Everybody gets stressed . . . it’s just the way we react that

Public mental health messages have stressed divisions between people who are experiencing mental health problems and those who are not, for example by using slogans suggesting ‘one in four’ individuals have mental disorder. Simple unambiguous messages that convey that ‘we all get stressed, we just react differently’ may be more inclusive and effective at destigmatising mental health problems. This is analogous to the attitude towards physical health problems which are accepted as affecting everyone. Such a theme is scientifically sustainable.


Need for a more inclusive approach
Public health messages about mental health issues for the general population have tended to stress differences between those with disorder and those without, for instance, 'One in four people will experience a mental health problem at some point in their lives -and they may well be one of your friends, colleagues or family members.' 1 This approach has been limited so far in its effect on reducing stigmatisation. An alternative is to stress continuities between those with mental disorder and the general population, as the title of the Royal College of Psychiatrists' campaign, Changing Minds: Every Family in the Land, did to some degree. But perhaps better would be a fully inclusive message applying to everyone, for example: Everybody gets stressed . . . it's just the way we react that differs. Some people get depressed, some anxious, others drink too much, or get confused.
The reaction depends on your 'make-up' such as personality, family history or childhood experiences, your current circumstances, for example available supports, and the nature of the stress you are experiencing.
Just as we all get physical problems at some time in our life, such as a cold or flu, so we can get stressed through overwork or become sad after bereavement. At the other extreme, we can experience a heart attack or arthritis -or psychosis -and just as it is possible to make a recovery or learn to cope with such physical problems, so recovery or coping is possible with psychosis and other mental health problems.
Such a message is much more socially inclusive than drawing distinctions between those who are ill and those who are not. It makes mental health and illness everybody's concern, just like physical health and illness. It can also be used to draw useful parallels about coping and the potential for improvement through self-help measures and treatment.

Voices from the profession
Such a clear unambiguous message received support at a recent presidential symposium on public health psychiatry involving the Department of Health, National Health Service (NHS) Confederation, and the College's Faculties and Divisions, but some psychiatrists also raised objections.
. Is this message scientifically accurate? What is the evidence that everyone gets stressed? Do we know why we react differently? . Are such reactions on a continuum with diagnosable mental disorders or are there qualitative distinctions?

Scientific evidence
The existence of mechanisms that enable humans to respond to physical and mental stress -fight, fright and flight -supports the contention that everyone gets stressed, as those mechanisms have evolved in response to survival needs. There is also strong evidence that people with different personality types react differently to stress and are more likely to develop specific mental disorders. 2 The issue of whether a continuum between normality and disorder exists may still be contentious but the evidence in support of it is now considerable. The current state of psychiatric research increasingly takes a stress-vulnerability approach to aetiology. 3,4 Genetics, childhood experience, personality and other predisposing factors interact with life experiences to produce the signs and symptoms that we recognise as mental and behavioural conditions. Such biopsychosocial models are not simply additive, 5 but dynamic, with early-life stressors or ongoing adverse circumstances becoming vulnerability factors for stressful events in the present. Terms such as 'reactive' and 'endogenous' forms of depression 6 have been abandoned in favour of 'mild', 'moderate' and 'severe'. 7 Dimensions have increasingly been considered even for psychosis, which was previously assumed to be a discrete entity.

Normality and mental illness
Continua of paranoid symptoms and hallucinations have been demonstrated 8 by investigations showing such symptoms to exist in the normal population as well as patient groups: the ranges of scores on the delusional inventory the researchers used overlapped considerably between the normal group and the group that had delusions (patients). The latter tended to have more severe distress, preoccupation and conviction but this was on a continuum with normal groups. 8 Similarly, Strauss examined Present State Examination data collected as part of the World Health Organization's International Pilot Study of Schizophrenia, in which 119 patients were interviewed. 9 The researchers found many of the responses made their questions difficult to categorise precisely. They scored half as many delusions 'questionable' as they did 'definite', and three-quarters as many hallucinations 'questionable' as 'definite'. Strauss concluded that 'phenomena like delusions and hallucinations represent points on continua'. In a later paper, 10 he expanded this to say that 'all intermediate gradations of experience exist, from normal perception to hallucinations and from normal ideation to delusions . . . many patients, for example, experience something that is more perceptual than just a strange idea but is not quite a voice. ' Strauss also stressed the importance of following patients over time, as considerable amounts of data exist that 'over periods of improvement symptoms may fade slowly through intermediate levels of experience. Hallucinations may be more and more dimly perceived until they disappear entirely'.
This universally applying message is normalising and destigmatising -if we are all affected, who are 'the mentally ill'? Any one of us can become ill depending on our circumstances -it may be transient or persistent. Some people are more likely to develop some mental illnesses but we differ according to circumstances and our individual attributes. For many people, mental illness will not interfere significantly in their lives at all or for a significant length of time, but unfortunate combinations of events can affect us all and cause more serious effects.
Would a more inclusive message have any drawbacks?
However, could such a message have the potential for adverse effects? Could it make the nation more narcissistic and less resilient? Might it increase the tendency to expect people to 'pull themselves together'? If everyone gets stressed, should not everyone learn to cope and get on with life? Will it lead to a loss of the focus that policy and services currently have on people with more severe problems? Could it risk trivialising psychiatric conditions? Such concerns need further investigation but it seems unlikely that people will become more stressed or inward-looking from better understanding the interaction of vulnerability and strengths with stress and fearing mental disorders less. It is more likely that people will present earlier with problems and primary care services would be better able and more willing to detect and manage them. Just as coping reactions to physical problems differ according to personal and social circumstances, so do self-help capacities for mental problemsneither is helped by the injunction to 'pull yourself together'. Similarly, although 'quick-fixes' can help some, more broad, sustained and systemic -and expensiveinterventions may be necessary.

Conclusions
Although there is currently a focus on people with more severe mental problems in Department of Health policy, discrimination in provision of mental health services by funding bodies at lower levels in the NHS often negates that prioritisation, and stigmatisation by the general population remains widespread. Better understanding and acceptance can change that situation if we, as a society, accept that mental health problems can be our problems as well.

Declaration of interest
None.