Posts Tagged ‘mind body medicine’
The scandal of cortisone injection material tainted with fungi has created a large burden of illness and death among a small proportion of individuals who received epidural injections for back pain. Calls for better regulation and oversight of compounding pharmacies are being made of the FDA and other governmental agencies. However, another story that may ultimately be more important needs to be highlighted. How many of these injections were indicated and how many were likely to be helpful to those receiving them? Unfortunately, studies demonstrate that the majority of these injections are not indicated and not effective.
In all medical decisions, it is incumbent upon the physician to calculate an analysis of the likely benefit of a given treatment versus the potential risk. This calculation is at the heart of all good medical practice. When a treatment is effective, doctors and patients are often willing to choose treatments that have a significant risk, such as is common in people with cancer. Another reason to tolerate treatment with significant risk is for conditions that are severely disabling, again as with cancer.
Medical decision-making for people with back pain has been very similar to that of cancer. Back pain is viewed by both doctors and patients as a severely disabling process that is likely to be chronic and unresponsive to simple interventions. Therefore, invasive treatments such as epidural and other injections, back surgery, and the use of opioid narcotic medications are commonly prescribed. The potential risk of these treatments is great as demonstrated by the fungal meningitis outbreak. In addition to this potential complication, the risks of surgery are well known, such as paralysis, infection, increased pain, and the need for re-operation. Opioids have been shown to have tremendous risk, having the potential for addiction, overdose and death, and the development of hyperalgesia, i.e., sensitizing the brain to actually experience more rather than less pain. Of course, the costs for back pain treatment are astounding, amounting to at least $100 billion per year in the U.S.
Speaking of the costs of treating back pain, the number of MRIs, injections, opiate prescriptions, and back surgeries has risen by 200-300% in the last decade or so, yet the rates of those with disabling back pain has also risen (by about 25%). What we are doing is clearly not working.
From my point if view, the problem is this: We are using the wrong approach for the majority of people with back pain. Only a small, proportion of back pain is caused by a clear pathological entity, such as a tumor, fracture, infection or obvious nerve root damage. These causes are estimated to comprise about 10-15% of those with back pain. The rest are likely caused by psycho-physiologic processes. This concept is so foreign to most people (and to most doctors) that it likely to be rejected out of hand. Yet, it is true. Minor “abnormalities” on MRIs are typically presumed to cause pain when there is no evidence that is the case. Abnormal MRIs occur in the majority of adults who have no back pain. Cutting edge neuroscience demonstrates that pain can be caused by the brain and that emotions lower the pain threshold. It is well known that the brain can create symptoms as severe as paralysis; this is called a conversion disorder.
What is not appreciated is that stress is the most common cause for chronic back pain (and other conditions such as chronic headaches, irritable bowel syndrome, and fibromyalgia). All pain is real — very real! Pain not caused by structural problems (e.g., fractures, tumors, infections) is caused by neural pathways that have been “learned” by the brain and create real physical pain. Careful histories of people with severe chronic pain uniformly uncover the underlying causes of the pain. Briefly, the situations that cause psycho-physiologic pain are those where an individual has been sensitized by stressful life events earlier in life (e.g., a controlling or abusive relative) and later a triggering event occurs such as a physical or emotional trauma that creates fear, anger, or guilt along with a sense of being trapped or feeling helpless. Severe pain develops as a reaction to these scenarios. The reason doctors never notice these connections is that they never take the time to look for them.
There is now an emerging body of literature showing that treatment of chronic back pain is effective when one uses a psycho-physiologic approach. We are in the process of publishing data showing that the majority of patients with severe chronic back pain can recover. This treatment approach is very cost-effective. In fact, it often only requires a change in how one views the cause of the pain and simple behavioral steps to change the nerve pathways causing pain. Dr. John Sarno has sold approximately a million books describing this model. From anecdotal reports, about 10% of those who have read one of these books have had rapid recoveries from chronic back pain. Can we learn something from 100,000 people? Most back pain (and other chronic painful conditions) can be cured. The current bio-technological approach of opiates, injections, and surgery is making us worse, rather than better. Millions of back pain sufferers need help and this help is closer than we think.
