Hi Dr Hanscom,

I have been meaning to check in with you for a while now and let you know that the DOC program seems to have worked for me. My lower back & leg pain has disappeared and I’m a firm believer in the process, especially the concept that anxiety is the driver of tension and pain in many cases. I picked up the book, Forgive for Good at your recommendation back in the winter and found it to be excellent. I’ve also been doing mindfulness training and it’s been extremely helpful.  If you aren’t familiar with the book, The  The Mindful Way through Depression, I’d definitely recommend checking it out.

I hope you are doing well and enjoying the summer now that it’s finally arrived.

Best, Jean

My Perspective

This patient is the daughter of an esteemed colleague of mine. She had burned out of practicing law and had embarked on a pre-med pathway at the age of 38. She had experienced low back pain for over two years. There was also significant pain, numbness, and tingling throughout her right leg. She had a normal MRI of her thoracic and lumbar spine. Electrical testing of her leg did not show any specific problems with the nerves. As I knew her father so well, I was especially anxious not to miss anything that might be serious. I could not find a structural cause for her symptoms.

I first saw her about 18 months ago, and on our last visit six months ago, she was just a little better. I tried not to be too discouraged but, I was not sure she was going to improve.

What is remarkable about her recovery is that it was truly self-directed. She did not see me in follow-up nor did she see another physician. I had recommended a mental health professional, as I thought she might be depressed. But she wouldn’t engage in that conversation. She did use the Feeling Good book and was diligent writing in David Burn’s three-column format. She also pursued obtaining a good night’s sleep, utilized the re-programming tools such as active meditation, and worked out regularly in the gym. Two years later she is re-pursuing her medical school dream.

This story is not an exception. With full engagement with a structured program the results are consistent.

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Profits over quality

The business of medicine, like any other business, is focused on making a profit. There are computer programs that monitor physicians’ contribution to the profit margin. The most revenue comes from performing procedures, many of which have been documented to be ineffective. (1) The downside risks include unnecessary costs, significant risks and patients are often worse off than before the intervention. (2) It has also been documented that only about 10% of spine surgeons are addressing the known risk factors for poor surgical outcomes. (3) Dr. Ian Harris, who is an orthopedic spine surgeon from Australia, has done extensive research on the utilization of ineffective procedures. He wrote a book, Surgery: The Ultimate Placebo, where he extensively documents the data behind many procedures that have been proven to be of no benefit and it hasn’t stopped physicians from using them – at all. (4)

What works

Effective treatments are often not covered or don’t have a way of generating revenue. For example, expressive writing has be shown to been helpful in multiple medical conditions in over 1,000 research papers. (4) Yet, I had never heard of it until I accidentally ran across it in 2003. It costs nothing, has minimal risk and is rarely presented as a treatment option. It has proven to decrease symptoms of asthma, depression, rheumatoid arthritis, improve student’s athletic and academic performance and diminish many other symptoms. I had dinner with the original author of the technique, James Pennebaker, who is a psychologist from Austin, TX. The methods may differ, but it has only been reinforced as an effective tool. There is a lot of debate of why it works, but not about whether it works.

Mindfulness-based stress reduction has also been demonstrated to decrease pain in many papers and is usually not covered by insurance. I watched several excellent pain programs in the Puget Sound shut down because they could not afford to keep them open. Listening is a proven healing modality in addition to being a basic requirement to understand a given patient’s whole situation. Dr. Francis Peabody, a famous Boston physician, was concerned about the intrusion of technology into the patient-physician relationship. One of his more notable quotes was, “The secret of care is caring for the patient.” He wrote this in 1927. (5)

The business of medicine

Currently, mainstream medicine is pretending to deliver medical care. At the same time, people still trust their physicians. My observation is that it isn’t the individual physicians that are the issue. The corporatization of medicine is backing us into a tight corner. Not only are we not given the time to talk to our patients, many are often penalized heavily for not being “productive enough.”

One problem that is not often acknowledged is that of inducing a depression from repeatedly dashing people’s hopes. This was powerfully demonstrated by Harry Harlow. (6)

Harry Harlow

Harry Harlow was an internationally renowned psychologist who pioneered research in human maternal-infant bonding using primates.  During the first half of the 20^th century, it was felt that mothers should touch their children as little as possible.  The leading mental health professionals aggressively discouraged mother-child interaction in research papers, lectures, books, and the media.  Interestingly, or tragically enough, their recommendations were based on rodent research.  Dr. Harlow was the leading force in changing the tide of opinion using various species of monkeys. His story is well-presented in an entertaining book, Love at Goon Park by Deborah Blum. (6)

In the 1960s, he turned his attention, also based on primate research, to some of the smaller details of human interaction.  One model he worked on for a while was that of inducing depression.  He used various isolation methods and ways of simulating parental neglect or even abuse. He was able to consistently produce monkeys that were seriously disturbed, but he wasn’t able to cause depression.  At the time, he was experiencing his own severe depression associated with his wife’s diagnosis of terminal cancer.

