Residents still suffering from 'quake-brain'

JOHN MCCRONE
Last updated 14:11 14/09/2013
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GREY MATTERS: Quake-brain has got worse for many as the earthquake recovery reaches its third year.

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Quake-brain, that feeling of mental fatigue and overload, has got worse for many as the earthquake recovery reaches its third year. So what do the experts say? JOHN McCRONE reports.

A couple of weeks ago I was celebrating. The quake-brain, the mental fog, had lifted. I celebrated too soon of course.

After a month of clear- headedness, a month of being busy, on the Monday morning I woke up with a ringing in the ears. The tinnitus, a feature since the earthquakes, was suddenly much worse.

There was that brain fatigue that said "don't want to be doing nothing". There was the inability to string sentences together when I did eventually force myself to work.

A day or so was lost out of the week's schedule and so followed the fluttering stomach, the sense of pressure and rush, as deadlines loomed.

A colleague told me how he had risen at 4am on the Saturday, driven to Twizel just for a morning of fishing. The notion of such an act of self-care was wonderful, but itself would have demanded a reserve of mental energy.

Climbing a mountain before lunch was something I used to get out and do in the old Christchurch. With quake-brain, weekends have contracted to a quiet read and gentle gardening.

It is no surprise that four big shakes and 10,000 aftershocks might have had some psychological effect. But unexpected is the way the impact has gone on and presented as a rollercoaster variety of symptoms. Or maybe it is only me.

The first year seemed all right. On February 22, as the Press building in Cathedral Square shook and the bricks rained past the window, while the ceiling beams danced in their sockets, I still found time in the dust to gather up my notebooks and files, collect what I needed to finish filing that week's feature. Keep calm and carry on.

It was only a year later after the aftershocks had almost gone that I found myself flinching much more than I cared to admit at any passing rumble - even the kids sliding a wardrobe door upstairs.

Then followed a strange succession of physical symptoms. A few weeks of arthritic flares in my ankles and hips were so severe that I could barely walk the length of a corridor. Then came the start of the tinnitus. Irritable bowel syndrome appeared for a short time. There was all the evidence of a stress reaction, yet not fitting a settled pattern.

Doctor's checks were fruitless. However I took the sensible advice. I got back into the regular exercise I had neglected because work was full on and I had been "too busy". Cut out drink completely after getting into the habit of an extra one to round out the evening.

On my wife's urging, I even took an "adrenal support" regime of St John's wort and vitamin B, despite health shop supplements not being my thing.

Careful living seemed to help with the physical signs. But then this year has come what seems the belated mental hangover. The flatness of actual depression when even food loses its taste - a woolliness of concentration that makes focusing to write a battle of will.

On the worst days I had to wonder if my mind was somehow permanently damaged. What if the sharpness never came back?

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But enough of the confessions. Already I am feeling guilty about dwelling on them when I know so many others around me are feeling worse, and with far more damaged homes and disrupted lives, they have every right to feel worse.

And you only have to mention Syria or Haiti to think this quake- brain complaining is largely "first world problems" talk. A loss of mental edge, a mild case of the blues, only matters in the context of expecting to be able to sit down in front of a keyboard and concentrate for at least six hours solid.

So enough about me. What about you?

The Canterbury earthquakes do appear to offer some gigantic lesson about stress and that now hated word - resilience.

Psychologists like Massey University associate professor of disaster mental health Sarb Johal say do not underestimate the effects. Remarkably few people died, so there is not the straight- out level of trauma seen perhaps in earthquakes, bushfires or civil wars elsewhere.

But this was an event that happened to a whole modern city, says Johal. And it repeated four times over 16 months, creating a compounding sense of dread and dislocation.

So while it is easy to dismiss many of the mental health concerns as indeed first world problems - yeah, life is tough, but it is tougher everywhere else - the impact the quakes have had on a well-prepared developed nation is all the more reason why the experts are interested in how we are coping and what could be improved.

First some disentangling. Quake-brain is a useful collective term for a lot of feelings that people are still having. But how it manifests is quite varied.

