Author Archives: Dr. Schubiner

Blog #37: Medical myopia and common sense

Deborah Amos, a reporter for National Public Radio, gave a talk recently about her work in the Middle East.  She was discussing the tense and contentious negotiations between the United States and Iraq regarding Iraq’s nuclear energy/nuclear bomb development program.  As an aside, Deborah noted that the Iraqi foreign minister developed acute back pain every time the negotiations hit a particularly tense spot.  The audience laughed and it seemed so obvious that this pain was causally related to the stress of the situation this man found himself in.  Simply common sense, it would seem.

Last month, there was a report on NPR’s Morning Edition about teenagers who are stressed.  The reporter described a growing trend of teenagers who are smart, highly motivated, and involved in many activities.  They tend to work very hard trying to obtain good grades in advanced placement classes, and are involved in several clubs, science projects, athletics, and volunteer work.  Unfortunately, they may develop signs of stress, such as headaches and stomach pains.  They are more likely to be young women who are conscientious, caring, and sensitive.  The report described one such young woman who decided to cut back on some of her activities and take fewer AP classes.  The result was that she felt better and her headaches and stomachaches went away.

These reports imply a relationship between stress and physical symptoms, such as back pain, headaches and stomachaches.  Simply common sense, it would seem.

Yet, when patients present to physicians with chronic symptoms, the concept that stress may be the primary culprit is not entertained, despite evidence to the contrary.

A report from the Kansas City Star this month described a growing trend of a disorder known as widespread pain disorder in young women.  This syndrome describes pain in one part of the body that spreads to many parts.  There is no known medical cause and there is no evidence of tissue damage.  The young women described in the article tend to be teenagers who are highly motivated, overly committed, and “stressed out.”  The article described a treatment program that centers on exercise and physical therapy, although it does include some family counseling.  These programs cost tens of thousands of dollars.  The physicians however are careful not to imply to the patients and families that this syndrome is caused by stress.

Similarly, an article in the New York Times this week described the syndrome of chronic pelvic pain that is being treated with an electrical wand that applies stimulation to trigger points in the muscles of the pelvis.  The wand must be applied through the rectum in men; and sometimes through the vagina in women.  Interestingly, the title of the article is “A fix for stress-related pelvic pain” and patients can buy the wand for $800 and learn how to apply it to themselves for $4300.  The protocol includes relaxation exercises, but avoids looking at the stress in their patients’ lives as a cause for the symptoms.

Finally, an article was recently published in the Journal of the American Medical Association on children with migraine headaches.  The research compared using medication plus cognitive behavioral therapy (CBT) to medication without CBT.  The study found that those who got CBT had fewer migraines than those who didn’t.  In an accompanying editorial, this comment seemed to sum up the view of modern medicine to these stress-related illnesses:

“Unless communicated carefully, suggesting a child see a therapist for headache treatment could inadvertently imply that the origin of chronic migraine is psychological.”

Modern medicine is myopic when it comes to stress-related illness.  Even when the evidence clearly points to stress as the cause of physical symptoms, we are loath to use common sense.  We attempt to avoid the simple explanation that stress causes real physical reactions in the body; that stress causes real pain.  Avoiding this concept leads to treatments that are expensive and don’t specifically target the cause.  Even if the patient gets better (it is interesting to note that none of the young women interviewed in the article on widespread pain syndrome were pain-free), they are not likely to develop the understanding and self-knowledge that they will need to deal with both current and future stressful situations.  They are also not likely to understand that physical symptoms that may arise in the future can also be stress-related, which is critical to avoiding costly and misleading medical workups.

If physicians and other health professionals used common sense, they would be more likely to help patients identify stress-related illnesses as being simply that: stress-related illnesses.  They could help their patients understand this and get treatment specifically directed at understanding the relationship between the mind and the body and dealing with thoughts and emotions that trigger pain and other symptoms.  Simply common sense, it would seem.

To your health,

Howard Schubiner, MD

 

Blog #36: The bio-technological approach to back pain: Dangerous road ahead

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

MBS Blog #35: When the cure is worse than the disease: Exposing medical myopia

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.

