Paré, the famous
16th century surgeon who
revolutionized the treatment of wounds, reported several cases in his
1585
Oeuvres
(Collected
Works). The "frog baby" born in 1517 was thought to be a
prime
example of the power of a pregnant woman's imagination. The
mother was advised to hold a live frog in her hand to cure her fever
and had been holding it when she became pregnant. In addition
to
the child "having the face of a frog" shown to the left, another baby
was born with the body of a calf. His subsequent 1573 book,
Des Monstres et Prodiges,
contained numerous additional accounts and illustrations of grotesque
human-animal forms of life. It is believed to have been the
source for Caliban, described as being a "savage and deformed slave" in
Shakespeare's
The
Tempest, published 50 years later.
Robert Burton’s
The
Anatomy of Melancholy,
published in 1621, warned that, “the mind most effectually
works
upon the body, producing by his passions and perturbations miraculous
alterations ... cruel diseases and sometimes death
itself.”
These beliefs in the power of imagination and strong emotions to
influence the onset and course of illnesses persisted in medical
textbooks, essays and monographs over the next two centuries and were
emphasized in Dr. William Falconer's 1788
A Dissertation on the Influence
of the Passions Upon the Disorders of the Body.
The discovery that bacteria could cause disease, Koch's postulates,
improved microscopes that facilitated pathological diagnoses, and other
19th century scientific advances shifted the focus away from mental and
emotional causes of illness. However, Charcot and his student
Freud had become interested in the phenomenon of hysteria and using
hypnosis to treat it by identifying and removing repressed memories of
traumatic events that appeared to be causing hysteria in some
patients. Freud later replaced hypnosis with his "talking
cure",
which was later called psychoanalysis. During World War I
Freud's
ideas about the emotional origins of hysterical symptoms were often
applied to "shell-shock" and other "war neuroses" for which no organic
basis could be found, and that now fall under the diagnosis of Post
Traumatic Stress Disorder. In 1930, Franz Alexander, a
graduate
of the Berlin Psychoanalytic Institute and brilliant disciple of Freud,
was invited to the University of Chicago, where the first University
Chair of Psychoanalysis ever had been established. Two years
later, he founded the Chicago Psychoanalytic Institute, which soon
achieved international renown as an outstanding psychoanalytic training
and research center, and whose graduates included Karl and William
Menninger.
Alexander made a careful distinction between classical conversion
hysteria and what he called "organ neuroses" due to automatic autonomic
nervous system mechanisms that controlled emotional and other responses
to stressful stimuli. Often called "The Father of
Psychosomatic
Medicine", he assembled investigators from various clinical and
laboratory disciplines at his Institute. This led to similar
research groups that were developed elsewhere, such as the one headed
by Stanley Cobb at the Massachusetts General Hospital. In
addition, Flanders Dunbar at Columbia Presbyterian Medical Center in
New York City, whom I later had the privilege of collaborating with,
had produced a masterful monograph,
Emotions and Bodily Changes: A
Survey of Literature on Psychosomatic Interrelationships.
Her subtitle gave this growing movement a name by introducing the term
"psychosomatic" into American Medicine. Four years later, in
1939,
Psychosomatic
Medicine was founded as the first medical journal devoted
specifically to publishing research in this rapidly expanding field.
World War II accelerated the growth of psychosomatic medicine even
further as psychiatrists and others trained in this discipline were
mobilized to treat shell shock and similar symptoms. Grinker
and
Spiegel's 1945
Men
Under Stress
detailed these experiences and in 1943, Weiss and English's
Psychosomatic Medicine and Dunbar's had also attracted a large medical
audience. Scientific studies skyrocketed and medical schools
created new programs for their curriculum to satisfy the demand for
more information on mind/body relationships. Psychosomatic
medicine was so much the "rage" at mid-century, that popular magazines
constantly ran relevant articles and psychosomatic theories were
featured in the lyrics of
Guys
and Dolls ("In other words, just from waiting around for
that plain little band of gold, A person can develop a cold."
