Sophia relaxed

Like most cats, she is clean and easily learned to use her litter box. About a year after we adopted her, she began to mess on the carpets and sometimes on our bed. We somewhat panicked and called the vet. She didn’t have a lot of suggestions but did point out that cats have strong behavioral patterns and can’t be trained like a dog. The episodes would occur when we were packing for a trip. Then she would pee in the suitcase. We were assuming that she was “angry” and acting out. After we were back home for a few days, things would settle back into a routine.

Last Thanksgiving, we took our usual precautions of locking her out of the bedroom and keeping the suitcases somewhat out of sight. I woke up early and saw that she had thrown up twice and created two unpleasant messes both up and downstairs. I also noticed she was meowing frequently and following my wife everywhere she went. It finally hit me that she wasn’t a malevolent cat with an agenda. She was anxious and it was manifesting in creating physical gastrointestinal (GI) symptoms. She had irritable bowel syndrome (IBS).

  Feeling abandoned

IBS

The essence of IBS is the occurrence of multiple disruptive GI symptoms. They are unpredictable in their type and timing. Symptoms include:

• Constipation
• Diarrhea
• Abdominal pain
• Excessive gas
• Bloating/ cramping
• Nausea/ vomiting

The symptoms are more frequent in females and are associated with multiple other physical symptoms. It is one of the most common reasons that people seek medical care. I am going to simplify the cause and effect. Anxiety is the sensation that is experienced when your body is full of stress chemicals such as cortisol, histamines, endorphins and adrenaline. Any mental or physical threat results in different levels of these hormones depending on its severity. Unpleasant mental input (thoughts and concepts) are more problematic because humans can’t escape their thoughts. This results in chronic exposure to an adverse chemical environment and people become ill. The list is almost endless but here are some of the ones listed as being associated with IBS:

• Fibromyalgia
• Chronic fatigue syndrome
• Chronic pelvic pain
• Dyspepsia
• Gastroesophageal reflux
• Major depression
• Panic disorder
• PTSD
• Higher chance of inflammatory bowel diseases such as Crohn’s Disease and Ulcerative colitis.

Physical symptoms

There is a paper out of Sweden (1) that documents a strong association between chronic stress and all autoimmune disorders, including the inflammatory bowel disorders. All these symptoms are included in the list of problems that are associated with chronic pain. The constellation of these symptoms is what I have termed, “Neurophysiologic Disorder” (NPD). Other names include:

• Stress Illness Syndrome
• Mind Body Syndrome (MBS)
• Tension Myoneural Syndrome (TMS)
• Central Sensitization Syndrome (CSS)

The bottom line is that a sustained adverse chemical environment causes physical symptoms. In addition to the above symptoms there is a higher incidence of heart disease, obesity, diabetes and early death. (2) This unconscious survival response is about a million times stronger than the conscious brain and can’t primarily be addressed by psychological means, although it has a role. The key to solving these symptoms is to use techniques to change the body’s chemistry to a more favorable environment. When you are truly relaxed, laughing and at play, your body is full of oxytocin (love drug), serotonin (antidepressant), dopamine (reward drug) and GABA chemicals (similar to Valium). This is a great chemical bath and you will feel relaxed along with a high chance that your physical symptoms will abate.

I thought I was so smart because I figured out that Sophia had IBS. Then I looked it up on the Internet and IBS is an established diagnosis for cats. The symptoms are similar. One of the listed causes is, “separation anxiety.” This is probably what is happening with our cat. At least she isn’t an angry cat that is acting out.

Childhood trauma

There is a high association between childhood trauma and many adult illnesses. This also includes a shortened life span. IBS is one of the problems that is connected with Adverse Childhood experiences (ACE). Reactions to the environment are programmed in by your parents and are the basis for future learning. Early dysfunctional parental patterning will worsen with time. It isn’t possible to see your own dysfunctional reactions because it is your own personal norm. As I was developing many physical and mental symptoms, I thought I was fine. I fancied myself as being somewhat “enlightened” since I had engaged in so much self-exploration. Little did I know I was reinforcing the patterns that were the source of my problems. I had no clue that I was angry. I just had “high standards” of myself and expected others to have the same. So I was constantly judgmental of me and others. I was just “frustrated”.

