My first year in training

I will never forget my first holiday season as an internal medicine resident in Spokane, WA. I learned that the holidays are a nightmare for the medicine service, especially the GI service. Diabetics don’t take their insulin and their sugars go out of control. Cardiac patients don’t take their meds and are admitted for chest pain and abnormal rhythms. The GI service is the worst in that patients with liver disease drink more and develop major bleeding in their gut. People are depressed and the stress of the holidays puts them over the edge.

He died?

We had a resident’s clinic once a week. One of my favorite patients was an 80 year-old gentleman, who was as nice of a person as you could meet. He had some moderate lung disease but otherwise was fairly healthy. He was admitted to the hospital on Christmas Eve with respiratory failure. It didn’t make sense to any of us, as his lung disease wasn’t that severe. We had a whole team working intensely to solve the puzzle. It didn’t matter. He died two days later. During the course of the hospitalization I found out that his son who lived in Seattle had not invited him over for Christmas and he had become despondent. I have since learned that the will to die is as strong as the will to live.

My descent into loneliness

I could not figure  this increase in illness and depression over the holidays for many years – until I descended into my own anxiety-driven depression and chronic pain. There were many unpleasant (terrible) aspects of being in the abyss, but maybe the worst one was feeling alone. I am an extremely social person. As I became progressively more anxious and reactive I began to feel isolated. In retrospect I realize that a lot of this was occurring in my own head. My friends were not avoiding me. I was not interacting with them. While I was trying to survive the terror of raw anxiety I was not able to reach out to others. I became more withdrawn and felt uncomfortable even talking to people. Discovering I had NPD

Obsessive thought patterns

What began to happen is that I developed what I now recognize as an obsessive thought pattern (classic symptom of the Neurophysiologic Disorder) that everyone else had a better life than I did. It did not matter what the evidence was to the contrary. I could not shake that thought. The holiday season made it much worse. First, it reminded me of times that were much better and I felt even more sorry for myself. Secondly, people really seemed like they were having a better time than I was. (jealous/angry). Finally it seemed like the merriment around me was almost mocking my plight. For over 10 years I would become dark around the holidays.

I became socially isolated. I imagined that people just didn’t want to be around me and the story in my head became strong and convincing. Fortunately, I had a few people that I connected with that could see through the storm of my thoughts. It was that human connection that kept me going. But the feeling of loneliness was one of the worst aspects of my descent into chronic pain.

Social exclusion and the ACC

A study published in 2003 (1) looked at the brains of volunteers who were hooked up to a functional MRI scanner (fMRI) which highlights metabolic activity of the brain in response to different stimuli. The volunteers were visually involved in a computer game of “three way catch”. They were not told that the other two “players” were just the computer. At a certain point they were suddenly excluded from the game while the other two “players” threw the ball back and forth another 45 times. The volunteer would consistently feel excluded and experience emotional distress. Interestingly, a part of the frontal lobe, the ACC, would light up. This part of the brain is “the neural alarm system.” It lights up when something in the environment is not right or threatening. Not surprisingly pain is a basic signal that also lights up this area. This study documented that emotional pain lights up the same area.

So chronic pain creates yet another vicious loop. Pain lights up the ACC (anterior cingulate cortex). While in pain you feel much less inclined to be social, which then reinforces the stimulation of the ACC. You now have added emotional pain to the physical pain.

Where does chronic pain begin?

People need people. People need to connect first with themselves and then with others. There are many societal factors, in addition to chronic pain, that create social isolation. It is unclear whether the social isolation that stimulates this “neuro warning center” could be the starting point of chronic pain.

Omega

My wife, Dr. Fred Luskin, and I put on a five-day seminar at the Omega Institute last summer. There were 11 participants who experienced a significant shift in their mood and pain during the week. As they went back to their home environment some had their pain return and many remained relatively pain free. The essence of the week was that we were able to relax and connect with one another. My impression was that the environment allowed us to open up and share. The capacity of people to heal each other was powerful. (The workshop was July 19-24, 2015.) “The Cup Song??”