He finally found a consistent methodology by devising an apparatus that resembled an upside-down pyramid. The sides were steep, but still allowed the monkey to climb to the top to peek outside. The top was covered with mesh. For the first couple of days, the monkeys would repeatedly climb up to look out and quickly slide back down. Within a couple of days they would give up, sit in the middle of the device, and not move. They became almost unresponsive, and when they returned to their families, they would not revert back to normal social behavior. It didn’t matter what problems the monkey had prior to the experiment. The abnormal monkeys became worse and normal monkeys suffered the same fate. Even the “best” monkeys from stimulating and interactive families would succumb. The researchers called the apparatus, “The Pit of Despair”. It was felt by the research team that this “learned helplessness” was from a combination of feeling the loss of a good life reinforced by occasional glimpses of the outside world and feeling trapped. Within a half a week, every monkey spiraled down.

Physical therapy, chiropractic adjustments, injections, acupuncture, vocational retraining, medications, traction, inversion tables, and finally surgery. How many times can your expectations be dashed before you lose hope?

1. Jonas, JB, et al. Are invasive procedure effective for chronic pain? A systematic review. Pain Medicine (2019); 20: 1281-1293.
2. Perkins, FM, and Henrik Kehlet. Chronic pain as an outcome of surgery. Anesthesiolgy (2000); 93: 1123-1133.
3. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.
4. Harris, Ian. Surgery, The Ultimate Placebo. New South Publishing, Sydney, Australia, 2016.
5. Peabody, FW. The Care of the Patient. NEJM (1927); 88:877-882.
6. Blum, Deborah. Love at Goon Park. Perseus Publishing, New York, NY, 2002.

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Each new year, many of us spend time figuring out how we’ll make it better and also to really complete some projects that we have been putting off, maybe for decades. Few of us are able to accomplish a fraction of what we envision. Why? It’s because our unconscious behavioral patterns are so powerful and are going to win over our rational mind.

ACE study

This process has been documented in the now famous and replicated “ACE” study performed on about 17,000 Kaiser patients in the mid-1990’s. (1) ACE stands for, “adverse childhood experiences.” Eight then ten questions were answered by the cohort and then the population’s health was looked at compared to the severity of the ACE score. The following questions were asked:

Abuse

• Emotional – recurrent threats, humiliation (11%)
• Physical – beating, not spanking (28%)
• Contact sexual abuse (28% women, 16% men, 22% overall)

Household dysfunction

• Mother treated violently (13%)
• Household member was alcoholic or drug user (27%)
• Household member was imprisoned (6%)
• Household member was chronically depressed, suicidal, mentally ill, or in a psychiatric hospital (17%)
• Not raised by both biological parents (23%)

Neglect

• Physical (10%)
• Emotional (15%)

This study was done on a sample of middle-class Kaiser patients and chronic pain was not taken into account. What is shocking is that only a third of the group had and ACE score of 0 and over a third had a score of 3 or more. It would be anticipated that these numbers would be worse in a lower income group, as there would be more stress and also in a group suffering from chronic pain. The higher the ACE score, the greater the negative impact on a person’s health. Aced out

“Damaged”

My ACE score is 4. At one point a friend of mine gave me a book, Damaged, which related the story of a young man who was so abused that he was never able to pull out of his tailspin. It was his way of saying to me, “You’re going to have to live with all of this internal chaos. You’re not going to be able to surmount your childhood abuse.” I know it was a well-intentioned move, but I was devastated, to say the least. I am sure the feeling it wasn’t too far off from what many of you have experienced when your physician tells you that everything has been done and you’re going to live with the pain. Many of you have also discovered through your self-healing journey that this simply isn’t true.

The health consequences are clear and severe as the ACE score climbs. They include:

• Early mortality
• Obesity
• Substance abuse
• Anxiety/ depression
• Teen promiscuity
• Attempted suicide
• Early smoking/ heart and lung disease
• High risk health behaviors
• Abusive behavior within their own families

What really caught my attention about this study is that it arose out of an intense weight loss program that was quite successful in helping the participants lose a large amount of weight. Yet the most successful ones were the most likely to drop out. It turns out that obesity does serve a function and the higher the ACE score, the more likely they were to return to their prior eating patterns.

Mental or physical health – which is more critical?

Good intentions

“The Road to Hell is Paved with Good Intentions”. This phrase is defined as, “Merely intending to do good, without actually doing it, is of no value.” (2)

I have years of my own resolutions that I have made and not followed through on. That has changed and I now follow through more often. However, it isn’t because of more will power or determination. It’s because I “gave up” and settled into what is real for me. My reality is that my core patterns revolve around being a victim. I was a victim and it was reinforced every day, until I became aware of being a victim was. I couldn’t solve what I wasn’t aware of. Although I made a lot of progress in 2002 after I began to use the expressive writing exercise, it wasn’t until I even learned the word, “victim”, did I begin to truly heal. I certainly had no clue that the word applied to me. In my mind, I had been “enlightened” for years, as I had done a lot of personal work.

By settling into what was and is for me, I’ve been able to move forward. I did the Hoffman process in 2009, which gave me even more clarity. It was there I learned that the victim role is permanent and will continue to manifest itself in more and more subtle ways, especially when I work even harder to disguise it and remain “enlightened”.