Adelaide's Lament).
The play won five Tony Awards, ran on Broadway for well over three
years, and was later made into an award winning movie that included
Marlon Brando, Frank Sinatra and other stars. By the time the
Holmes-Rahe life events scale was published in 1967, there was also a
huge lay audience thirsty for such information and it also received
enormous media coverage, including
Time
magazine, the popular syndicated
Dear
Abby column and Alvin Toffler's
Future Shock.
In that regard, Stewart Wolf, who was well acquainted with its origins
as well as Tom Holmes and Richard Rahe, once told me that it should
have been called the Rahe-Holmes scale. I suspect that after
the
following interview with Richard Rahe, you will understand why.
PJR: I
suspect that most people
are familiar with your name because of the (SRE) Schedule of Recent
Events approach and the Holmes-Rahe rating scale (SRRS) Social
Readjustment Rating Scale that has been a gold standard of stress
assessment for four decades. As a result, they may be unaware
of
your many other achievements. I first met Tom Holmes in 1951,
when I had a Fellowship with Hans Selye, and we visited him at New York
Hospital during his return visit from The University of
Washington. He had been a member of the "Wolffpack", a group
of
physicians under the tutelage of Harold Wolff at Cornell that included
other pioneers in psychosomatic medicine like Stewart Wolf, George Wolf
and Larry Hinkle. Tom was interested in the relationship
between
allergic rhinitis and stress, which was allegedly kindled by the
observation that he usually developed a cold when his mother-in-law
came to stay with him for a week or more. The clear
relationship
between the frequency and severity of colds and the magnitude of stress
has since been confirmed in numerous studies. His book, The
Nose,
had recently been published, showing that nasal responses to stimuli or
stress almost always involved changes in deeper respiratory function
and often affected other organs and systems. Like Stewart
Wolf,
Tom became a good friend as well as a very early Member of the Board of
Trustees of The American Institute of Stress. I think it
would be
of interest to our readers to learn how you became associated with him
and how the Holmes-Rahe Scale was born.
RHR: Thanks
Paul. I might
first point out the differences between the SRRS and the SRE.
The
SRRS presents average magnitudes for 42 life change events and is often
called the Holmes-Rahe scale. The SRE was the initial
research
instrument used at the University of Washington to collect
subjects‘ recent life changes information.
Here’s the story of how the SRRS came into being.
At the
University of Washington School of Medicine, first and second year
students could apply for a small research grant to work within a
department of their choice during summer vacation. My first
summer I worked with Robert Rushmer, a noted cardiovascular
researcher. The second summer was spent in psychiatry with
Thomas
Holmes. He first suggested that I review all the life changes
and
illness papers coming from the Department of Psychiatry. I
did so
and wrote a review article, where, among other issues, I pointed out
that in many of these articles, recent life changes were measured
differently. Most often, simple counts of the number of
changes
were used, but none of the methods differentiated between severe life
changes, like death of a spouse, from minor changes, such as a vacation.
On my Psychiatry rotation as a third year student, Dr. Holmes and I had
attended a presentation by Eugene Galanter, PhD, on scaling the
severities of juvenile crimes using a proportionate scaling technique
devised by his mentor, E.E. Stevens. On the way back from the
talk, Dr. Holmes speculated that this scaling method might be an answer
to my review article critique. All Tom needed to do was to
suggest this possibility and I quickly volunteered to conduct such a
scaling study. It took me two years to collect all the data
from
over 400 subjects of differing ages, gender, education, race, and
social status. I did the first analyses of these data by
sorting
questionnaires into various demographic groups on the living room floor
of my apartment. Later on, I obtained funding for a computer
scientist to collate all this information. I finally
submitted
the report in a publishable form at the end of my fourth year of
medical school. Although Tom assiduously edited my drafts, he
always left the work to me. As Professors mentoring young
investigators often did in those days, Tom said to me, "For your first
two papers you were the first author. I think I'll put my
name
first on this one." I later discovered he had done the same
with
a sociologist graduate student who studied life changes in patients
prior to the onset of tuberculosis. This common academic
practice
ultimately led many peer reviewed journal editors to begin requiring
authors to specify their individual contributions to a submitted
manuscript.