Sophia was a rescue cat and abandoned by the side of the road before she was weaned. My wife was at a farmer’s market and called me about bringing her home. As she was holding her, Sophia instantly attached herself to her neck and began nursing. Of course, some serious bonding was happening at that moment. We always thought she would stop doing it, but nine years later she hops on the bed every morning and nurses more fervently than ever. If my wife doesn’t let her do her thing, there’s a noticeable difference in her behavior throughout the day.  Early patterns are permanent.

The day she came home

Solution

The DOC process represents a set of concepts that allows you to become aware of when you are triggered and teaches you strategies to alter your body’s chemistry to a more favorable state. Not only will IBS symptoms resolve but so will the multiple other ones. I was experiencing 17 of them simultaneously while I was in the depths of my own Abyss. It is still surprising to see most of these gone. I had migraines, tinnitus, and burning feet for over 25 years. Who would have thought they’d disappear?

1. Song H, et al. Association of stress-related disorders with subsequent autoimmune disease. JAMA (2018); 319: 2388-2400.
2. Faletti VJ and RF Anda. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorder and sexual behavior: implications for healthcare. The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic – Chapter 8. Editors Ruth A Lanius, Eric Vermetten and Clare Pain. Cambridge University Press, 2018.

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Trapped

When the real or perceived threat persists we feel trapped. This, of course, causes the secretion of even more hormones and the feeling of being angry. Anger and anxiety are similar entities. Many reactions occur in your body, which include:

• Shift of blood supply to skeletal muscles, which enables you to flee danger.
• Decreased blood flow to your brain – especially to the frontal cortex where most thinking occurs.
• Increased blood pressure
• Faster heart rate
• Sweating
• Rapid breathing

Adrenaline also effects every cell in your body with each organ systems manifesting its own unique response. There are four categories:

• Smooth muscles – control the digestion, bladder emptying, and diameter of blood vessels and lung airways.
• Skeletal muscle – muscles used for motor function including heart muscle
• Central nervous system – is intended to protect you and one starting point is to amplify danger signals from the environment such a pain
• Conversion reaction – a given organ system will just shut down.

Adrenaline/ Cortisol

There are over 30 symptoms that can occur with this sustained “adrenaline bath” from the different organ system reactions. They include:

Smooth muscle

• Migraine headaches
• Irritable bowel
• Spastic bladder
• Sweating
• Pounding sensation of your heart

Skeletal muscle

• Back pain
• Neck pain
• Rapid heart rate
• Fibromyalgia
• Chest pain
• Tendonitis

Central nervous system

• Burning sensations throughout the body
  • Can feel like peripheral neuropathy
• Itching
• Skin rashes
• Insomnia
• Extreme anxiety/ depression
• Obsessive thought patterns
• Tinnitus or ringing in the ears
• Eating disorders
• Obsessive compulsive disorder (OCD)
• PTSD

Conversion reactions – whole systems shut down

• Paralysis
• Blindness
• Weakness

Your body – a cell culture medium

Dr. Bruce Lipton is a world-renowned cell biologist formerly from Stanford. He has authored several remarkable books including, The Biology of Belief and The Honeymoon Effect. My wife and I had the pleasure of meeting him and his wife. He succinctly pointed out that when he places human cells in a culture medium that contains adrenaline and cortisol that the cells shrivel. When placed in a culture dish that contains oxytocin and growth hormone they flourish. The difference isn’t subtle. Oxytocin is the hormone secreted at birth and is felt to be significant in a mother bonding with her infant. It is also nicknamed “the love drug.”

He also points out the human body is essentially one big culture medium contained by skin. BTW, there are about 50 trillion cells in the body. Therefore, as adrenaline is in contact with every cell the effects are profound. The way you think does affect your body chemistry. What chemical environment do you want your cells to be exposed to on a daily basis? You do have a choice.

Anxiety, anger, and adrenaline OR awareness, forgiveness, and acceptance.