I had another insight as to why I was able to re-create my life. I recently read a book, How Emotions are Made, by Lisa Feldman Barrett. She runs a neuroscience research lab and presents data explaining the formation of human consciousness. Every millisecond we are interpreting sensory input to make sense out of environment, including thought and concepts. They become imbedded in our brains and are our version of reality. The are as real to us as the chair you are sitting in. You are programmed by your past. I was initially discouraged about this idea until she pointed out that from this second forward you have a choice about how you want to program your nervous system. Repetition is key and I found it encouraging that I have that much choice about my life and what reality I want to create.

Awareness

A while ago another level of awareness arose in me. It was that essentially my whole being was created around truly being victim. I had been trying to fix and solve it for decades. However, if victim part of me “disappeared”, I would cease to exist as me. When I finally learned that the answer was to assimilate it, I’ve been able to create a reality that is rich, functional, productive, rewarding and a lot of fun. Solving the unsolvable

I would suggest that one resolution that’s more possible to keep is simply committing to becoming more aware. It isn’t possible to solve anything unless you understand the nature of the issues. I spent over three decades doing battle with adversaries that I didn’t know or see. I just kept fighting and fighting. Settling in and “being” takes much less effort. Paradoxically, you will have more energy to actually accomplish your dreams.

1. Felitti VJ, Anda Rf, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine (1998); 14:245-258.
2. The New Dictionary of Cultural Literacy, Third Edition, Houghton Mifflin Company, 2005.

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• Consider ongoing environmental input separately from your body’s responses.
• Understand the essence of illness/ disease is sustained exposure to real or perceived threats.
  • It creates an adverse chemical profile that increases metabolism (your rate of fuel consumption) and causes inflammation. Your tissues will be physically damaged over time.
• The core of the solution is discovering and learning methods to shift your physiology (body’s function) from threat (fight and flight) to safety (rest and digest).

All living creatures survive by mobilizing resources in their bodies to deal with threats and replenishing them when feeling safe. Both are necessary for life. However, sustained exposure to threats causes a shift in the chemical profile that breaks down your body causing mental and physical diseases. (1)

It is important to understand the nature of threats, the various ways they present, and the makeup of your body’s neurochemistry in a survival flight or fight mode. In other words, your body is collecting massive amount of data from multiple sensors in your body that is transmitted to the nervous system, which is translating it into action. The reaction causes changes in your physiology, stimulates physical actions, and creates behaviors that are appropriate to the situation.

Physiology

Physiology is the term that describes how the body functions. We stay alive because living creatures maintain an incredibly delicate balance of the body’s acid/ base balance, electrolytes, blood pressure, temperature, heart rate, and the list is long. It is a dynamic process that changes by the second in response to input from your surroundings.

The physiological changes cause sensations that we call emotions. But emotions are just words that describe what you are feeling when your body is in action. Your physiological state affects every organ system and translates into symptoms  Every physical and mental symptom you experience is explained by an inherited problem, an identifiable structural abnormality, or changes in your body’s physiology. There no such entity as unexplained symptoms.

Nature of threats

Any mental or physical threat, perceived or real, is going to be met with a defensive response from your body. Much of this mediated through the autonomic nervous system (ANS). It is called “autonomic” because all the effects are automatic in response to input. The stimulation/ survival aspect is a function of  the sympathetic nervous system (SNS), and the calming part is mediated through the parasympathetic nervous system (PNS). The vagus nerve is the main nerve that transmits these signals. It is the 10^th cranial nerve that originates in the midbrain just below the brain.

Physical threats include allergens, parasites, bacteria, viruses, lions, tigers, bears, and people we perceive as or are dangerous. Less obvious, but even more inflammatory, are mental threats, because we can’t physically escape our thoughts and emotions. Repressed ones are even  more problematic.

Mental threats are processed in a similar manner in the brain as physical ones and cause an inflammatory response that forms the basis for chronic mental and physical disease when sustained. Examples of mental threats are memories, negative thoughts, suppressions, repressions, insecurities (social, financial, health, etc.), cognitive distortions, and loss of life perspective and purpose.

Your body’s chemical makeup under threat

The survival response is the well-known flight, fight, freeze, and faint reaction. (2) We are all familiar with the physical manifestations of threat that includes an increased heart rate, sweating, muscle tension, and elevated blood pressure. But what you may not know is that the immune system also gets fired up and mobilizes many types of cells that fend off predators such as bacteria, viruses, and cancer cells. Cytokines are the signaling mechanism to mobilize or calm this response.

Cytokines are small proteins that serve as messengers throughout the body, transmitting higher-level signals and coordinating activities at the cellular level. They are central to modulating the immune system and inflammatory response. There are two kinds of cytokines: pro-inflammatory (Pro-I) and anti-inflammatory (Anti-I). While Pro-I cytokines protect us by warding off acute perils, Anti-I cytokines keep us safe by allowing us to regenerate, thrive, and prepare us for battle with environmental/ internal enemies.