After graduation I did a straight medicine internship on Cornell
University's wards at Bellevue Hospital in New York City. I
had
intended to become a medical resident under Harold Wolff, but he died
the day before I was to first meet him to present a case of
hyperthyroidism seemingly brought on by severe recent life
stresses. I changed my residency to Psychiatry and returned
to
the University of Washington. During my residency I continued
to
conduct studies of recent life changes and illness onset for colleagues
who were willing to help me. I developed the Life Change Unit
(LCU) concept to measure the magnitude of life changes and in
prospective studies, the higher the residents’ LCU score
reported
for the year prior to study, the greater were the numbers of reported
illnesses over the following year. Residents with life
changes
totals from 0 to 150 were generally healthy the following year and
those with totals from 151 to 300 tended to report one or two minor
illnesses. However LCU's greater than 300 over the previous
year
were frequently associated with multiple minor illnesses and
occasionally a severe illness over the following 12 months.
Tom
held on to these two papers saying that he wanted to replicate them
before publishing. After two more years and no action on his
part, I published the material as a chapter in a book.
PJR: You
were able to continue
your research while on active duty in the Navy and modified the SRE to
make it more meaningful for naval personnel. You rescaled
your
original 42 life change events along with 12 new military related
events in 1980. In 1997 you had added a total of 36 new life
changes to the original 42 and did another rescaling experiment with a
group of subjects carefully selected to closely match the original
sample in number, age, education, race, religion, and socioeconomic
status. That same year, you presented and discussed the
results
of these changes at our Ninth International Congress on Stress in
Switzerland. Of particular interest was the observation that
LCU
values for the original 42 events listed in 1967 had increased on
average by 45 percent over the next thirty years!
I emphasize
this since I see so many articles in lay and even medical
publications
that still use the original Holmes-Rahe scale to assess stress, or cite
it as the preferred measure, and are unaware of important updates you
have periodically made over the past four decades.
With respect to your early work in the Navy I also recall that you did
some studies with patients recovering from a heart attack that later
led to further stress and coronary heart disease investigations in
Sweden. This work resulted in contacts with Ray Rosenman,
Stewart
Wolf, Töres Theorell, Lennart Levi and other mutual friends,
who,
like yourself, have contributed so much to our International Congresses
on Stress. How did this set of fortunate circumstance come
about?
RHR: My
research at the
University of Washington had attracted the interest of Ransom J.
Arthur, M.D., Commanding Officer of the Navy Medical Neuropsychiatric
Research Unit in San Diego, California. I was due to spend
two
years on active duty following my residency and Dr Arthur arranged for
me to be assigned to this facility. Here I was able to
conduct a
variety of life changes and illness studies utilizing several Navy
populations, including Underwater Demolition Team (UDT) Trainees, Naval
Aviators, Navy Submariners, and Naval Officers and enlisted men aboard
two heavy cruisers and an aircraft carrier. It proved
necessary
to alter the SRE for better application to these military
populations. Recent life changes magnitudes were summed over
2
years, 1 year, and 6-month intervals to see which time interval was
most predictive of near-future illness. Dr. Arthur and I
decided
to label these values life change units, or LCU. In one major
study I followed over 1,000 Naval officers and enlisted men on a
6-month shipboard cruise. Each man’s LCU total for
the year
prior to the cruise was obtained along with all illnesses that each man
experienced throughout the cruise. As illnesses of any
significance were routinely reported to sick-bay aboard ship for
treatment, illness data could be collected in this study without having
to rely on subjects’ memories. These shipboard
results
proved to be extremely similar to those that I found in my studies of
medical residents mentioned above. It was of great interest
to me
to see these early life change and subsequent illness studies supported
in Sheldon Cohen’s recent paper three decades
later. Cohen
examined volunteers’ antecedent life change intensities and
found
them significantly related to their subsequent development and severity
of an induced upper respiratory infection.
