Dr Nick Read

Too tired to remember Easter.

Easter passed me by this year.  It’s not because I’m an atheist.  I think beliefs, faiths, meanings are essential to our well being, but very personal and for me not to be culturally regulated.   I believe in love, metaphysics, forgiveness, wild places and regular exercise.  No, it was because I spent Easter in the Intensive Care Unit of the Oulu University Hospital,  fighting off Malaria.  I’ve already described the circumstances in my previous blog (But they don’t get Malaria in Finland,  10th April).  What I want to think about in this piece is the why I can hardly remember anything about it, just odd glimpses of green, a male nurst who was a professional strong man, and somewhere in there the thought that I may not get through this.  I was never unconscious (except for the brief periods when I was asleep) but I was terribly tired.     

Maybe it was the tiredness.  Maybe my body was physiologically in a state of conservation and repair.  I’d stopped fighting or thinking.  I was just existing.   With the first few bouts of fever, the sensitivity of my scalp, the persistent headache, the shivering, induced a state of despair.  I was  delirious and repeating, ‘ Oh my God, Oh my God, Oh my God’, worryingly reminiscent of my mother’s  anxiety dementia.  But then I seemed to give up and accept whatever would happen. 

 Such states of body and mind correspond to Hans Selye’s  General Adaptation Syndrome (1936),  in which he documented a stereotypical responses to stressors of all kinds, physiological, medical and psychological.   They all, he concluded, tap into the same mechanism. 

The first response to a stressor is to fight it with the sympathetic nervous system; hence the anxiety, the pain, the shivering  but this gives way to a state of sweating and sleep; a state of conservation  dominated by the parasympathetic nervous system.  You see the same response in animals, whose ultimate response to overwhelming stress is to curl up in the corner of their cage and ‘play possum’.   But both people and animals vary according to whether or how quickly they exhibit which response.     

Post Traumatic Amnesia is a kind of dissociation.  It is a response to overwhelming trauma and could be thought of as a mechanism that protects the individual from the knowledge that would destroy their sense of self, like risk of death, abuse, or the collapse of a key relationship.   It is often associated with other aspects of the post-traumatic stress reaction, such as nightmares, bodily weakness, and a variety of somatic symptoms.   If you cannot remember or deal with what has happened, then nightmares and somatic symptoms often remain to express the trauma in coded form. 

So what is the mechanism?  But what is the mechanism?   The stress response not only involves the autonomic nervous system (sympathetic and parasympathetic), it also includes the hypothalamo-pituitary adrenal (HPA) system, which releases a cascade of transmitters and hormones (CRF, ACTH, cortisol, aldosterone) as a compensatory mechanism to offset the damaging effects of excessive and sustained  sympathetic arousal on the body.  The HPA system maintains the function of the organism in the face of overwhelming stress, maintaining energy supplies, damping down the immune system, suppressing inflammation and pain and blocking memory.  

So can it all be explained by activation of the HPA axis.   If so, why are Chronic Fatigue Syndrome and Alexithymia (the disconnection of the emotional and rational expression), which may both coexist as part of the post traumatic reaction, associated with diminished cortisol responses.   Does this represent a state of exhaustion or switching off.  There is never an easy response to anything. 

With a days of the Malaria being treated, the tiredness disappeared is.    I became frustrated with  being in hospital and although still weak began, to devise strategies for discharge.  The will to live had reasserted itself; what would have been the point of remembering what it was like?