When threats activate pro-inflammatory (Pro-I) cytokines, the resulting inflammation allows “warrior cells” to exit the blood stream through widened openings in the vessels to destroy the invaders (antigens). However, when they are chronically activated, inflammatory cells will destroy normal tissues. They are elevated in almost every chronic disease state. For example, researchers discovered that some types of depression are inflammatory responses of the central nervous system to chronic stress. (3)  Anxiety, bipolar, obsessive compulsive disorder (OCD), and schizophrenia also have elevated inflammatory markers. (4) Chronic stress also causes early mortality. (5)

Your body’s chemical profile when feeling Safe

 Anti-inflammatory (Anti-I) safety cytokines are the underpinnings of health and wellness. With the elevations of the Anti-I’s, we see the states of “breed and feed” and “digest and rest.” We are restorative, connected, bonded, sexual, reproductive, cognitive and creative. We also have high immunity.

There is a dramatic difference in your body’s neurochemical makeup when you feel safe compared to sensing danger. There is a deep sense of relaxation, contentment, sense of well-being. So, why do we not exist in this state most of the time? Generating a sense of safety is complicated for humans in that we have language and consciousness that is not present in any other species of life. You cannot outrun your mind.

The essence of healing

The essence of disease is sustained threat and the solution lies in connecting to your sense of safety using specific strategies.

Discovery and acknowledgement of all our threats–whether real, imagined, anticipated, or repressed–is the first step towards addressing them. The second is choosing an adaptive rather than maladaptive escapes to safety, whether the threat be physical or spiritual. We are better at physical escapes to safety than we are at spiritual ones.

If you have a choice of solving an unpleasant situation, that is clearly the first choice. But the stresses that have the greatest impact on your health are the ones that are not solvable. Being trapped by anything or anyone really fires up your defenses. But since you can’t escape your consciousness, what can you do?

There are multiple ways of dealing with threat while creating safety.

It is the reason that The DOC Journey is a specific sequence. The anger from being trapped by pain is intense and unpleasant but also powerful and protective. The antithesis of anger is being vulnerable, which living creatures are not naturally programmed to allow. You must build a foundation and learn safety at a doable level. Then it is important to proceed at your own pace to tolerate being vulnerable and still feel safe. If you dive in too quickly without a solid base, you will react in a way that makes your defenses stronger. As you deliberately progress through the healing journey, you will learn to trust your skills and discover ways to find safety regardless of the circumstances. You have regained control of your life.

Recap

The cause of chronic disease is sustained exposure to threats. The solution lies in learning ways to find safety. Although you cannot control your thoughts and most of your external stresses, you do have control of shifting your body’s physiology. They are simple tools that become automatic with repetition. Acquiring these skills will allow you to live your life on your own terms – and feel safe.

What about the need to tolerate vulnerability? There are no rewards in nature for being vulnerable. You won’t survive and that includes humans. Yet being vulnerable is the core of human relationships. But what if you were abused and don’t inherently trust people – and why would you?

We have a dilemma

• The essence of chronic disease is sustained exposure to threat (feeling vulnerable).
• Yet allowing yourself to be vulnerable is at the core of human relationships.
  • You must be able to trust someone before that can happen.
  • If you had a chaotic, even abusive upbringing, how do you know who to trust?
• What happens if you don’t have the tools to deal with rejection or being hurt?
• How can you feel safe while allowing vulnerability?
  • Every relationship requires taking risks.

This is one of the reasons you must learn in a sequence, steps, and at a comfortable level. It is not a straight-line path, nor will it ever be. You do have to care for yourself and learn to “fail.” Every person has their own way of learning to feel safe and live life on his or her own terms.

References:

1. Smyth J, et al. Stress and disease: A structural and functional analysis. Social and Personality Psychology Compass (2013);7/4:217-227. 10.1111/spc3.12020
2. Porges Stephen. The Pocket Guide to the Polyvagal Theory: The Transformative Power of Feeling Safe. Norton and Co, New York, NY, 2017.
3. deHeer, EW, et al. The association of depression and anxiety with pain: A study from NESDA. PLOSone (2014); 9:1-11. e106907.
4. Shields SS, et al. Psychosocial interventions and immune system function. JAMA Psychiatry(2020); doi:1001/jamapsychiatry.2020.0431
5. Torrance N, et al. Severe chronic pain is associated with increased 10-year mortality: a cohort record linkage study. Eur J Pain (2010);14:380-386.

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Loneliness causes many physical problems including a higher mortality rate equivalent to smoking 15 cigarettes per day. Mental health problems continue to increase and approximately 1 in 6 adults suffer from a mental health condition. Most also suffer from loneliness. (1)

Anxiety is the driver

I have observed from working with many patients and my own experience with loneliness during my ordeal with chronic pain, that there is a circular interaction with anxiety, anger and becoming isolated.  For many, I feel the starting point is anxiety, which is the pain.

There are an endless number of reasons for humans in this day and age to have disruptive anxiety. This has been endlessly discussed in the media. However, once it kicks into gear, there is no turning back and it will become relentlessly progressive. Since is an automatic unconscious survival response that is much more powerful than your conscious brain, you can’t control it or solve it with rational means. You also will never be rid of it, since without it, you would not survive for more than a few minutes.

The key to lowering anxiety is learning to assimilate it into your life. It is intended to be unpleasant, since it is your basic warning system. As you learn to work with it and quit fighting it, you will be able to lower your stress chemicals and de-energize it. Anxiety both protects you and also allows you to navigate new challenges.