Anger – The “Continental Divide” of Chronic Pain

Listen to the Back in Control Radio podcast Anxiety, Anger and Adrenaline

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In the first edition of my book, Back in Control, my advice was that if you had a surgical problem, get the surgery done quickly and engage in the rehab process after you recovered from the operation. I had felt that people in pain could not tolerated the extra burden created from a structural problem. I also thought that surgically correcting severe pathology would relieve the pain to the point that people would be compelled to move forward with their lives. However, I had many patients continue to do poorly in spite of a well-performed indicated operation. I was perplexed and could not predict when this would happen.

Inducing more pain

But I wasn’t aware of the research that shows there is a 40–60% chance of inducing chronic pain as a complication of any surgery if you operate in the presence of untreated chronic pain in any part of the body. It can become a permanent problem 5-10% of the time. (1) Chronic pain as a complication of surgery is not a well-known concept. If I had a neurological complication rate of 5%, I would not have remained in practice for long. This occurs even if the procedure goes well.

My staff pointed out that our patients that had gone through a structured rehab program prior to a procedure were doing much better, and we made a team decision to not perform surgery unless a given patient was sleeping, working on stabilizing medications, experiencing improvement in his or her anxiety/ depression and willing to deal with anger issues. We called the program, “prehab”, and asked our patients to fully engage for at least 8-12 weeks. When we considered major deformity surgery, the prehab might take up to a year.

Many patients did choose to go elsewhere, but the ones who stuck with it, consistently did better and frequently patients with significant structural anatomic problems cancelled surgery because their symptoms had improved or resolved. This turn of events was completely unexpected. It appears that as the nervous system calmed down that the pain threshold was elevated.

Four patients

I saw four patients within a two-week span that I had an almost the same conversation with regards to their decision to undergo surgery. All were professional men between the ages of 45-65. They had leg pain originating from an identifiable problem in their spine. The pain was severe enough that each wanted to have surgery, but they were all at least an 8 out of 10 on the anxiety scale and were sleeping poorly. Their stresses included seriously ill children, loss of jobs, marital problems, etc. and none of them were coping that well.

Can you live with your anxiety?

They were familiar with the DOC project but had not engaged with the concepts at a meaningful level. They were coming back for their second and third visits. Finally, I asked each of them the same question, “What would it be like if I could surgically solve the pain in your leg, but the anxiety you are experiencing would continue to progress over the next 30 to 40 years?” Their eyes widened with a panicked look and every one replied, “That would not be OK. I couldn’t live like this.” Each of them also grabbed his leg and asked, “Won’t getting rid of this pain alleviate my anxiety?” My answer was “No.”

Anxiety is a sensation generated by the body’s chemical response to a mental or physical threat. It is a deeply unpleasant sensation, and the intent is for you to take evasive action and survive. Although surgically removing the spur and pain will relieve the pain and some anxiety, it doesn’t come close to solving it. The essence of lowering anxiety is training your body to secrete less stress hormones.

The quest

I told them that although I would love to get rid of their leg pain with surgery, my bigger concern was their severe anxiety and possibly chronic pain. I recalled my 15-year battle with pain and anxiety. I was on an endless quest to find the one answer that would give me relief; especially for the anxiety. I also remembered the intensity of that need. At that moment I realized that each of these patients felt that by getting rid of the pain they could lessen or solve their anxiety.

It is actually the opposite scenario. As your anxiety resolves, it is common for pain to abate. Crippling anxiety is a solvable problem with the correct approach. That usually doesn’t include surgery. Also, after a failed surgery, another level of hope has been taken away.

Can you live with your leg pain?

Then I asked each of them that if I could resolve their anxiety but they would have to live with their leg pain, what would that be like? Although not completely happy about the scenario, they thought they could deal with it. It was more palatable than experiencing no improvement in their fear.

“No” to surgery

These patients didn’t want to jump to surgery and wanted to give the DOC program a try. Within six to twelve weeks their pain disappeared or subsided to the level where they weren’t even considering surgery. Although I know pain and anxiety are linked circuits, I had never realized that for many patients the pain relief they were asking for was really for peace of mind.