When I completed my obligatory two years of active duty in mid 1967, I
extended my tour for another year to continue my studies of patients
recovering from a heart attack at the San Diego Naval
Hospital. I
had uncovered evidence of elevated recent life change magnitudes in
patients’ lives over the year preceding their
infarctions.
I received advice and encouragement from Meyer Friedman, Ray Rosenman,
Larry Hinkle and Stewart Wolf at meetings of the American Psychosomatic
Society to pursue this research. Stewart proposed that I
apply
for an NIMH Special Fellowship to study life changes and coronary heart
disease at the Karolinska Institute in Stockholm, Sweden under Gunnar
Biorck, M.D. Gunnar was Chief of Cardiology at the Serafimer
hospital, where all cardiac patients in the city of Stockholm were
referred for treatment. I received the NIMH award in 1968 and
spent the next 15 months conducting several life changes and coronary
heart disease studies with four of Gunnar’s MD/PhD
candidates. One of these candidates was Töres
Theorell. I also met Lennart Levi, who was then completing
his
PhD work and he referred to some of my published papers in his thesis.
PJR:
Please tell us a
little more about your studies in Sweden and particularly your
association with Töres Theorell, who followed Lennart as
Director
of this important and very productive Division of Psychosocial Factors
and Health at Karolinska. At our 1997 International Congress
on
Stress, when you were the recipient of our Hans Selye Award, several
co-workers paid homage to your achievements. I was
particularly
impressed with Töres' presentation on "Life Stress And
Coronary
Heart Disease In Sweden" as being a generous and appropriate
tribute. I recall that you coauthored several papers with him
and
also collaborated with Ray Rosenman and others on various aspects of
stress and heart disease that would be of interest to our readers.
RHR:
Over my 15 months in
Stockholm (1968-1969), I designed both retrospective and prospective
studies of life change experiences both preceding and following a
myocardial infarction with Johannes Paasikivi, Töres Theorell,
and
Ingvar Liljefors. I also carried out investigations of the
build-up of life change events prior to sudden cardiac death with Evy
Lind. I met with other Scandinavian scientists during this
time
and to my delight, many of my Swedish results were later replicated by
researchers in Finland and Norway. My collaboration with
Töres Theorell continued over many years after my return to
active
duty at the Navy Research Unit in 1969. Töres made
visits to
the USA to spend time at my laboratory and later to carry out a lengthy
data review with Stewart Wolf. I eventually decided to
complete
20 years of active Navy duty, retiring in 1986. I was allowed
to
continue at the Research Unit until completion of my three years as
Commanding Officer in 1980. I was then a Captain and was sent
to
run Navy Hospitals from 1980 to 1984. My final two years were
spent as a Professor at the Uniformed University for the Health
Sciences in Bethesda, Maryland where I started a Military Stress
Studies Unit that remains very active to this day.
Back in 1969, I had reestablished connections with Ray Rosenman and
Stewart Wolf. Ray and I published a paper on the heritability
of
Type A behavior, as I had previously done work in Sweden on this
topic. Around this time, I also started a five-year,
randomized,
controlled trial of psycho-educational therapy for post myocardial
infarction patients beginning shortly after their discharge from the
hospital. Five, one-hour, group sessions were devised to
introduce them to stress assessments and stress reduction
techniques. Meyer Friedman was beginning his long-term study
of
psychological intervention for Type A Behavior patients following an
infarction and encouraged my efforts. The outcome of my study
was
that patients in my treatment group developed significantly fewer
re-infarctions and showed a significantly lower mortality rate compared
to controls over a four to five year follow-up interval. One
great advantage of studying Naval personnel was the ability to obtain
near-complete follow-up data – as most all of my patients
continued receiving their cardiac care at the San Diego Naval Hospital.