OCD

The interaction I experienced while in pain was that I was crippled with anxiety in the form of disruptive unpleasant thoughts that evolved into an obsessive compulsive disorder (OCD). I had become a major spine surgeon by suppressing anxiety and wasn’t connected to it. I also thought anxiety was a psychological problem when it actually is simply a physiological reaction to a mental or physical threat.

As my anxiety progressed, I became more isolated. My patterns of thinking changed dramatically, and I was consumed with thoughts of self-deprecation and why would anyone want to hang out with me? This was occurring in spite of me historically being a social person to a fault. I had a wonderful group of friends from middle school on. There was no new activity I was not up for trying. In college, I took more than a full academic load, worked heavy construction 10-20 hours a week, played intramural sports, and spent a lot of time with my friends. I don’t remember sleeping much.

Trapped

As I spiraled down with progressive anxiety, I became severely depressed. I now know that depression is a group of symptoms driven by anxiety. The isolation progressed rapidly over five years, in spite of having warm and very nice people around me. I couldn’t connect. I was so busy trying to survive, I couldn’t reach out to others. As others tried to reach out to me and failed, they eventually quit trying as hard, which only made it even harder for me to. I don’t have the words to describe the feeling, but it was crushing, suffocating and one of most intolerable experiences I have ever had and, even worse, there did not seem to be a way out. I use the word, “Abyss” to describe being in chronic pain. I think the loneliness was a step beyond or below. Even thinking about it 20 years later is causing my stomach to knot up.

My depression became severe. I lost all hope in spite of aggressively seeking professional help and reading many self-help books. One that I picked up was, Darkness Visible: A Memoir of Madness, where the author described his own struggle with major depression. (2) What struck me was that he was famous, wealthy, and had recently received a lifetime achievement award for his literary excellent. In spite of it all, he was miserable. What struck me about his story, is that he didn’t find or offer a solution. He  had nowhere to go and just remained in one spot. I couldn’t explain what happened to me but I felt a deep shift. That is all I can say. I did not immediately begin to heal, but I somehow realized that I was on the wrong track in my endless pursuit of a cure. The answers where inside of me. In an odd way, I gave up, which turned out to be the eventual answer.

It is OK to be on “The Bottom”

It is OK to be depressed. Anxiety is normal and fighting it gives it more power and it does become disruptive. Your brain will develop wherever you place your attention, especially if you are suppressing. By remaining still, I gave myself some space to heal. I become aware of many aspects of my life and experience that weren’t possible while I was traveling so fast. I quit trying to fix myself and inadvertently allowed my brain to heal. I became more connected to me.

This song is written and performed by my nephew, who I have spent many hours talking to about anxiety, depression, and life. His struggle with it was epic but he not only made it through, he is thriving. One of his gifts from the ordeal is having insights into the magnitude of the problem and has a deep appreciation for life. This song, The Bottom, reflects his perspective.

Alex Hanscom – The Bottom

Learning to be with yourself, including your fears, is key to moving forward in life on your terms and not at the mercy of other’s opinions. It is also much easier and you are able to reach out to others and be aware of their needs. It works the other way around in creating an upward spiral. I have rekindled many friendships because I have healed, but my connections are also part of the healing journey.

1. Cigna U.S. Loneliness Index. Published survey results, 2018.
2. Styron, William. Darkness Visible: A Memoir of Madness. Random House, New York, NY, 1990.

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“I know better”

So, anxiety is not primarily psychological and not solvable by your rational brain. Have you ever wondered why so many people (maybe all of us) act badly when we know better? How successful are we at keeping our New Year’s resolutions? Why would you treat your loved ones worse than you would treat a stranger? What about the atrocities that are commonly committed at a societal level? This list is endless because you can’t outrun or overpower your mind and need to survive.

I have known for many years that anxiety is the driving force behind depression, and have seen smatterings of it being discussed in the literature and news. I suffered from a major depression for over 15 years with the last eight of them being extreme. In 2002, I was actively suicidal, and am still not quite sure why I didn’t go through with my plan. I got lucky and have been given a second chance. About 18 months later, I pulled out of my downward spiral of anxiety and major depression. Little did I know that they were the same entity.

I eventually was able to live a fuller and richer life than I dreamed was possible. It is also the experience of many of my patients who escaped from the grips of chronic pain in that their quality of life is even better than before they developed chronic pain.

Why is depression just the expression of sustained anxiety?

• All people with depression have anxiety (although it can be suppressed by anger), but not everyone with anxiety has depression.
• One of the earliest signs of depression is waking up in the morning and not being able to fall back asleep. This is usually from racing thoughts – connected to anxiety.
• Then you can’t fall asleep. Again, from disruptive thoughts, but also from your body being full of stress chemicals. You are on high alert, which isn’t conducive to falling asleep.
• You’re not sleeping – a cardinal symptom of depression.
• Eventually, you have trouble concentrating, which is a combination of your racing thoughts and not being able to sleep.

You have already defined a minor to moderate depression – and the relentless anxiety continues and becomes increasingly intolerable. It was by far and away the worst part of my ordeal. From a survival perspective, the intention is to create such an unpleasant feeling that you are compelled to take action that to escape the threat. But I couldn’t escape my thoughts and they progressed to vivid, obsessive thought patterns, which is the core of OCD (obsessive compulsive disorder).  I was introduced to another realm of suffering I never would have imagined. It is beyond words, and that is why I use the term, “The Abyss.” I watched my patients try to describe how deep their suffering was, and all that kept coming up for me was the word, “dark”, and without any hope of light. The next word was, “despair.”