Conversely, I’ve had many patients over the years undergo a successful surgery for a severe structural problem with no improvement or worsening of their pain. Now I understand. “Neurons that fire together wire together.” Pain, anxiety, and anger are tightly intertwined. As long as the anxiety/anger pathways are fired up, they will keep the pain circuits firing.

Surgery may or may not help your arm or leg pain. It rarely solves neck or back pain. It really doesn’t work for anxiety. What relief are you asking your surgeon for?

Listen to the Back in Control Radio podcast Am I Operating on Your Pain or Anxiety?

1. Ballantyne J, et. al . Chronic Pain after Surgery or Injury. IASP (2011); 1-5.

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I was 5 years old and lived in a small town in New Hampshire. Our house was right across the street from the town common. I was so excited in that the fourth of July fireworks were going to be launched in the common within just a few hundred feet of our front door. I had waited for weeks to be so close to the event.

Around 4 o’clock I developed a headache. I don’t remember ever having one this severe and within an hour it progressed into a screaming migraine. At 10 o’clock the fireworks began. For  almost an hour the house was rocked with explosions that were dramatically magnified in my pulsating brain. I don’t have the words to describe the unpleasantness of the evening. The only good news was that my usually raging mother stopped to put a cold washcloth on my head. That was a pattern that persisted in that the one event that would always bring a dead halt to her screaming at us was the severity of my migraines.

Stuck in bed

This festive event marked the beginning of a lifetime of migraine headaches. Every two to three weeks I would develop a severe headache that was often extreme. Usually it was associated with projectile vomiting. I used to welcome that phase in that somehow my headache would abate a little. I would be stuck in bed motionless for 8 to 12 hours with a cold washcloth on my head. Every movement was excruciating. I don’t know if I would ever fall asleep, as I seemed to drift in and out of consciousness. I was always fine the next morning. I could never tell what might set the next one off.

Imitrex

In the 1980’s a drug called Imitrex was developed that I could inject into my thigh. If I could administer the injection in time the migraine would be cut short or avoided. That medication had a huge impact on my life. The only problem was that since it was an injectable I would frequently wait a little too long and still experience significant symptoms. Occasionally I would be caught without it.

Maxalt

About 10 years ago a drug called Maxalt was developed that I could just put under my tongue. I was much better at quickly taking it and could usually abort the migraine. Still on occasion, I would not have it with me and the severe sequence of events would still knock me flat. I would need to take it two to three times per month. Then it began to not work as well and I would have to add in a cup of coffee and Ibuprofen. That usually kept the headache at bay.

Migraines and NPD

I don’t have migraine headaches anymore, and I quit buying the drugs many years ago. If I get a mild sense one might be occurring, a little coffee and Ibuprofen knocks it right down. I did not realize why the headaches disappeared until I learned that the methods I had been using to successfully allay my anxiety-driven burnout were following the treatment principles of the Neurophysiological Disorder (NPD). I was taught about NPD by Dr. Howard Schubiner who was a keynote speaker at a course I co-chaired, “A Course on Compassion: Empathy in the Face of Chronic Pain.” Migraine headaches are one of the classic symptoms of the NPD. As my nervous system calmed down, the headaches disappeared along with 17 other NPD symptoms I was also experiencing.

Migraines are nasty. With engagement of a program that treats threat physiology, you can experience the same relief that I did. It took me many years of making the wrong moves to figure it out. Usually you can experience significant relief within months.

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• Understand the complexity of chronic pain and how it evolves from acute to chronic.
• The factors to consider are the source, sensitization, memorization, and the “modifiers” of anxiety, anger, and sleep.
• Breaking chronic pain into its component parts allows them all to be systematically addressed and it becomes a solvable problem.
• Each person’s journey is unique and the only way to heal is to understand pain through your eyes and take control.

Chronic pain has traditionally been defined as, “pain that lasted longer than the expected healing time.” We now know that this is incorrect. It is a neurophysiological problem. Based on current neuroscience research, chronic pain is, “…an embedded memory that becomes associated with more and more life experiences, and the memory cannot be erased.”¹ Therefore, interventions focused primarily on anatomy and structure cannot and will not work. As in any arena of life, it is necessary to thoroughly  understand a problem before you can solve it.