And there is the further question of how much is due directly to the experience of the earthquakes themselves, the chronic exacerbation of biological fight-or-flight responses, and how much relates really to the problems of the recovery - the insurance issues, the school closures, the lost central city, even just the daily battle with the potholes and traffic.

One apparently obvious thought is that a woolly brain might be largely a physical reaction to a prolonged exposure to stress hormones, some kind of neurotransmitter burn-out. Parallels have been drawn with the phenomenon of chemo fog, or post-chemotherapy cognitive impairment (PCCI), a similar sounding malaise in those undergoing chemotherapy.

PCCI was first recognised in breast cancer patients who complained of difficulties in concentrating and multi-tasking that ran on even long after their treatment had finished.

Researchers noted this mind fogging was picked up precisely because breast cancer patients included a lot of young professional women who were quickly back at work and needed their mental edge - women who if they couldn't push themselves to the limit, felt impaired, as one medical scientist remarked.

A more recent study has made a link with the body's immune response. Doing elaborate experiments with gene-knockout mice, University of Virginia school of medicine neuroimmunologist Jonathan Kipnis has claimed that a misfiring immune system can hit the brain by triggering a low-level inflammatory reaction.

The brain is a molecularly active organ, says Kipnis, with a high turnover of cellular building blocks as it continually makes new connections. The immune system can mistake this activity for a foreign invasion, attacking the brain at a low level, and a fuzzy flu- like state results.

Cognitive impairment is a common symptom of many immune and stress-related diseases, such as irritable bowel syndrome and multiple sclerosis. The fact just doesn't get remarked upon because the other symptoms of such diseases seem of obviously greater importance.

So quake-brain could be the mental hangover produced by the intimate connection between the brain, the immune system and prolonged stress. Although Otago University School of Medicine researcher David Perez, who has been studying "cancer brain", warns he would be cautious of any simple answer here.

Perez says there is indeed evidence of raised cytokine immune signalling and inflammatory responses in the brains of cancer patients. "But you can be pretty sure it'll be a multi- factorial thing, " he adds.

Others, like Canterbury University associate professor of psychology Deak Helton, agree.

Helton, who has compared students' performance on concentration tests before and after the earthquakes, says it is tempting to think of quake-brain as simply jangling nerves - a belated shellshock. But the nervous system is in fact well designed for coping with immediate physical threats like the quakes themselves.

Helton well remembers stumbling out of his seven-storey university building on February 22 and watching it continue to jump up and down by a metre. 

"That's hardly normal." Yet he says except in cases of true trauma, the mind recovers quite well from such sudden shocks.

So he puts quake-brain down much more to the recovery. Helton says it is about the dispiriting new complexity of life and the cognitive overload that results. The brain has a limited capacity to attend to things and the quakes have ripped up almost everyone's normal routines.

"It's not so much about emotional distress but that our environment is still radically changing. Constantly things are coming and going. Like in Sumner, they've just found the local movie theatre has structural faults and is having to shut down.

"You have to use a lot of mental effort just to keep up with where things are. I use the analogy that it's like you're making dinner and someone came in right beforehand and moved everything in your kitchen around. It takes extra time just to find your spice rack."

Helton says when the earthquakes were actually happening, the city was in its heroic phase. People were banding together, just doing what was needed to cope. "It was basic survival mode stuff."

But now it has got more individual again as people are having to sort out their lives and face a barrage of decisions. The stresses become cumulative.

"Many of us are dealing with very cognitively complex negotiations with insurers and builders. And these people have their realities too. We know they are going to rush to get things signed off.

"So we need the willpower to stay on it. But that's hard to do when the burst of physical excitement from the quakes has gone and we're doing it when we're also really fatigued."

Helton says personal differences, probably genetic, do play a role. Broadly speaking, the brain has two kinds of responses to stressful situations - anxiety or depression.

This is part of the brain's ancient flight-or-fight machinery. When danger threatens, we can either cast about frantically for avenues of escape, or instead follow the other ancient evolutionary strategy of just freezing - sitting tight, immobile, hoping danger does not notice us and walks on by.

Helton says after the earthquakes, he found these different cognitive tendencies showing up in how people performed on tasks like spotting a target word amid a screen full of distractors.