The holiday season during my burnout was the equivalent of being excluded from the computer game. I’m sure that if I was placed into a fMRI during that period my ACC would have lit up like a small nuclear reactor. The sense of social exclusion was crushing. My Battle With NPD

I was very fortunate to not only escape from the abyss, but thrive. I wish the same for you in 2016.

1. Eisenberger, Naomi, et al. “Does Rejection Hurt? An fMRI Study of Social Exclusion”. Science, 2003, pp. 290 – 292.

The post Happy Holidays – Not first appeared on Back in Control.

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• We are trained that if we can solve enough of our problems, we’ll have an “enjoyable life.”
• Life’s challenges never stop, and we may slowly sink into darkness, “The Abyss.”
• We become desperate trying to escape; especially from our RUT’s (Repetitive Unpleasant Thoughts)
• The most effective way to dispel darkness is turning on light.

We are born as blank impressionable slates full of openness, curiosity, playfulness, and eagerness to learn. There are innumerable sources of learning, and we trust those who we perceive as having wisdom to teach us way to live an enjoyable and productive life.  Words and concepts are important but imitating actions are more powerful ways of learning. The possibilities are limitless.

But what often happens? In a protected and nurturing environment, the light may remain bright for many years and sometimes indefinitely. But for many of us, the light becomes progressively dimmer and at some point, we tip into the Abyss of chronic mental and physical pain. The light is extinguished, and it is a dark place without the slightest hope of escape. This is not what any of us planned when our spirits were shining.

A famous quote

It is not true that people stop pursuing dreams because they grow old. 

They grow old because they stop pursuing dreams.

                         Gabriel Garcia Marquez¹

I modified this famous quote based on my personal experiences and observations of anxiety:

It is not true that people stop pursuing dreams because they grow old. 

They grow old because their dreams are crushed by anxiety.

                         Gabriel Garcia Marquez

                          (Modified by Dr. David Hanscom)

Darkness

How quickly does darkness descend when you never felt safe and nurtured? Maybe you never felt the light that exists within you. Even if you had a great start, what about the onslaught of life?

• Unmeetable expectations
• Bullying – peers, coworkers, siblings
• FOMO
• Social media
• Poor diet/ no exercise
• Never-ending to-do list
• Lack of resources – housing, food, education, finances
• Job issues
• Difficult parenting
• Unrelenting Repetitive Unpleasant Thoughts (RUT’s)

The darkness settles in to the point where we can’t see a way out and eventually, we might forget what the light even felt or looked like. Additionally, there is the relentless wind, that also wears you down. Life keeps coming at us, especially the RUT’s.

So, what do most of us do? We are used to problem solving and we either keep working at fixing our lives (getting rid of the darkness) or many of us give up. Nothing seems to be working. Where do we go next and how can we get out of a place that seems to have no definition or limits? It really is an Abyss.

You cannot “fix” darkness”. It is simply absence of light. You also can’t control most of your thoughts (RUT’s) and stresses (the wind).

Darkness disappears with light. A small match is lit, and you must protect the flame from the wind. You may have to keep lighting it many times. Eventually, you are able to protect the flame and allow it to grow. Even when the light is dim, it still penetrates the darkness. As you continue to add fuel, the flame becomes a fire, then a large bonfire that can hardly be contained. The wind will eventually fan the flames and make them stronger.

“The fog rolled in.”

Many years ago, I was discussing chronic pain with a patient who was also a physical therapist. She related that she had an idyllic upbring with her parents and two siblings enjoying each other. Family outings including scenic drives, trips to Coney Island, music, and playing board games. There was a lot of fun and laughter. Then when she was 12, her father lost his job and her life permanently changed. The fun was replaced with verbal abuse, drinking, rages, and hardly even coming home. She described it as “the fog came in,” and life became dark. It never changed. I only saw her a couple of times recall how sad she was. I did not know much about chronic pain at that time and was perplexed how life could change so quickly. I did not understand the physiological nature of anger and that the thinking brain does not work is well. I don’t know what eventually happened to her.