I also experienced the more advanced symptoms of a major depression (anxiety).

• Loss of appetite and weight loss – adrenaline decreases the blood supply to your GI tract.
• Lack of energy – being full of these chemicals keeps your body on high alert and it just wears you down. It is similar to attempting to sprint a mile.
• Multiple diffuse physical symptoms – direct effect of your body’s hormones on the different organ systems. I was experiencing over 17 of them at the worst phase of my ordeal.
• Social isolation – the one worst part of my journey, besides the anxiety, was loneliness. It was crushing and many self-deprecating thought patterns emerged. This occurred in spite of the fact that I am normally extremely social. It still took me down.
• Suicidal ideation – and action plan.

You get the point. What we are calling depression is a set of symptoms created by sustained levels of stress chemicals (anxiety).

Anger – stepping it up a notch

Then the story gets worse – a lot worse. One antidote to anxiety is control, and normally when a physical threat is solved, the anxiety drops, and you’ll live another day. However, when you can’t escape (your thoughts for example), your body will secrete more adrenaline, cortisol and histamines in an effort to regain control, and you’ll feel angry (trapped). So, anger is anxiety with a chemical kick and is the same entity. The problem is that anger is truly the last-ditch effort to survive and is destructive. An animal will do whatever it has to do to stay alive. Humans have the same need, but the destructive behavior doesn’t have an endpoint because we have consciousness. Additionally, it is self-destructive.

Sustained anger will drive you deep into the hole, cause more intense physical symptoms, and to me felt like a pile driver was driving my soul right into the center of the earth. Then, since you may be beyond caring, you might neglect your health. Complete disregard for your physical health is akin to a slow suicide. Talk about knowing better and then doing something different, is the classic illustration of the unconscious behavioral patterns winning out over willpower. Why else would you not want to feel physically great and live life to the fullest?

Medicine has missed it

I will get a lot of push back on this article from almost every corner of the medical world. But, they have missed this one – badly. Anxiety and depression are conceptualized, labeled and treated differently. They are not only the same entity, but neither are truly solvable with isolated psychological interventions. Although, psychological treatments are important aspects of care by providing support, wisdom, guidance and symptom control they must be combined with other strategies that teach you how to develop your own individualized way of regulating your body’s chemistry. Learning how to change your hormonal profile to “play”, which includes oxytocin (love drug), dopamine (rewards), GABA chemicals (anti-anxiety), and serotonin (antidepressant) is simple, effective, easily learned and will change your life.

Anxiety and depression are the same entity. The core driver is anxiety, which is not primarily a psychological problem. We can’t get rid of it or we wouldn’t survive. Understanding the nature of any problem will allow you to address the root issue. It is a solvable problem using strategies that stimulate your brain to rewire. Solving the unsolvable 

The post Depression is Anxiety first appeared on Back in Control.

The post Depression is Anxiety appeared first on Back in Control.

Each new year, many of us spend time figuring out how we’ll make it better and also to really complete some projects that we have been putting off, maybe for decades. Few of us are able to accomplish a fraction of what we envision. Why? It’s because our unconscious behavioral patterns are so powerful and are going to win over our rational mind.

ACE study

This process has been documented in the now famous and replicated “ACE” study performed on about 17,000 Kaiser patients in the mid-1990’s. (1) ACE stands for, “adverse childhood experiences.” Eight then ten questions were answered by the cohort and then the population’s health was looked at compared to the severity of the ACE score. The following questions were asked:

Abuse

• Emotional – recurrent threats, humiliation (11%)
• Physical – beating, not spanking (28%)
• Contact sexual abuse (28% women, 16% men, 22% overall)

Household dysfunction

• Mother treated violently (13%)
• Household member was alcoholic or drug user (27%)
• Household member was imprisoned (6%)
• Household member was chronically depressed, suicidal, mentally ill, or in a psychiatric hospital (17%)
• Not raised by both biological parents (23%)

Neglect

• Physical (10%)
• Emotional (15%)

This study was done on a sample of middle-class Kaiser patients and chronic pain was not taken into account. What is shocking is that only a third of the group had and ACE score of 0 and over a third had a score of 3 or more. It would be anticipated that these numbers would be worse in a lower income group, as there would be more stress and also in a group suffering from chronic pain. The higher the ACE score, the greater the negative impact on a person’s health. Aced out

“Damaged”

My ACE score is 4. At one point a friend of mine gave me a book, Damaged, which related the story of a young man who was so abused that he was never able to pull out of his tailspin. It was his way of saying to me, “You’re going to have to live with all of this internal chaos. You’re not going to be able to surmount your childhood abuse.” I know it was a well-intentioned move, but I was devastated, to say the least. I am sure the feeling it wasn’t too far off from what many of you have experienced when your physician tells you that everything has been done and you’re going to live with the pain. Many of you have also discovered through your self-healing journey that this simply isn’t true.