Chronic pain is a complex disorder

 There are many factors that affect your perception of pain, and The DOC Journey systematically presents the variables and tools to deal with them. The skills are not difficult, but it requires learning and repetition to master them. What doesn’t and hasn’t worked is applying random simplistic treatments to the complexity of chronic pain. An important early step is learning how chronic pain evolves. Aspects of it to consider are:

1) The source

2) Sensitization process

3) Memorization of the pain circuits

4) Modifying factors – sleep, anxiety, and anger.

 Sources of pain

• Structural – identifiable abnormalities with matching symptoms
• Non-structural – Inflamed/ sensitized soft tissues/ overuse – cannot be seen on a test
• Sustained exposure to threat physiology

Much pain originates from anatomical abnormalities that are clearly identifiable on an imaging study. For the lesion to be considered a structural source of pain, the symptoms must be specific and correlate with the expected pattern of pain. For example, back pain is widespread, and a localized abnormality would not be expected to cause this pattern of pain. This contrasts with a pinched nerve from a bone spur that causes pain only in the pathway of that nerve.

Non-structural pain is defined as pain arising from soft tissues, such as tendons and ligaments, and testing cannot identify the source. For example, shoulder pain can be created from irritation from the tissues around the rotator cuff and imaging tests are usually unrevealing. Pain can also be caused by a torn rotator cuff, which is easily seen on an MRI – and that would be a structural issue.

Both structural and non-structural sources of pain can be effectively treated with various surgical and non-operative treatments. But most chronic symptoms in your body are caused by sustained exposure to stress hormones, elevated metabolism (fuel consumption), and inflammation. It is the neurochemical makeup created by your body’s flight or fight response to threats. There is never an identifiable source of pain, as your physiology (your body’s function) changes every second.

Environmental cues of threat set off a defensive response. Immediately, before you are even aware, your immune system girds for the possibility of injury by initiating inflammation (to protect cells against bacterial or other invasion), elevates metabolism to provide fuel for defense, increases the speed of nerve conduction–which increases your alertness but also your pain sensitivity, and elevates the levels stress hormones (cortisol, adrenaline, noradrenaline, histamines). Much of this defensive state is modulated by small signaling proteins called inflammatory cytokines.

So how do you think you feel when you are in this physiological state? Your heart is racing, you are sweaty, tired, anxious, overwhelmed, nervous, stomach feels tight, blood pressure is elevated, pain is worse, and your breathing is rapid. The bottom line is that you don’t feel great when your body is in this heightened neurochemical state. Are these symptoms imaginary? Not a chance. None of them.

Sensitization

When your brain is hammered week after week, month after month, and sometimes year after year with the same pain impulses, it becomes efficient in processing them. It takes less of an impulse from your back to elicit the same response in the brain. The same impulse causes more neurons in the brain to fire. It is this process that causes patients to complain that their pain is getting much worse despite no additional trauma.

This phenomenon was clearly documented in a clinical study done in 2004.² Volunteers who had no experience with chronic pain had a light pressure applied to a finger. The researchers measured the response in the brain with an MRI that can track metabolic activity. It is called a “functional MRI (fMRI).” They consistently identified one small area of the brain that responded to this pressure. The same pressure stimulus was then applied to patients who were experiencing chronic pain. There were two chronic pain groups: one consisted of people with chronic LBP of more than three months; the other consisted of people who suffered from fibromyalgia. In both groups, five areas of the brain lit up. Although the fibromyalgia group experienced more diffuse body pain, anxiety, and depression than the CLBP group, the fMRI scan data was almost identical. This carefully done study documents clearly how the brain becomes sensitized to repetitive impulses.

Memorization

 Pain circuits become etched into your nervous system with repetition. The process is like an athlete, artist, or musician learning a skill. However, the frequency of chronic pain impulses is more like a machine gun. These circuits have been documented by dynamic brain imaging to become deeply embedded within six to twelve months.³ Similar to knowing how to ride a bicycle, they are permanent.

