• Avoiding danger is what keeps us alive. Humans call this signal anxiety.
• Avoiding this sensation drives much of dysfunctional human behaviour. We know how to stay alive but not necessary thrive.
• Anxiety is a physiological reaction that is about a million times stronger than the conscious brain. It cannot be controlled.
• We can auto-regulate and redirect it. Addressing anxiety at the root physiological cause will solve many mental health problems.

Why is Anxiety Considered a Psychological Diagnosis?

Anxiety is simply a warning signal. Every form of life has a withdrawal/ avoidance response to real or perceived danger. All life forms, from one-celled organisms to humans respond with complex changes to optimize the odds of survival. This unconscious automatic reaction is powerful and has evolved to feel extremely unpleasant in higher life forms. It compels action to lessen the sensations. The species who did not pay attention to these danger signals, simply did not survive.

 Staying alive

When you sense danger, how do you feel – anxious? Although this a basic survival feeling, humans have the capacity to name it. It is the result of stress, threats, and life challenges, not the cause. Avoiding this sensation is the driving force behind much of human behavior, and seeking safety is necessary to store up reserves to fight another day.

What happens in your body that creates this sense of dread? The term is, “threat physiology.”

Threat physiology

Physiology is the term that refers to how your body functions. Your survival reactions are mostly unconscious, and about 40 million bits of information are processed per second. Our conscious brain deals with only about 40 bits per second. Your unconscious brain is a million times stronger than your conscious brain; the responses are hardwired and automatic, and the reason it is not subject to being controlled. However, it can be regulated and reprogrammed.

Examples of physiological actions are heart rate, blood pressure, blinking your eyes, acid-base balance, sweating, breathing, bowel and bladder function, hunger, and the list is almost endless.

These are some of drivers activating threat physiology.

• Stress hormones – adrenaline, noradrenaline, histamines – ready the body for fight and flee
• Cortisol – mobilize fuel (glucose) from tissues throughout your body.
• Glutamate – Neurotransmitters change from calming to excitatory to increase alertness and sensitivity to danger signals.
• Inflammatory cytokines (small molecules that transmit signals between cells) – the many aspects of the immune system kick into action.

Anxiety is a physiological state

This is a small fraction of actually what occurs in fight or flight physiology. Consider how you feel when your body is in this state. Here is a suggested word progression.

• Alert
• Nervous
• Afraid
• Angry
• Paranoid
• Terrorized

They fall under the umbrella of “anxiety” or “fear.” We will do almost anything to avoid this sensation resulting in many bad behaviors. Psychological diagnoses are ALL anxiety driven. The exceptions are in the positive psychology domain.

A paradigm shift

The way we view mental health must change. Here are some suggestions.

• Eliminate the word anxiety from the DSM coding system. It is the driving force and cause of poor mental and physical health.
• Most psychological diagnoses are descriptions of behaviors driven by the sensations created by threat physiology. Descriptions are less pejorative than labels (diagnoses).
• Substitute the word anxiety with the phrase, “activated threat physiology.”
• Anger is “hyperactived threat physiology.”

“Dynamic Healing”

The root cause of our mental health crisis is sustained threat physiology. There are many ways of lowering it and creating “cues of safety.” The model is called “Dynamic Healing” and is at the core of how medicine should be delivered. The portals are:

• The input – you can process your stresses so as to have less impact on your nervous system.
• The nervous system – the resiliency can be increased so it takes more stress to set off the flight or fight response.
• The output – your nervous systems takes in sensory input, summates them, and sends out signals of threat or safety. There are ways to directly dampen the threat response.

None of the approaches are difficult and require few resources. There are many clinicians in all medical fields that understand and are applying these approaches. It is just not happening on a wide enough scale.

There is no question that symptoms and behaviors must also be addressed while people heal. But if the root cause is not dealt with, their suffering will continue. Hence, the nationwide burden and fallout of poor chronic mental health continues to skyrocket.

Let’s do this!!

Our mental health crise reflects a lot of needless suffering as deep science has pointed the way to effective treatments for over 40 years. Most of clinical medicine is not connected to the data or is categorically ignoring it. It is certainly not being widely taught in medical school.

Where will the energy come from to wake us all up? It has to emanate from the public demanding better care because the business of medicine seems to have little interest in true change. It is the responsibility of the medical profession to honor the known data and implement what is already known.

The answers for our mental health crises are right in front of us if we just pay attention. Take your medical care and life back. It is your right.

The post There is an Answer to the Mental Health Crisis first appeared on Back in Control.

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Roadmap to a solution

What are the clues? Over 90% of people who have died of COVID-19 have some other chronic medical condition(s) (1). The common perception is that in this scenario, the body simply gets overwhelmed. The pre-existing situation is unsolvable and the outcome is inevitable. This idea could not be farther from the truth.