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MBS Blog #34: Can tics be contagious?

Can tics be contagious?

The story from upstate New York doesn’t want to go away. There have been at least three national TV spots in the last few weeks about the 12 high school students who have developed tics. Neurologists consider tics and Tourette’s syndrome to be chronic neurologic disorders that are primarily inherited. The treatment consists of medications to attempt to control the abnormal movements and it is not generally believed that individuals can have any control over their tics.

However, the mini-epidemic in LeRoy High School near Buffalo is believed by excellent neurologists to be caused by a conversion disorder, i.e. a physical symptom that is not a pathological or structural process, but is caused by stress and unresolved emotions. In other words, this is a manifestation of Mind Body Syndrome (MBS) or a Psychophysiologic Disorder (PPD). (I will use these terms interchangeably.)

When one looks at the history of mini-epidemics of PPD, evidence abounds that PPD is a contagious disorder. There have been well-documented epidemics of repetitive stress injury, sick building syndrome, and psychogenic seizure-like activity (also known as pseudo-seizures). There is an interesting research article from Germany that demonstrates that back pain appeared to be contagious after the fall of the Berlin Wall. So, it isn’t really surprising that almost any symptom can be caused by MBS. Once a careful medical history, physical exam, and environmental evaluation rules out evidence for a pathological disorder, the diagnosis of MBS should be confirmed.

In the LeRoy High School situation, experts have done this and have concluded that the girls are suffering from PPD. However, this apparently hasn’t gone over very well with the patients, their parents, or many members of the community. Today’s report showed angry parents filling a meeting of the school board asking them to prove that their buildings are safe. Of course, they have a clean bill of building health from the state of New York and the CDC. Yet, a psychological explanation for physical symptoms doesn’t seem to ring true or satisfy most people.

Over the past few weeks, I have encountered several stories about tics and Tourette’s syndrome that suggest that it may not be as much of a neurological disease as we once thought. Story #1: A friend told me about a young man who suffered with Tourette’s for his whole childhood and adolescence. As an adult, he participated in an intensive psychological retreat during which he expressed and processed many emotional issues from his life. The tics resolved.

Story #2: I met a psychologist who told me that he cured a teenager of Tourette’s “by accident.” The young man was sitting in the psychologist’s office and while waiting, he was throwing some balls into a box over and over. When the psychologist entered, the boy apologized for his behavior and stopped. But the psychologist suggested that it was fine to throw these balls and encouraged him to continue to do so, which he did. During the course of a single one hour session, the boy expressed many issues that were bothering him and threw the balls more forcefully. Following the session, he seemed relieved. The tics disappeared and never returned.

Story #3: I was telling these stories to a friend. He immediately began to tell me his story. As a child, he was diagnosed with Tourette’s syndrome. The tics were incredibly embarrassing and humiliating to him. He hated them and vowed to stop them. He decided to resist them and spent many nights in bed holding his body against the urge to “tic.” After a few weeks of mental effort directed to stopping the tics, they went away and have not recurred.

I am not suggesting that all tics or all Tourette’s syndrome is caused by PPD, but it wouldn’t surprise me if many cases are. It is interesting that over time, people with Tourette’s tend to grimace and even swear uncontrollably. Grimacing and swearing, of course, are signs of anger. Could it be that some people with Tourette’s syndrome have unresolved resentment, anger, or rage? It would certainly be wonderful if there were a relatively simple solution to these horrible disorders. We need to do some studies to determine if tics and Tourette’s may respond to our usual MBS approach and treatment. If you know of people with these disorders who are interested, please have them contact me at hschubiner@gmail.com

It shouldn’t be too surprising that some neurological events are contagious. Patterns of speech are clearly neurological events. People who grow up in the south have different speech patterns and inflections than do those from the north. Phrases such as “like” and “you know” have become ubiquitous in the speech patterns of teenagers (and adults) in recent years. If these neurological events are contagious, why not tics?

To your health,
Howard Schubiner, MD

MBS Blog #33–The Hero’s Journey (guest blog by Jared Egol)

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.