Healing happens by moving forward towards your vision

It isn’t logical for us to spend so much time and energy fixing the dark and not paying attention to the light. But it is the only way that healing occurs. You are the only one who can light the match over and over again, protect the flame, and create a fire that can’t be put out. Knowing the tools to process darkness are necessary and are a separate skill set from connecting and nurturing your light. That is why there is a sequence of healing: 1) connection, 2) confidence, and 3) creativity.

Recap

Why do we feel that focusing and fixing our troubles is going to give us the life that we want? Not only can you escape from The Abyss with light, what about walking outside and soaking in the warmth of the sun?

Your dreams and play are always within you. Connect with and nurture them and allow your body to heal.

Questions and considerations

1. Our biological imperatives are to first survive and then pass our DNA to the next generation. Our unconscious brain evolved to look for trouble and resolve it in order to physically survive.
2. Humans are more complex in that we possess language and must deal with emotional pain, which is processed in a similar manner as physical pain.
3. Instinctively, we are programmed towards problem solving.
4. Although we also develop through play, it often gets buried in the ongoing chaos of life. We also have the human problem of our inability to escape from our unpleasant thoughts.
5. How much of your life is consumed w ith fixing problems versus nurturing joy? Have you created any “space” for joy?
6. If you wish to live a different life, you must create some “space” to nurture creativity and joy. Light will dispel darkness whereas all the fixing in the world will not pull you out of it.

 References

1. Gabriel García Márquez. Cien años de soledad (One Hundred Years of Solitude. 1967. Editorial Sudamericanos, S.A., Buenos Aires.

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10 years in a wheelchair

Jane, a woman in her early 60s, was exactly such a patient. She’d lived with severe scoliosis all her life. Then, in 2001, she was rear-ended while driving, and the following year, she had a bad fall while grocery shopping. By the time she came to see me, she had severe pain everywhere. She’d been using an electric wheelchair for nearly a decade. She was taking over 200 mg of morphine per day and high doses of anti-anxiety drugs.

When I examined her, she was tilted forward and to the left, barely able to stand. Her spinal curve was severe enough that I recommended surgery but I warned her that the treatment had a high rate of complication.  Because of this, it was unsafe to do the operation until her medications were stabilized, her pain significantly diminished, and she was more mobile. The term we use is “prehab” or rehabilitation before surgery to optimize the outcome.

I gave her my book, Back in Control and referred her to a colleague to coordinate her care. She was not that interested and they mutually agreed to not continue care. Eight months passed and I saw her on my schedule. I was curious because I knew the size of her curve and the severity of her pain. High-dose narcotics makes it all the more difficult because they sensitize the nervous system. I did not have high expectations…

Out of the wheelchair

I was shocked when I walked into the room and there was no wheelchair, walker, or cane. She was standing up to greet me. She was off all of her medications, had no pain, and was working out in the gym three times per week. She was animated, smiling, and engaging. I ended up an hour behind in schedule, as I wanted to find out what had turned her life around.

Jane admitted that she had spent the last 10 years sitting alone in her house stewing over all the wrongs that had been done to her. She only went out when necessary. After understanding the linkage between anger and the pain pathways, she decided to forgive. She forgave her ex-husband, the person driving the car that had hit her, the people involved in her legal battle, and the medical system that had not helped her. This process took several months to work through – but within weeks of doing so, her pain began to abate.  She still had scoliosis but as her pain diminished, she stopped stooping over protectively to guard her back. She now could stand up straight and tall.