All these chronic conditions are associated with elevated inflammatory markers from the body responding to threats. A major aspect of this response is the immune system. Mental threats are more problematic than physical threats in that you cannot escape disturbing thoughts and emotions and repressing them is even worse. Therefore, every human being is exposed to some level of elevated stress hormones and inflammation. Many people have learned to process threat in way that causes little damage. However, many, if not most of us, have not been taught these skills and therefore are  exposed to elevated levels of inflammatory cells. It is the essence of chronic disease.

The following chronic diseases are all connected to sustained inflammatory and metabolic destruction of tissues: cardiovascular disease, peripheral vascular disease, Parkinson’s disease, autoimmune disorders, obesity, adult-onset diabetes, anxiety, depression, obsessive compulsive disorder, and bipolar disorder. It is all the same process with different clinical manifestations and many people suffer from multiple different ones.

Plan A–Lowering Inflammation Lengthens Life

This document, Plan A, presents 12 categories of interventions that will lower your levels of inflammation. If most severe cases of COVID are connected with chronic medical conditions, then address them. By starting with lower levels of inflammation, there is a better chance of staying below the critical threshold where the inflammatory process spins out of control, there is diffuse damage to many different organs, and your lungs fill up with fluid. There are now multiple professionals advocating a similar approach. One group looked at it from using preventative medications, but it can be achieved with these other means.

Getting and being happy is a learned skill and it is well-documented that those who learn it live longer with a better quality of life. Dealing with COVID-19 requires the same approach as dealing with chronic disease–lower threat and inflammation and create safety. Obviously, it all occurs at a much faster rate with COVID.

Join us in this grass roots movement

Please circulate Plan A to as many of your friends, family, and colleagues as possible and also encourage them to pass it along to their circles. This plan was assembled by a group of physicians and scientists who feel strongly that this approach will have an impact in lowering the severity of this deadly disease. It also represents a template for the future of healthcare moving from an illness to a wellness model. It boils down to means of creating safety instead of being at the mercy of threats. Most chronic mental and physical disease is preventable and some if it even reversible. This booklet represents a major effort to change both the trajectory of COVID–19 pandemic and also the manner in which we approach health care and chronic disease.

There is another aspect of all of this to consider. Inherent in this approach is each person taking full responsibility for his or her role in their health. It is easy to look at others or society for solutions when they truly exist only in each one of us. It is possible with a collective effort of taking personal responsibility for every aspect of our lives, we can change the course of this relentless pandemic, the nature of health care, and create societal changes that will enhance the quality of our lives and those of future generations. We each have to take action, as the burden of chronic disease is crushing us. (2)

Seeing such clear relationship between chronic stress and disease, both in my clinics and in the literature is what finally persuaded me to quit my practice. The DOC Journey is the most recent evolution of the healing process. It has been inspiring and energizing to continue to see people without hope consistently connect to their own capacity to heal.

Plan A – Lowering Inflammation, Lengthening Life

References:

1.   Williamson EL, et al. OpenSafely: factors associated with COVID-19 death in 17 million patients. Nature (2020); https://doi.org/10.1038/s41586-020-2521-4.
2. O’Neill Hayes, Tara and Serena Gillian. Chronic disease in the United States: A worsening health and economic crisis. Americanactionforum.org; September 10th, 2020.

The post Plan A–Lowering Inflammation Lengthens Life first appeared on Back in Control.

The post Plan A–Lowering Inflammation Lengthens Life appeared first on Back in Control.

Consider the following:

Thoughts are the mental link to the environment that allows you to assess your situation second by second in order to make choices that allow you to first survive and then thrive. If our thoughts are pleasant our bodies will secrete chemicals such as oxytocin, growth hormone and dopamine that create a sense of relaxation and well-being.

Conversely, if you feel stressed then your thoughts will create a chemical environment consisting of adrenaline, cortisol and other hormones that create a sense of insecurity and dread. You will be motivated to control you or the situation to alleviate these feelings of anxiety. If you cannot escape or solve it, you will feel trapped and angry. If you are in a constant hyper-vigilant state, then your body will be continually on overdrive. It is like driving your car 70 mph down the freeway in second or third gear. It will break down much sooner than if you were in 5th gear and cruising.  Anxiety, Anger and Adrenaline

I am aware that life is not easy. Very few people can live their lives on “cruise.” Additionally, avoiding stress also becomes its own stress. You cannot run from your thoughts, which can torment you regardless of your environment. In fact, when I was in the most severe period of my Obsessive Compulsive Disorder (OCD) my mental distress was worse when I was less busy. OCD, BTW, is manifested by intrusive thoughts and extreme anxiety. Some day I will write about my battle with it in more detail but the only metaphor I can use to describe the experience is “having a hot branding iron on my brain”. The misery being in that hell of unrelenting anxiety is indescribable. OCD is no fun and not funny – extreme mental pain

Control

One of the main antidotes to anxiety is control. When you lose control your body will kick in more adrenaline to physically help you solve the problem. For example, if you were physically fighting someone for food to feed your family, the adrenaline boost would up your odds of winning. Unfortunately, just thoughts of danger can create the same chemical response even when there is no physical threat. Now you are in trouble because you have no way of physically solving the problem and there is not an endpoint.