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The Black Swan and the Pursuit of Perfection: MBS Blog # 32

If you’ve seen the Black Swan, you will probably recognize many aspects of Mind Body Syndrome in the protagonist, Nina. She lived in a world where she denied herself pleasure because she had placed too many demands upon herself and her body. Her’s was the world of ballet, but it is truly a metaphor for the millions of women who are trapped in a world of work, child and parent care, financial issues, difficult marriages, and troubled relationships with parents, children or siblings. A common thread often seen in the development of chronic pain or other mind body syndromes (such as fibromyalgia, neck or back pain, irritable bowel or bladder syndrome, pelvic pain, headaches and migraine, chronic fatigue, and insomnia) is the pursuit of perfectionism. People who grew up with emotionally, physically, or sexually abusive events or with love being given primarily for performance tend to have low self-esteem. They tend to try extra hard to please and to prove that they are worthy, good, and lovable. Unfortunately, their quest often becomes never ending as they may seek love from those who have criticized or abused them or from people who act in similar ways. They frequently repeat their childhood experiences and continue to feel even more unworthy and unlovable.

The only way out of this horrible cycle is to recognize this whole pattern and take control over it. There is no such thing as someone who is unworthy of self-respect and of love. We all have those things as part of our birthright. The most important thing that I teach in my Mind Body Syndrome program is “be kind to yourself.” Cultivating kindness to self, acceptance of self and forgiveness to self are key aspects of healing. Without this, we are often stuck in an endless search for relief from pain and suffering. There are several exercises in the program (see Unlearn Your Pain) that help to create these qualities. When people are kind and accepting to themselves, they feel so much better about everything in their lives. Research confirms this as work by Dr. Kristin Neff at the University of Texas shows that self-compassion improves motivation and happiness, while decreasing anxiety and depression. There are a couple of excellent books that I recommend. The Spirituality of Imperfection by Ernest Kurtz and The Mindful Path to Self-Compassion by Chris Germer offer great insight and exercises to help those who tend to “beat themselves up.” Dr. Neff is publishing a book entitled, Self-Compassion: Stop Beating Yourself Up and Leave Insecurity Behind.

In The Black Swan, Nina sacrificed herself for her art and plunged into the depths of insanity. I have seen people who were so consumed with guilt, shame or fear that they were held hostage by these powerful emotions, stuck in chronic pain, fatigue, anxiety, and/or depression. Developing a healthy sense of self, giving oneself the benefit of the doubt, taking time for oneself, and accepting our faults are all critical steps in the process of healing. Do yourself a favor by doing yourself a favor!

To your health,
Howard Schubiner, MD

MBS BLOG # 31–The King’s Speech as Mind Body Syndrome: Finding your voice and reclaiming your life

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.

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#12 Back pain: the truth and the science to prove it

This is the second part of a blog about back pain.  This blog deals with the MBS approach to understanding back pain.

 

How can back pain occur in the absence of something wrong with the back?

 

There is a way to explain this based on new research into how the brain changes over time (neuroplasticity).  One way is to consider what happens in phantom limb syndrome.  In this situation, there is pain in the area of the body that is missing; that has been amputated.  Clearly, there is nothing wrong with the area where the pain is felt, yet there can be severe pain.  In this case, the pain appears to be due to sensitization of nerve fibers that go back to the brain, amplification of pain in the brain and a conditioned response of nerve fibers going back to the body.  The brain and body have in essence learned to have this pain.  The nerve connections have gotten fired after the amputation, but then have gotten “wired” and keep sending pain signals, which are felt to be in the amputated limb.  It is likely that back pain (and other pain syndromes, including headaches, abdominal and pelvic pain, whiplash, fibromyalgia and TMJ pain) is caused in many people by similar nerve pathways. 

 

 

 

What triggers this type of back pain to start and become chronic?

 

The answer is surprising and even offensive to some people and that is stress and emotional reactions to stressful events.  A classic study showed the Boeing employees over four years and found that psychological stress predicted back pain much more than any other variable, including how much they used their back on their job.  Other studies in Sweden, Holland, and England showed similar findings.  In fact, job satisfaction is the most important factor that appears to determine if someone will develop chronic back pain or return to work after back surgery.  Continue reading