PJR:
My recollection is
that you also measured serum cholesterol and uric acid levels in heart
attack patients. What was the reasoning behind this and did
you
learn anything? Later on, you started to study prisoners of
war
returning from the Vietnam conflict as well as military and civilian
hostages held captive in Iran. You also developed group
treatment
programs for these and others suffering from what is now called PTSD or
Post Traumatic Stress Disorder. PTSD has been skyrocketing
because of the war in Iraq and an increase in terrorist and violent
acts such as 9/11, the Columbine massacre, as well as catastrophic
natural disasters like Katrina. The problem is further
complicated by confusion with respect to diagnosis and lack of access
to adequate treatment. What has your experience been in these
areas?
RHR: Ransom
Arthur wished to
create a “Biochemical Correlates Laboratory” at the
Research Unit. Ransom and I had carried out studies of serum
uric
acid and serum cholesterol with Navy frogmen over their four months of
UDT (Underwater Demolition Team) training in 1966 and 1967.
In
1968 Robert Rubin, MD, PhD came to the Research Unit for his two years
of active duty. Bob had previously studied stress and serum
cortisol at UCLA and it seemed desirable to include cortisol analyses
in our UDT database. Ransom appointed me as Head of this
Biochemical Correlates Laboratory and, whenever possible, I measured
serum uric acid, cholesterol, cortisol, and later salivary testosterone
levels in my stress studies. What became clear from several
investigations was that serum uric acid levels generally peaked for
subjects immediately prior to their taking on a very stressful
challenge. In most instances, the higher the peak the better
was
their performance. In later work, we surmised that these uric
acid increases were likely the result of decreased serum volume of the
body due to an elevation in catecholamines resulting in
vasoconstriction. From our total cholesterol data we found
marked
elevations for subjects showing difficulties coping with current life
stresses. Cholesterol concentrations were particularly high
for
subjects who were actually failing in their coping efforts.
This
was in the days before high and low density lipoprotein measurements
were readily available. In terms of serum cortisol results,
rather than finding short-term rises for persons at the beginning of a
life challenge, as had been reported by others, we discovered levels
which were twice the upper limit of normal that persisted over four
weeks of demanding UDT training. Bob Rubin still continues
investigations of subjects’ estrogen and testosterone
variability
under stress.
In the early 1970s, Ransom Arthur began preparations for a
comprehensive medical program that would both evaluate and, when
necessary, provide treatment for returned prisoners of war from
Vietnam. Army, Navy, and Marine POWs were to be seen at the
Naval
Hospital in San Diego and Air Force POWs would be transported to Brooke
Army Medical Center in San Antonio. I helped design the
psychiatric evaluation portion of this program and when the POWs were
returned in 1973, I was among the psychiatrists selected to be an
interviewer. In addition, when Iranian political activists
occupied the American Embassy in 1980, I was one of the Department of
Defense/Department of State psychiatrists assigned to debrief the 52
former captives over a five-day evaluation at the Air Force Hospital in
Weisbaden, Germany. I learned a great deal about both
successful
and unsuccessful coping with severe stress from these former
captives. I learned a great deal about both successful and
unsuccessful coping with this type of severe stress from former
captives. Using this information, I modified my 5
psycho-educational sessions for post myocardial infarction patients and
adapted it for use with these and other severe trauma
survivors.
I developed my Stress and Coping Inventory (SCI) to assist in this
treatment, and for some individuals, I also used a modified version of
Adolf Meyer’s Life Chart to portray their life stresses,
coping,
and illness experiences.