Neurophysiologic Disorder (NPD)

There are many terms to describe the physical consequences of sustained levels of stress chemicals in your body. Some of them include Mind Body Syndrome (MBS), Tension Myositis Syndrome (TMS), Central Sensitization Syndrome (CSS), and Stress Illness Disorder. The term I have chosen is “Neurophysiologic Disorder” (NPD). Your thoughts are the neurologic input to your nervous system that creates a physiological response. We are programmed to gravitate towards the reward chemicals and avoid the stress ones. Within a pretty wide range we are able to conduct our lives in a functional and enjoyable manner – except when we can’t. There are solutions to the problem, which are the focus of my book. However, consider the effects of not addressing it.

These next few paragraphs were part of a proposal to address the effects of high ACE (Adverse Childhood Experiences) scores beginning in elementary school that are directly linked to your responses to stress.  Aced Out

Effects of Untreated NPD and Anxiety

There are several ways that untreated Neurophysiologic Disorder (NPD) manifests itself. Remember that the main focus of the school project is to deal with the lifelong impact of adverse childhood events. The worse the ACE load, the higher will be the anxiety a child brings into the classroom. The devastating impact on mental and physical health of a high ACE score is well documented. This does not even take into account the power struggle that occurs amongst these students to deal with unrelenting anxiety. Bullying, at the moment, is not even counted in the ACE score.

First, NPD can directly cause over 33 different physical symptoms. Medicine is focused on treating symptoms instead of the root cause of a fired up nervous system. Many of these conditions will begin in childhood, such as migraine headaches, insomnia, anxiety, eating disorders, stomach pain, etc. My Battle with NPD

Second, anxiety is the result of sensory input also that drives anger. One common cause of anger is loss of control. When you lose your ability to control your anxiety the anger will become intense. Anger is always destructive, including self-destructive. Although it may not become manifested during school years, it eventually results in complete disregard for personal health. This is an addition to the symptoms directly caused by the MBS. My observation is that complete neglect of your health is akin to a “slow suicide.”

Third, anger is abusive. Chronic pain creates and indescribable depth of frustration. When you are angry, it is all about you. It is a survival response and you lose awareness of the needs around you. Lack of awareness is the essence of abuse. Families of patients in chronic pain become the targets of this deep anger, and hence the cycle of adverse childhood events continues. There is a high chance that these children will act out their frustrations at school. Also, their parents have modeled anger as the normal way of dealing with adversity. Pain = anger = abuse

Unrelenting anxiety/anger cause profound physical effects on your body. Another week I will present the data regarding mental health and life span. It is not a pretty picture.

Your Unconscious Brain

I am aware that no one intellectually wants to be sick or unhealthy. The solution lies in addressing pre-programmed behavioral patterns that are part of the unconscious brain. The unconscious brain is much more powerful than the conscious brain. Your conscious brain energies manifesting as “good intentions” or “will power” have no chance of solving the problem. You must utilize strategies that stimulate your brain to rewire. You cannot “fix” yourself because your attention is still on you. Solving the Unsolvable

The DOC project is a framework intended for you to organize your thinking in a manner to connect with your own body’s capacity to heal. Your unconscious brain will resist this process to the max. Just sit down with Stage 1 on this website and start the therapeutic writing as described in Step 2. Your brain will begin to change and you will be able to move forward.

So my feeling is the mental health is the highest priority. Your body’s chemistry is optimized, you are able to enjoy your life with your family and friends, and your capacity and motivation to care for your health will be higher.

Why are New Year’s resolutions so hard to keep?

The post Mental or physical health – Which is more Critical? first appeared on Back in Control.

The post Mental or physical health – Which is more Critical? appeared first on Back in Control.

• Without the distractions of work, pain is more noticeable.
• It’s usually not known when the patient can go back to work, which is anxiety-inducing.
• Being labeled a “chronic pain patient” by everyone, including the medical profession, begins early.

NBC News Post

NBC News last week reported that with the recent economic downturn, many Italians are committing suicide. Here are excerpts from the notes left by the victims:

• “I decided to end it because I am a failure. I can’t live without work.”
• “I can’t live without a job.”