The health consequences are clear and severe as the ACE score climbs. They include:

• Early mortality
• Obesity
• Substance abuse
• Anxiety/ depression
• Teen promiscuity
• Attempted suicide
• Early smoking/ heart and lung disease
• High risk health behaviors
• Abusive behavior within their own families

What really caught my attention about this study is that it arose out of an intense weight loss program that was quite successful in helping the participants lose a large amount of weight. Yet the most successful ones were the most likely to drop out. It turns out that obesity does serve a function and the higher the ACE score, the more likely they were to return to their prior eating patterns.

Mental or physical health – which is more critical?

Good intentions

“The Road to Hell is Paved with Good Intentions”. This phrase is defined as, “Merely intending to do good, without actually doing it, is of no value.” (2)

I have years of my own resolutions that I have made and not followed through on. That has changed and I now follow through more often. However, it isn’t because of more will power or determination. It’s because I “gave up” and settled into what is real for me. My reality is that my core patterns revolve around being a victim. I was a victim and it was reinforced every day, until I became aware of being a victim was. I couldn’t solve what I wasn’t aware of. Although I made a lot of progress in 2002 after I began to use the expressive writing exercise, it wasn’t until I even learned the word, “victim”, did I begin to truly heal. I certainly had no clue that the word applied to me. In my mind, I had been “enlightened” for years, as I had done a lot of personal work.

By settling into what was and is for me, I’ve been able to move forward. I did the Hoffman process in 2009, which gave me even more clarity. It was there I learned that the victim role is permanent and will continue to manifest itself in more and more subtle ways, especially when I work even harder to disguise it and remain “enlightened”.

I had another insight as to why I was able to re-create my life. I recently read a book, How Emotions are Made, by Lisa Feldman Barrett. She runs a neuroscience research lab and presents data explaining the formation of human consciousness. Every millisecond we are interpreting sensory input to make sense out of environment, including thought and concepts. They become imbedded in our brains and are our version of reality. The are as real to us as the chair you are sitting in. You are programmed by your past. I was initially discouraged about this idea until she pointed out that from this second forward you have a choice about how you want to program your nervous system. Repetition is key and I found it encouraging that I have that much choice about my life and what reality I want to create.

Awareness

A while ago another level of awareness arose in me. It was that essentially my whole being was created around truly being victim. I had been trying to fix and solve it for decades. However, if victim part of me “disappeared”, I would cease to exist as me. When I finally learned that the answer was to assimilate it, I’ve been able to create a reality that is rich, functional, productive, rewarding and a lot of fun. Solving the unsolvable

I would suggest that one resolution that’s more possible to keep is simply committing to becoming more aware. It isn’t possible to solve anything unless you understand the nature of the issues. I spent over three decades doing battle with adversaries that I didn’t know or see. I just kept fighting and fighting. Settling in and “being” takes much less effort. Paradoxically, you will have more energy to actually accomplish your dreams.

1. Felitti VJ, Anda Rf, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine (1998); 14:245-258.
2. The New Dictionary of Cultural Literacy, Third Edition, Houghton Mifflin Company, 2005.

The post Why are New Year’s Resolutions So Hard to Keep? first appeared on Back in Control.

The post Why are New Year’s Resolutions So Hard to Keep? appeared first on Back in Control.

Dr. Sarno

He is a well-known physiatrist who described the “tension myositis syndrome.” (TMS) I had been familiar with his observations described in his best-selling 1984 book, Mind Over Back Pain. He felt that the nervous system was created muscle tension and inflammation. He also made the astute observation that anger or rage was a critical factor in the evolution of chronic pain. He was partially correct about the anger, but modern neuroscience research has shown that the symptoms are created from the physiological response to threat and not primarily from muscle tension.

Dr. Schubiner

Howard Schubiner is a pain physician who practices in Detroit, MI, who spent time with Dr. Sarno. He has authored a book, Unlearn Your Pain, which addresses chronic pain as one of the symptoms of the Mind Body Syndrome (MBS), which is another name for the tension myositis syndrome. I have chosen the term, Neurophysiologic Disorder (NPD).

In March of 2011, he was one of the keynote speakers of a seminar I co-chaired, A Course on Compassion-Empathy in the Face of Chronic Pain. I had a vague understanding of what I had been through but was still searching for more answers. As I sat in the lecture I had a deep insight into my experience and it instantly all made sense. He concisely presented the over 30 possible symptoms of stressed nervous system and I realized that I had experienced almost half of them. In chapter five of his book, Unlearn Your Pain, Dr. Schubiner lists 33 symptoms of NPD (He uses the term Mind Body Syndrome).

The Neurophysiological Disorder (NPD) – Make the Right Diagnosis

As your nervous system is connected to and controls every cell in your body, the potential symptoms and combinations are almost endless. Mainstream medicine does not embrace these concepts and that would, historically, include me. I have both watched it and experienced it. Our medical culture has “medicalized” a neurological diagnosis. The first step in being successful in treating any disease is making the correct diagnosis.

My Experience with NPD

Here is the list of my symptoms of NPD. I will tell the stories in detail in later posts.