PJR:
I know that you
continued your research in this area and added further measurement
refinements and in recent years have focused on improving the
understanding of PTSD and therapy techniques. However, I
don't
want to jump ahead too fast and we will return to this later.
Since many readers may not be familiar with Adolf Meyer's Life Chart,
it might be helpful to explain that Meyer was appointed Chief
Psychiatrist at Johns Hopkins Hospital in 1908 and designed its Phipps
Psychiatric Clinic in 1913 to integrate teaching, research, and patient
care from a psychobiologic approach. Meyer developed the
"life
chart" approach to depict both biographical and medical information to
enable clinicians to appreciate the temporal relationships between
patients’ stressors and subsequent illnesses. In
his life
chart, each year was identified by a new horizontal line and a column
on the left listed a patient's complaints and illnesses and to the
right, any psychosocial or environmental changes and their
reactions. In between these two columns, curves outlined the
growth and maturation of various organs and systems, resulting in a
diagram shaped like a torpedo. Harold Wolff taught this
"Meyerian
torpedo" approach to his group at Cornell, which included Tom
Holmes. When Tom went to the University of Washington in
1949, he
was assigned to a tuberculosis hospital, and in the early fifties,
co-opted Norman Hawkins, who was obtaining his doctorate in sociology
to do a study that showed higher rates of infection in patients with
low economic status. There was nothing very new about this
but
Hawkins wondered why others with the same profile did not develop the
disease. He postulated that susceptibility was increased by
psychosocial stress and his subsequent study confirmed increased
clusters of such personal stresses in the years preceding
admission. This was reminiscent of Meyer's life chart
findings
and in attempting to evaluate stress he concentrated on seven issues
that Wolff had emphasized. Hawkins developed a measurement
instrument he called the Schedule of Recent Experience (SRE).
Hawkins and Holmes then did a prospective study of hospital employees
who developed tuberculosis that also found increased SRE measurements
in the preceding years. In 1959, Holmes had Thomas Hart, a
medical student, do his thesis on another prospective tuberculosis
study that used the SRE in addition to other instruments, during which
Hart assigned point values to various items.
Hawkin’s
original SRE and possibly Hart's modifications were forerunners the
Holmes-Rahe Social Readjustment Rating Scale that assigned life change
and readjustment points to 42 representative life events.
Except
for your review article as a medical student, Hawkins and Hart are
rarely referred to. My recollection is that your own medical
student thesis in 1961 on stress and hernia also followed Meyer's
approach using the SRE. It would be of interest to learn more
about these early contributions as well as your magnificent study of
Vincent Van Gogh and his life chart.
RHR:
Tom had all third
year medical students on their Psychiatry rotation use the SRE and the
Life Chart approach with a patient of their choice. This
work-up
took about 4 hours of interviewing and another hour to write the
report. Tom had simplified the Life Chart to some degree
–
eliminating the torpedo shaped weights for the body’s organ
systems. Students in my class had not been exposed to the
Holmes-Rahe SRRS – as I was still in the early phases of that
research. It wasn’t until I was taking extensive
personal,
social, and medical histories of former political captives that I
returned to using the life chart. I simplified it further,
adding
yearly LCU values to the life events column, illness severity units for
reported illnesses, and a column for yearly assessments of two aspects
of coping – social support and life satisfaction.
To
illustrate the potential clinical usefulness of these revisions, I
constructed a Life Chart for Vincent van Gogh shown below. As
you
will see, my life chart is horizontal rather than Meyer’s
vertical display.
The chart was based on
more than 600 detailed letters to and from his
younger brother Theo, who unselfishly and continually sent him money
for living and art supplies and modeling expenses and was his main
source of social support. These letters covering a span from
1872
to 1889 provided a treasure trove of information on Vincent's life
changes, illnesses, how he coped with these and their temporal
relationships. I was able to show that periods of low life
change
and high coping capabilities coincided with good health as well as the
reverse. Conversely, the onset or exacerbation of his several
illnesses was almost always preceded by a large build-up of life change
events and poor coping skills as illustrated below. As can be
seen, there was a marked rise in life change events and an associated
huge increase in the number as well as the severity of his health
problems towards the end. It was also clear that he was
completely unable to cope with these, so it is not surprising that this
was the time he chose to end his life by shooting himself in the chest.