Compared with before the earthquakes, everyone did worse because their minds were elsewhere. But those with a more anxious, action-seeking, disposition were making mistakes because they reacted to the task with impulsive speed, while those with a more inward or depressive response were striving for accuracy and so took too long to hit the button.

So you have a general issue of minds clogged by complications and uncertainties says Helton. Even for those whose homes escaped lightly, dealing with life in post-quake Christchurch is a fatiguing preoccupation.

And then there are the differences of whether this produces a more anxious or more depressive response. Then on top of that, finding yourself tired, forgetful or distracted has a feedback effect. Not getting things done becomes its own source of pressure, a further preoccupation.

So Helton feels quake-brain is not so difficult to explain really. Nor why, three years after the earthquakes but only part way into the recovery, the mental health issues may still loom quite large.

Believe it or not, Canterbury was in fact ready for the rolling psychological impact of an event like the earthquakes. There were systems in place and now those systems have been tested.

Massey's Johal says around the world developed nations have been thinking about how to deal with the psycho-social aftermath of disasters. For the United States, the September 11, 2001 attacks were a wake-up call. The United Kingdom acted rather directly to the 2002 Bali bombings, and Australia to its bushfires. International guidelines have been written now.

Johal himself led the drafting of New Zealand's Ministry of Health strategy in 2007. And it marked a shift in thinking due to the ''positive psychology'' movement where the emphasis is on avoiding over-medicalising mental health issues and instead relying on self-help techniques and community-level social support.

''Rather than focusing on vulnerabilities and what  agencies can do to fix people, we look at what we can do to enable people to understand their situation and to help each other as well as help themselves - support that rather than doing it for them,'' says Johal.

So the authorities had a manual that from the start made for a consistent approach after the Canterbury earthquakes.

''There was an intervention pyramid so that we knew for the majority of people, basic support - food, water, community reunification, good communications - would go a long way to making them feel connected with their communities, safe and secure for the challenges ahead

''Once you've got that sorted, that's a really good platform. And you don't go in and do counselling until you do get that stuff sorted.''

It was also understood that the support would have to be there for the long haul. Australia, for instance, made a mistake in withdrawing its services too soon, only after about a year, following the bushfires. But the research warned recovery stress was cumulative. The third year can be the hardest, as many in Canterbury are finding.Canterbury had its own valuable mental health initiatives already in place as well, says Johal - general changes to mental health care that had been designed to catch problems earlier, nip them in the bud.

The District Health Board (DHB) had introduced a doctor-level system of brief interventions where people can get two or three quick counselling sessions from their GPs. Canterbury also makes more use of NGOs such as Mental Health Advocacy and Peer Support (MHAPS) to tackle anxiety and depression before issues become acute.

Johal says another feature of the Canterbury earthquake recovery has been the use of social messaging - treatment at the public level.In mid-2012, it was picked up that the ''resilient'' and ''staunch Cantabrian'' tags were becoming self-defeating. It was important for people to feel it was normal to be finding it tough and OK to be seeking help. So the ''All Right?'' wellbeing campaign was launched and has been a great success.

''There's been a really good wrap-around group of services and, internationally, people have been looking at this and going 'wow'. The All Right? campaign was an example of how to deploy the principles of positive psychology in the public mental health space, enabling people to reflect upon their lives and encouraging them to take action, giving them the options.''

So far as there is a first world approach to the mental consequences of such a widespread event, Canterbury has being using the right model to support its population, Johal says.

Yet still people will struggle. The earthquakes were a shock, especially to people's sense of agency, says Johal.

Again, the first world problems - we expect a lot of control over our lives and first nature showed us who was in charge, then there were the red-zone decisions, the insurance fights, the demolition of much that was familiar.

So quake-brain is a state of mind that is pretty normal given the circumstances. And even when mild, it may loom as significant when we are accustomed to a world that is usually so highly ordered.

But with the sensible basics, says Johal - sleep, exercise, social contact, pacing yourself, accepting help - people will give themselves the best chance to come through it. Time really is the healer here.

- The Press

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