Reconnecting through forgiveness

Forgiveness researchers, such as Dr. Fred Luskin, have shown how rumination and anger influence central and autonomic nervous system function and impair functioning of the hypothalamic-pituitary adrenal cortical axis (stress system). While forgiveness is seen as a coping mechanism that helps to relieve the stress of anger, it also has direct and indirect effects on health and nervous and endocrine function.

It has been my position that anxiety-induced anger is the driver of chronic pain. The manifestations of unrelenting anger are profound and one of them is becoming socially isolated. Now you have all the time in the world to think about your pain and all the ways you have been treated badly. You body is full of adrenaline, which decreases the blood supply to the frontal lobe (thinking area) of your brain. Indeed, it is well-documented that patients’ brains shrink in the presence of chronic pain. Between the adrenaline and not using the creative part of your brain, that would make sense. Fortunately, your brain will re-expand with resolution of the pain. (2) Anxiety, anger and adrenaline

Social isolation

Besides moving too fast, our modern societal structure does not encourage us to interact with each other in a meaningful way. I read a US News & World Report article several years ago, which reported that the average number of close friends that person in the US had was 2.2. That means that many people have essentially no close friends.

I am a pretty social person but when I was in the midst of my own burnout I became isolated. It wasn’t that there weren’t people around. I had so many intensely negative thoughts about myself whirling around in my head that I couldn’t believe that anyone would want to hang out with me. The loneliness was crushing. When I arrived back in Seattle in 2003, a close friend invited me over for a barbeque and I was shocked. I have not forgotten that day and it was the beginning of my re-entering life.

People being with people

We have held three five-day Omega workshops and this year we will be putting on a weekend seminar with Dr. Bernie Siegel, author of Love, Medicine, and Miracles. My priority was to create a safe environment where people could be with other people and share experiences. One of the most effective ways to re-connect is play and as people began to relax and laugh their pain would disappear. Of course it, returned when they returned to the real world and their triggers. But most of the participants learned the skills to consistently remain out of pain. The more satisfying aspect of the process though was that as the pain abated many re-engaged with their lives in a much more powerful way. Play

As we presented our material throughout the week, I realized that we did not have to do much. It was the participants being with other people that created healing. It was remarkable. Dr. Louis Cozolino wrote an exhaustive review in his book, The Neuroscience of Human Relationships. (3) He points out that humans evolved by interacting with other humans. Therefore, the consequences of becoming isolated are consistent and often severe. Studies out of Australia have shown that there are damaging mental health effects when workers become disabled and out of the workflow of the day. Sitting around the house without a sense of purpose is not a great way to thrive. (4)

One of the first Omega participants sent me this video link. She experienced profound healing after being in pain for over 35 years and has been a true inspiration. TED talk: Our lonely society makes it hard to come home from war

This Fox segment was filmed with another one of our Omega participants. She has a great story amongst many others. We never anticipated the power of people healing people.  Video: Write your way out of pain

Jane was in a wheelchair for over 10 years and on high dose narcotics with a severe spinal deformity. It was by her working past her anger, getting out of the house and re-connecting with her friends did she heal. No medical treatment can replicate the power of the body to heal itself. Anger disconnects – play connects.

1. Eisenberger N. “The neural bases of social pain: Evidence for shared representations with physical pain.” Psychosom Med (2012); 74: 126-135.
2. Seminowicz DA, et al. “Effective treatment of chronic low back pain in humans reverses abnormal brain anatomy and function.” The Journal of Neurosci­ence (2011); 31: 7540-7550.
3. Cozolino, Louis. The Neuroscience of Human Relationships. Norton and Co. New York, NY, 2014.
4. Waddell, G and Kim Burton. Is Work Good for Your Health and Well-Being? TSO. London, England, 2006.

Listen to the Back in Control Radio podcast Social Isolation and Chronic Pain

The taste of freedom – Omega 2017

Social Isolation and Chronic Pain

The post The Pain of Social Isolation first appeared on Back in Control.

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