After retirement from the Navy I was a Research Professor at the
University of Nevada School of Medicine from 1986 until 2001.
I
conducted over 30 forensic examinations dealing with alleged stressful
life events and possible illness consequences and found that my life
chart approach often discriminated between probable versus improbable
stress causation in the onset of an illness. In that regard,
it
is very important to emphasize that life stresses, even when frequent
or severe, do not necessarily result in illness. There are
numerous influences that affect susceptibility to different diseases,
such as heredity, gender, age, race, occupation, dietary and exercise
habits, prior experience, coping skills etc.
Van Gogh Self-Portrait, 1889
Stress
differs from these and other predisposing factors in
that it
helps to explain the timing of illness onset and often its
severity. Thus, in one respect, stress may be thought of as
pulling the trigger of a loaded gun. Episodes of major
depression
recurred several times in van Gogh’s Life Chart, but the
timing
of his suicide was clearly linked to the extraordinary increase in life
change events, their associated health problems and the almost complete
lack of coping skills toward the end of his life. The
self-portrait on the left was painted after he had cut off a large
portion of his left ear in 1888. It appears to be the right
ear
because he was probably looking in a mirror at the time he was painting
this.
PJR:
I should mention
that your remarkable monograph on Vincent van Gogh explaining this in
greater detail, includes several beautiful color plates that reflect
his mood changes can be ordered on your web site
(
www.drrahe.com).
This site also offers the stress
assessment,
coping tests and stress management materials referred to in this
Newsletter, as well as the ability to schedule a telephone conversation
with you about these, and is highly recommended. After you
retired from the Navy you continued to refine and improve your
diagnostic measures as well as your treatment approaches to myocardial
infarction and PTSD. I gather that PTSD is now your major
focus
of interest since moving to Washington State in 2004 and then to Oregon
earlier this year.
RHR:
You are absolutely
correct. At the University of Nevada School of Medicine I
chose
to place my research laboratory at the Veterans Affairs Sierra Nevada
Health Care System – since my studies at this time were
highly
relevant to veterans. In my studies of reduction in health
care
utilization I modified my five psycho-educational sessions for post
myocardial infarction patients to be applicable for persons seeking
health enhancement. I also customized my Stress and Coping
Inventory (SCI) to assist in these sessions. In treating
lower to
mid-level workers, attending one session a week over five weeks proved
to be optimal. For high-level executives, however, I found
that
combining all five sessions into a weekend retreat guaranteed their
attendance to all the sessions – something that could not be
done
over a five-week interval.
My most extensive health promotion study was conducted in
California’s Silicon Valley during the hectic days of rapid
growth and profits for computer chip companies. Over 500
persons
participated in this one-year study. A Five Session Treatment
Group was offered to a randomly selected sub-sample, the remaining
subjects divided into two control groups. All three groups
received an initial SCI, a second SCI 6 months into the study and a
third SCI at the year’s end. One control group was
mailed
all the teaching materials from the five sessions but the second
control group waited to the end of the investigation to obtain this
information.
The
treatment group not only showed a
significant
reduction in illness experiences over the first three months, they
maintained this reduced illness rate over the rest of the year in
contrast to rising rates seen for both control groups.
Reviewing
HMO computerized illness reports, the Treatment group also showed a 34%
reduction in doctor visits over the follow-up year - this
reduction in
health care utilization being statistically significant.
