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Fort Hood: When Stress Kills

It's beginning to look like our lives are more at stake than we care to acknowledge and if we don't do something different, well...any one of us could be dead sooner than we think.
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Maybe it's time to put daily stress reduction activities more front and center in the big picture of a personal preventive health strategy.

It's beginning to look like our lives are more at stake than we care to acknowledge and if we don't do something different, well...any one of us could be dead sooner than we think.

Another report of tragic loss and violence hit the news. This time it was a massacre of soldiers at Fort Hood, Texas. Initially, I did not hear that the perpetrator, U.S. Army Major Nidal Malik Hasan, was a psychiatrist and fellow soldier. This piece of information added a deeper layer of complexity to understanding why this happened. Psychiatrists are among a handful of professionals we trust to manage distressful emotional states and it's highly unusual for a person with his training to feel such a deep sense of anguish about his situation that the only option would be to kill others. In journalistic interviews subsequent to the killings, classmates from his Walter Reed Hospital medical training days shared that his discontent was professionally evident. Furthermore, his blogs indicated that he had unusual views on violent religious self-sacrifice. Bottom line: facing his first deployment to the Middle East it seemed that, as a Muslim American, he was deeply conflicted about the United States' commitment to the wars in Iraq and Afghanistan. So strongly did he feel trapped by the idea of serving in one of these war zones that something inside him snapped, transforming him from a healer into a murderer.

Major Hasan's actions caused me to reflect on the experiences of a colleague who, a few decades back, had accepted a military scholarship for medical training. The debt for each year of medical school training was covered in trade for subsequent service as a board certified physician in a military hospital or medical facility. Alternatively, if he opted for conventional financing he faced medical school tuition debt that would quadruple yearly from the time he began borrowing funds. The proposition of a military scholarship looked enticing. The US was in peace time when he thought about his choices. At worst he reasoned, he would be deployed in a remote military hospital or rural dispensary around the world helping his fellow soldiers in peace time situations. Then came the Desert Storm and later our involvement with Bosnia. As time passed it became increasingly apparent that his eventual tour of duty would not necessarily be in a peace time situation. He struggled with the ideology of service in an active wartime situation--as a pacifist it had not occurred to him that his personal ideology would be so professionally psychologically disruptive. After all he was an emergency room physician where emotion and professional performance were easily walled off from one another. And yet the commitment of military service--even as a physician had become personally problematic. After much deliberation even to the point of considering fleeing the United States to dodge service, he opted to undergo the process for early release from his military scholarship.

Early repayment posed a significant financial burden, there would be financial penalties that increased the amount of money he was required to payback but he reasoned it was worth it. As it turned out, the process was arduous and long. Understandably, establishing reasonable cause for his early departure from the obligation of his military scholarship was a big assignment. Furthermore, because he was leaving on the basis of being a conscientious objector to war--he was subjected to an endless battery of tests and psychiatric evaluations. The process was grueling and humiliating. Before long he began to feel demoralized. In the darkest moments he truly felt trapped -- envisioning that there would be no option for a way out. In this moment of despair, his mental state was so fragile he became suicidal and required in-patient psychiatric observation. His wife, also a physician, was facing enormous pressure -- coping with the painful psychiatric condition of her husband, their uncertain future and the demands expected of her in her own career. Chock full of strain, their marriage was sadly also in a tenuous situation. Thankfully the complexity of their lives did not include children.

In a year's time, I witnessed the transformation of my friend from a robust, jovial, highly competent physician and compassionate human being into that of a shell of his former self. As a friend to both, it was enormously painful seeing things unravel so darkly. In the end, he was released from his obligation, he repaid the scholarship money which had funded his medical education and also paid off the financial penalty for early withdrawal from the program. It took several years for my friends to recover from the incredible pressure and extreme stress of that time. For them life has a happy ending. They weathered the difficulty, are still together and have healthy grown children.

Fast forwarding to today and reflecting once again on the massacre at Fort Hood, it's clear that we don't yet know all the details about why this individual chose to be violent. However, we do know that this physician struggled deeply for years with his religious beliefs and his impending tour of duty and role in the military. I wonder if the cumulative effect of two decades worth of lifestyle and cultural changes were significant enough factors to predispose someone who feels trapped to behave in a much more extreme--even violent way. Americans' views on religion and politics are much more polarized than ever before. Collectively we are expressing much more intolerance towards others differences. Financial security is on the line and the future of a more benign outcome is uncertain. Our lifestyle is much more frenetic and hurried. On top of all this, the usual means of weathering difficulty through social support often falls to the wayside. And lastly, in a military setting, I imagine working in an environment where many are serving multiple tours of duty must be an additional source of strain.

Sadly, not twelve hours after I learned of Major Hasan's rampage, I heard about another troubled individual--this time a civilian in Orlando, Florida going on a shooting spree, killing two and injuring eight others. It's November and it seems to me that this year in particular we have been hearing of more and more random acts of violence by individuals on killing sprees. Clearly our ability to cope with extreme stress has been challenged and those with undetected psychiatric disturbances are demonstrating their distress more violently as well. The Mental Health Parity act which goes into effect on January 1st, requires that group plans who cover more than 50 people provide the same level of coverage for mental health and substance abuse as they do for medical ones. Hopefully this will translate into all of us using the increased mental health access. No one knows whether this mandate will generate a rash of new pre-certification requirements by employers as they attempt to implement this legislation. Will the support be enough? Or do we need to be even more proactive about reducing the effects of stress on our health ?

In a preventive medical healthcare setting before disease hits we as patients are, in the best of proactive medical situations, educated by our doctors and other healthcare professionals about diet, exercise and positive lifestyle practices. Stress is generally acknowledged as unhealthy. We're told we should reduce it in our lives but there isn't a lot of time devoted to teaching how to cope with it. It doesn't necessarily take that much time to teach people something they can do daily to reduce stress and its effects. As an example, here is a simple breath exercise I share frequently with patients that is one of my favorite relaxation techniques. I call it the 4/5 breath exercise. It takes less than a minute and quickly accesses the body's natural relaxation response. It goes like this: you inhale through the nose to a count of four, hold your breath for at least one count then exhale slowly through your mouth to a count of five. I usually recommend four breaths in the morning and four in the evening. It's not a panacea for complex psycho/social situations but chronic stress without some healthy daily stress reduction pushback is showing us new, novel and unwanted outcomes