A classic example of this is “phantom limb” pain. It occurs in patients who require an amputation, usually because blood supply to the limb is compromised by vascular disease. Common causes are diabetes or atherosclerosis, when there is not enough blood to sustain viability to the limb. Prior to the amputation, lack of oxygen causes the limb to become very painful. After the limb is removed, up to 60% of patients feel the pain as though the limb were still there.  Almost 40% of sufferers characterize the pain as anywhere from distressing to even more severe than before.⁴

There is not a more definitive operation than removing the entire source of the pain by performing an amputation. The nervous system does not even know the leg is gone, and it still feels the same sensations and pain. From those of us who have the visual experience of performing these amputations, this is a dramatic example of the power of the nervous system. It is also a reminder that the brain also is an extremely complex sophisticated computer, which is programmable. “Reprogramming” requires specific skills that are not difficult to master and persistence. What doesn’t work is positive thinking and will power.

The “modifiers”

 Anxiety, anger, and sleep are all factors in the chronic pain experience. They will be each discussed in detail throughout this guided course of The DOC Journey.

 The sum of all these elevated stress hormones/ inflammatory markers is a strong unpleasant feeling that compels us to take action to resolve the threat. All animals experience this heightened state, but humans have language and consciousness. We can label it. This feeling of dread is what we call anxiety. It is so deep and uncomfortable that there is no choice but to act. Once the threat is gone/resolved and the body is back in balance (homeostasis), you can go on with your life.

Anxiety describes the cumulative sensation caused by threat. It is not the cause of a threat. It is a symptom, not a diagnosis, disease, or disorder. Therefore, it isn’t treatable by addressing it as the primary psychological problem.

 Anger describes the feelings generated by a more intense survival response. The solution to anxiety is to control you or the situation to resolve the threat. When you cannot accomplish this, your body kicks into a stronger survival response to increase the odds of survival. Anger is anxiety with an extra kick. They are the same entity. Both reactions sensitize the nervous system, increase the speed of nerve conduction and you will experience more pain.

When this sustained state of high alert is sustained, it has negative effects on your health, resulting in a variety of chronic physical and mental diseases. Each organ system will uniquely respond to this heighted physiological state, and it is why so many different symptoms and diseases are possible.

Sleep is a major factor affecting your perception of pain. Lack of consistently restful sleep has been shown to CAUSE chronic low back pain and not the other way around.⁵ There is a higher correlation of insomnia with disability than the severity of pain.⁶ Lack of sleep is inflammatory and increases pain. Insomnia is addressed early in the course and is addressed as a separate issue from the pain. Getting a consistently restful night’s sleep is a concrete step in allowing other tools to be effective. Conversely, it is difficult to move forward without adequate sleep.

Recap

Understanding the evolution and complexity of chronic pain is an important step in approaching it with a dynamic multi-pronged self-directed approach. The source of pain can be 1) structural 2) non-structural 3) in response to your body’s chemical makeup (threat physiology). Over time your nervous system becomes sensitized to pain impulses, and then they become permanently memorized. When you add in the “modifiers” of poor sleep, anxiety, and anger, life becomes truly miserable. It is also clear that the complex nature of it explains why simplistic treatments focused on symptoms cannot work.

References:

1. Mansour AR, et al. Chronic pain: The role of learning and brain plasticity. Restorative Neurology and Neuroscience (2014); 32:129-139.
2. Gieske T, et al. Evidence of augmented central pain processing in idiopathic chronic low back pain. ARTHRITIS & RHEUMATISM (2004); 50:613–623.
3. Hashmi, JA, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain (2013); 136:2751–2768.
4. Gallagher P, et al. Phantom limb pain and RLP. Disability and Rehabilitation (2001); 23: 522-530.
5. Agmon M and Galit Armon. Increased insomnia symptoms predict the onset of back pain among employed adults. PLOS One (2014); 9:1-7.
6. Zarrabian MM, et al. Relationship between sleep, pain, and disability in patients with spinal pathology. Archives of Physical Medicine and Rehabilitation (2014); 95:1504-1509.

Listen to the Back in Control Radio podcast The Evolution of Chronic Pain

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