Following 9/11, I started using these five sessions for Recovery from
Trauma. My emphasis has always been to work on recovery
following
trauma rather than to dwell on the trauma itself. I strongly
believe that this is the right approach for our current military and
civilians returning from their combat experiences in Afghanistan and
Iraq. I differ from many established PTSD treatment
approaches
that encourage a “reliving” of the trauma as being
therapeutic. For these Recovery from Trauma sessions, I
created a
Brief Stress and Coping Inventory (BSCI) along with a BSCI Exercises
Booklet to enhance the educational materials that I use during the
sessions. I should mention that an on-line version of the
BSCI
and related teaching materials is now available on
www.drrahe.com.
I
am really looking forward to discussing this and my PTSD studies at
next year's 12th International Congress on Stress, which will now be
held in the U.S.
Whenever possible, I have introduced my five Recovery Sessions from
Trauma when dealing with PTSD patients. Such sessions also
utilize the BSCI and Exercises Booklet in dealing with re-entry life
challenges following return from combat. I have found a
gratifying response to these sessions and plan to train other treatment
group leaders on how to implement these very helpful
instruments.
I can’t fully retire. Over the past four years, I
have been
working half-time as a Staff Psychiatrist for the Veterans Affairs in
Washington State and now in Oregon. I am frequently asked to
give
lectures on my research, particularly PTSD, and how to best approach
the ever increasing numbers of veterans and civilian contactors
returning from the war in Iraq. By coincidence, I just
returned
from giving the keynote address at Ana Maria Rossi's VII Congress on
Stress of the Brazil branch of the International Stress Management
Association. I also had the pleasure of presenting their
annual
Paul J. Rosch Award to Professor Sheila Murta, from the Universidade
Católica de Goiás, which provided an opportunity
to
explain a little about you and your contributions.
Dr. Richard Rahe and Professor Sheila Murta,
recipient of the annual
Paul J. Rosch Award
As you well know, Ana Maria is a human dynamo and Jim Quick and I
marveled at her boundless energy and how she has steadily improved this
event so that it has now become an important international
event.
This year's event attracted 700 people from Brazil and four other
countries including two psychologists from Angola. Redford
Williams from Duke, and President of the International Society of
Behavioral Medicine discussed "Psychosocial Risk Factors for
Cardiovascular Disease" and Ronald Schouten, Director of the Law
&
Psychiatry Service of the Massachusetts General Hospital and Professor
of Psychiatry at Harvard Medical School gave an equally informative
presentation on "Assessing and Managing Disruptive Behavior by
Executives and Professionals." Ana Maria is also very excited
about your next Congress and is eager to assist in promoting this in
any way she can.
PJR: Many
thanks. I
neglected to mention that in addition to our Hans Selye Award, you have
been the recipient of numerous honors, including the Career Achievement
Award from the International Critical Incident Stress Foundation, Navy
Commendation and Meritorious Service Medals, and have served as
President of The Psychosomatic Society and the USA branch of The
International Stress Management Association. I am looking
forward
to your participation in our 12th International Congress on Stress in
2008, where you will have a chance to reunite with old friends and
colleagues who are also enthusiastic about participating in and helping
to plan this conference, like
Herb
Benson, Cary Cooper, Lennart Levi,
Ken Pelletier, Jim Quick, Ray Rosenman, Charlie Spielberger,
Töres
Theorell, as well as others I have not yet invited to
serve on our
Scientific Advisory Board. This will be held for the first
time
in North America and although the dates and location of this two or
three day Congress have not been finalized, the new Wynn hotel in Las
Vegas and similar elegant sites in New York or Chicago are among the
current leading current contenders. Unlike prior Congresses
at
Five Star hotels in Switzerland and Hawaii, where space constraints
limited attendance and precluded having exhibits, next year's venue
will permit 500 or more registrants and up to 50 exhibits. In
addition, it will have an emphasis on Job Stress that will be targeted
to a lay audience as well as our usual assemblage of physicians, other
health care professionals and researchers. Stay tuned for
more
information on this exciting event in future Newsletters as well as
periodic updates on our web site.