To your health,
Howard Schubiner, MD
The history of medicine consists of two major themes: development of new techniques to study the body and attempts to understand why illness occurs. Often these two themes lead to a synergism that creates a great advance, such as the development of the microscope so that we could actually see bacteria that cause disease. Before such technological breakthroughs occur, we are stuck trying to explain disease in the absence of being able to actually see the problem and therefore we develop theories on what is causing the problem. Sometimes these theories are correct, sometimes they are horribly wrong.
Ignaz Semmelweis was a Hungarian physician who noted that women who gave birth in the hospital setting had very high rates of post-partum infections (often fatal), while women who gave birth at home had much lower rates. The doctors at the time were doing autopsies and going from one procedure to another. Semmelweis thought that the doctors might be transmitting something to their patients thus causing the infections. He did an experiment to show that hand washing (using lime salts) actually did reduce the rates of death to below 1% (they were as high as 35%). However, he could not show why this worked and doctors didn’t believe him (despite being shown the research evidence). Sadly, Semmelweis ended up dying in an asylum in 1865 after becoming mentally ill. When one doesn’t understand the problem, the solution can be right in front of your face and yet you can’t see it.
I saw a woman this week whose story is shocking. She had a great childhood with loving parents who taught her that people could be trusted, the world was good, and that she should act with kindness and caring towards all others. She learned to sweep emotions under the rug and work harder when problems arise. She did not learn to speak up for herself. Her life was great until high school when she started a 3-year relationship with a boyfriend who came from an abusive household. Over time, he became jealous and possessive. She continued to make excuses for him and tried to be a good girlfriend, thus acceding to his increasingly controlling ways. He pushed her away from her family and her friends. He didn’t let her go out unless he was there. He even hit her on two occasions. And she continued to make excuses for him and cover up her pain and distress. She tried to be an even better girlfriend and hoped he would change. He didn’t; and finally (with the help of her sister) she broke up with him. She went off to college and did well. Her life was back on track. She was an active athlete and even ran in marathons. In her first job, she desperately wanted to prove herself and become the best employee in the company. However, her boss was someone who took advantage of that attitude and her inability to speak up for herself. The boss piled more and more work onto her, causing her to work evenings and weekends. The boss did less and less. Yet my patient never spoke up to ask for some changes to be made. She felt trapped and her feelings were similar to how she felt when in a relationship with her abusive high school boyfriend. It was during this period in her life that her pain started.
This blog was written by a friend and writer, Jared Egol. He writes eloquently about the patient’s history as “story” and the concept of “narrative medicine,” i.e. seeing the patient’s story as critical to healing. When the person with Mind Body Syndrome sees that they are, in fact, the “hero” of the story, they will be much farther on the road to recovery.
To your health, Howard Schubiner, MD
The Hero’s Journey as Story: The Irreducible Diagnostic Criterion
by Jared Egol
The patient, in present times, faces chronic, painful and dismissively mistreated and misappropriated syndromes of stalled emotional progress. Despite seeking to function at our service against pain and a variety of illness, medicine is traipsing feet-first into a biologic-centric approach to the treatment of our stories. Stories are completed, edited, examined, shared and propagated. And, most importantly, they are added to. They are not treated. Any treatment becomes a subscript to the through-line of how our life proceeds postscript. Health, like being human, is raconteurism. It wishes to be resolved and triumphant.
While the scientific community begins to trumpet the mind-body connection as a wellspring for treatment possibility, it seems to passively disconfirm the blunt fullness of what mind-body awareness can be, greater than the sum of its words on paper: that the qualitative first step to treatment starts pre-diagnosis and pre-medicine, at the human condition, which in and of itself is idiopathic. If the mind-body paradigm is to someday be championed as a keystone of accepted treatment in the 32nd century, it must concede that the human condition’s only unit of perceivable measure by outside meters can be its stories, just as atmospheric pressure cannot be interpreted in kilojoules. By dimensional analysis, if spoken words are the sub-units of those stories, then the feelings evoked, hugs had, nods afforded and change experienced by the recipients of them are the units of their transfer: lessons.
I believe that the doctors who rise above the ranks will be those identified as narratorial asides in the stories of the hero –the patient– who takes and imparts lessons in equal measure to the physician. Even the word-bare, thought and action-heavy field of intensive care, which my father occupied himself with for almost three decades, will one day evolve to contain the parameters of narrative in its protocol, even if I don’t know how it will look.