• Migraine headaches
• Migratory skin rashes
• Severe burning in both of my feet
• Obsessive compulsive disorder
• PTSD
• Anxiety/panic attacks
• Severe depression
• Chronic tendonitis
• Heartburn/acid reflux
• Tinnitus
• Insomnia
• Back/neck pain
• Tension headaches
• Unrelenting itching
• Chest pain
• Palpitations

Every one of these symptoms has vanished or is at a level that causes minimal interference with my quality of life. However, if I quit practicing the principles that I am teaching some of my symptoms will re-occur in about two weeks. These are permanent pathways. Usually my ears will begin to ring, my feet will burn and a skin rash will appear on the back of both of my wrists.  Fail well

Terminology

There have been many attempts at using a term to describe the array of symptoms that occur when your body is full of adrenaline and cortisol. These terms include:

• Tension Myositis Syndrome (TMS)
• Mind Body Syndrome (MBS)
• Stress Illness Syndrome
• Central Sensitization Syndrome
• Neurophysiologic Disorder (NPD)

All of these terms are describing the same process. Any stress, perceived or real is going to put your body into a fight-or-flight mode and you will experience multiple physical symptoms. The key to healing is feeling safe, which creates a wonderful chemical environment where you can both physically and mentally thrive. It is a learned skill that is not difficult.

The post My Battle with NPD first appeared on Back in Control.

The post My Battle with NPD appeared first on Back in Control.

Every injured worker should have access to some level of mental health support. I work with a veteran pain psychologist who is wonderful. 90% of her practice is caring for my patients. If she feels it is necessary, she will refer a patient to one of several psychiatrists for medication management.

Chronic Pain and Mental Health

It is unclear, from the psychiatrist’s viewpoint, what constitutes a diagnosable psychiatric disorder. On my intake questionnaire, I have a simple 0 to 10 scale for anxiety, depression, and irritability. Essentially every injured worker that has been out of work for more than six weeks is greater than a 6 out of 10 on at least two of these scales.  What would be my threshold for a formal referral, especially in light of the fact that my state will not pay for an evaluation in a timely manner? What is even more worrisome to me is the patient who puts down a zero for all three. He or she is just a time bomb.

Diagnosis Problems

In the disability literature, there are hundreds of papers linking stress and disability, but there is not a clear-cut definition of anxiety disorder to aid practitioners in diagnosing an injured worker. How bad does a patient’s anxiety have to be in order for it to be diagnosable? What is the definition of a diagnosable mental health disorder in general?  As there is not a concise definition, I am in a continual battle with worker’s comp trying to persuade them to “buy” a psychiatric diagnosis. While the patient is waiting, what are we to do?  Their stress level climbs even higher as they wait for an answer.

A Case

I saw a patient a few months ago who is a young mother. I have known her for years.  She developed quite severe axial back pain. We had a short but direct conversation about stress and pain. She came in a couple weeks later with her back pain feeling moderately improved but seemed upset. I had a little extra time to talk to her. She started out by saying that she had separated from her husband and was having a hard time finding a job and a place to live. I knew that he had not been working and she was home with two young children. It turns out that he had been regularly beating her. It happened enough that her children felt afraid of her if she yelled at them, but the physical abuse that occurred in front of them seemed OK. If you met her, you would be more than upset. She is one of the nicest people you could meet. Under no criteria would she have a diagnosable psychiatric condition. She really did not know what direction to go. Her mother was helping out the best she could. I emailed my pain psychologist and although she had no funds, she was able to be helped out. On top of that, her husband has chronic pain from failed back surgery.

Stress Management

Every person from elementary school on should be taught stress management and mental health skills. I feel the one factor that determines one’s success in life is the ability to process and handle stress. Even basic stress management tools are extremely helpful.

Support

Every injured worker needs to have access to at a group or organization that teaches these type of skills and offers other support. Individual referrals to psychologists can be figured out more easily in this setting. Losing a job in a capitalistic society is a disaster.  It is bad enough if you are single; it is much worse if you are the breadwinner of a family. Even the thought of being in this situation is mentally crippling.

Labels

A major concern and obstacle to accessing mental health support is our tendency to label people. Injured workers quickly become labeled. This is particularly true if they make the mistake of complaining too loudly or expressing their frustration. They become “difficult” and “manipulative.”  If their stress becomes higher, they may have more pain and ask for more meds. This gets them labeled “drug seekers.”  The list of labels goes on. If a patient is labeled as “anxious” or “depressed,” they are often put on antidepressants and their anxiety is considered “addressed.”  If after a few months they are still depressed, then they might be referred to a psychiatrist or psychologist. By this time, months have passed and often the lives of patients have unraveled.

The Patient is a Person

The patient’s whole life, including her mental life, must be acknowledged from the minute she is injured. Every person that comes in contact with her makes a difference. Even the acknowledgment of her suffering is important.

I made a comment a few weeks ago to David Tauben, who is the head of the University of Washington pain center, and David Elaimy, my surgical performance coach, that they should put on a mini-seminar, “Enjoying the Management of Your Chronic Pain Patients.”  A major part of the enjoyment of being a physician is addressing the whole patient and making the correct diagnosis. If I had just sent the young mother I mentioned above to physical therapy for neck pain, it would not have been helpful. Thanks to the DOCC Project methods, she will be able to get her life back on track and have the tools to live a much more fulfulling life.

BF

The post Everyone Needs Support first appeared on Back in Control.

The post Everyone Needs Support appeared first on Back in Control.