If you’ve seen the movie, The King’s Speech, you will immediately recognize that the king suffered from a form of Mind Body Syndrome. He had a very difficult childhood, despite (or because of) being a prince. His parents were not present (as was the custom for those days and that class) and his major source of “parental” affection was from his nanny. Unfortunately, his nanny favored his older brother who tormented him and therefore George grew up feeling less worthy, unloved, and unable to assert himself. All of this eventually led to the expression of his underlying emotional conflicts in his stammer. The origin of his stammer was clear (it was the physical manifestation of underlying psychological issues). Why did it persist for so many years? The answer is that it became a learned nerve pathway. That pattern of speech became ingrained into his nervous system over time and that was the natural way that his brain processed the signals when he was required to speak. Of course, the stammer would be more severe under times of stress, but it couldn’t be reversed until he had treatment that helped to uncover the underlying conflicts and conscious application of methods to reverse the nerve pathways.
Stuttering (or stammering, I believe these can be used interchangeably) is quite common in children. I don’t recall this, but my mother told me that I started to stutter right after my sister was born. I guess I was used to being the “prince” in my household until she came along to usurp my parents attention. Fortunately, it didn’t last too long. My mother got me to sing songs (the stutter disappeared during singing) much of the time, gave me extra attention, and the nerve pathways reversed over time.
Stuttering typically begins in childhood, but there is another form of stress-induced speech disorder that usually begins later in life that is similar to stuttering, spasmodic dysphonia. This condition occurs primarily in young adults (ages 30-50) and is more likely to affect women, which is similar to the demographics of those who suffer from Mind Body syndromes, such as headaches, fibromyalgia, back and neck pain, and irritable bowel and bladder syndromes. There is no known abnormality of the vocal cords, per se. The difficulty in speaking is variable, can be made worse with stress, and may not occur during singing or speaking in high pitched voices (when slightly different nerve pathways are activated, as apparently my mother figured out when trying to help my stuttering). Some professional singers suffer from this condition and can have difficulty in singing.
When I have conducted detailed interviews with people with spasmodic dysphonia, the typical pattern emotional events that create MBS are present. We find childhood priming events (such as emotional, physical or sexual abuse, or situations similar to those experienced by the later King George) and triggering events later in life (such as losses, situations that trigger the “danger” signals, etc.) that produce the nerve pathways leading to the characteristic speech pattern of spasmodic dysphonia.
Naming an illness can be one of the most critical aspects of caring for someone, especially if the illness falls into the category of stress-related illnesses. It is a universal truth that anyone with medical symptoms wants and in fact, needs to know what is causing it. So often in modern medicine, our answer is “We don’t know.” We don’t know why some people get cancer and others don’t. Many people with heart attacks have normal cholesterol levels and no obvious risk factors for heart disease.
For stress related illnesses, such as migraine and tension headaches, fibromyalgia, TMJ syndrome, irritable bowel and bladder syndromes, fatigue, and most people with chronic neck and back pain, it is absolutely critical to be able to name the illness correctly. Doctors who are unfamiliar with the powerful role the mind has in being able to produce significant and sometimes severe physical symptoms will always label the illness as a purely physical one. Hence, we see the proliferation of illnesses named as a syndrome or with a description that doesn’t help the person understand the true underlying cause of the illness. Fibromyalgia is a good example of a severe syndrome who’s name literally means “pain in muscles and tendons.” Unfortunately, people with this disorder already know that they have pain. The name helps to legitimize the disorder, but it doesn’t help to solve the problem of helping them get rid of their pain. In fact, the name can become a prison of sorts and can give them the impression that they will always be in pain, because the medication and physical therapies usually do not work.
Therefore, for stress-related illnesses in which there is no tissue destruction in the body (e.g. not cancer, or stroke, or heart disease, or diabetes, or lupus, or rheumatoid arthritis), it can be extremely helpful to learn that one actually has a mind body issue, which Dr. Sarno terms Tension Myositis Syndrome, while I tend to use the term, Mind Body Syndrome. These terms mean the same thing; that the symptoms are caused by reactions in the body to stress and emotions, which can be both conscious and/or subconscious. The reason I don’t use TMS as often is that it implies some inflammation in the muscles (the definition of myositis), and there is no inflammation in the muscles in TMS/MBS. Dr. Sarno has started to use the term, Tension Myoneural Syndrome more recently, which keeps the same letters of TMS, but takes out the inflammation reference. Read more »