This feeling of failure and loneliness is at the heart of acts of desperation among the business community in Italy. These messages left are the same mantra repeated by workers and businessmen who either tried to kill themselves and lived to tell the tale or by those who thought about trying, but found other reasons to live.

Another excerpt:

• “My business is like my family. I feel responsible for each of my employees. If my business fails, I fail with it.”

(This article was called, “In debt or jobless, many Italians choose suicide,” by  Claudio Lavanga. NBC News World Blog, May 9^th, 2012)

My old attitudes

I can speak only for myself in mentioning some of my old perspectives. However, my old attitude might generalize to how some physicians currently think about this issue.

• I had the impression that many patients wanted to stop working.
  • Only some wanted to stop working.
    • Most did not.
• I did not understand how devastating it was to a patient and his/her family to lose a job.
• The mental health consequences of being home and disabled are severe.
  • Social isolation creates the same symptoms as chronic pain
• It is often easier for me just to take a person off of work.
  • It’s time-consuming to go into the details of light duty, etc.

My approach changed

• There are major implications of losing a job.
• Being out of work creates further health problems.
• Any time off work should be for as short a duration as possible with specific dates prescribed to return to work.
• If a patient is already off of work, broach the subject of returning to work very quickly.
• If they have no intention of returning to work, the issue has to be clearly discussed and an alternate plan implemented.

People inherently want to be a part of society and contribute. Being active in the workforce is an important part of that need.

The post “Many Italians Choose Suicide” – People Need to Work first appeared on Back in Control.

The post “Many Italians Choose Suicide” – People Need to Work 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.

I have argued for 25 years that a claims examiner should not be in charge of a given case.  The caseload for a given examiner used to be 400-600 workers.  Even if you had an occupational medicine physician in each claims examiner’s chair, she could not manage the claim.  I would hope the ratios were better, but even if it were 200-300 claims per examiner, the responsiveness would not be even close to the workers’ needs.  Each worker’s ENTIRE LIFE depends on an overloaded examiner.

Many claims examiners seem to have the mandate to “be tough” and move the claim through as quickly as possible.  I assume that the vast majority of examiners are initially motivated to provide the best service possible to the patient.  However, after dealing with angry workers on a regular basis, it is difficult not to develop a “thick skin.”  What that attitude does is make the claimant angry, and everything grinds to a halt.  I have to spend a lot of time just calming down my patient (and myself).  In the end, the “labeling” of workers as anything less than a “human being caught in the quagmire of a huge system” is counter-productive.  There has always been an obvious dividing line between workers with a benevolent claims examiner and those with a hard-liner.

I understand from the claims examiner’s perspective that it is important to move a claim through quickly.  However, claims tend to be dealt with more quickly when the relationship of the examiner to the worker is one of an ally helping navigate the worker through the maze of worker’s comp.

Additionally, there is a high turnover rate amongst claims examiners.   It takes several weeks for the new examiner just to get through his or her stack of claims, during which time patient anxiety goes through the roof.  How would any of us feel to have our middle school teacher changed halfway through the year and then find that her replacement has no idea who any of us are or what are needs are?

The level of medical training a claims examiner has is minimal. The claims examiners do not have enough medical training to make thoughtful medical decisions.  Currently, even if your surgical approval company approves a given surgery, I often have to still argue with the examiner about getting the surgery performed.  An insane phrase I here all too often: “The final word rests with the claims examiner.”

Many examiners do develop a valuable perspective in recognizing outliers and dangerous medical care.  However, that perspective is not uniform, and I cannot quantify what percent have that kind of experience.  I do know that many examiners are new and do not have that perspective.  There is too much variability to put so much responsibility into this position. Even if I could clone myself and sit in every claims examiner’s chair, I could not competently make the best medical decisions for that given patient.  Medical care cannot be delivered at that distance.  The examiners are in a “no win” situation.

I am also well aware of the “rumor mill” amongst the claims examiners.  Certain physicians are labeled and care is delayed.  Different treatment philosophies get picked up within the system.  Their own concepts of the human body and medical care enter the medical decisions.  When confronted, they will ask for an IME, which delays all care for at least 4-6 weeks.  They then use the IME recommendations as a template for the care of the patient.  The IME physician spends just a few minutes with the patient and their attitude is not one of providing the optimum care for the patient.  I understand that there is a need for IME’s, but that need is not to influence ongoing medical care.  With that “authority,” the claims examiner often makes everything even more difficult for the physician and the patient.

Meanwhile, I try to help “calm down” the patient, as the circumstances are extremely adverse from our perspective, and the patient’s pain and tolerance to the pain is completely out of whack.  As the final nail in the coffin, I usually cannot persuade worker’s comp, which has wreaked havoc on my patient’s life, to approve any mental health services.

I disagree with comments about the ideal system not being able to respond to the needs of a given patient.  Payments of modest financial incentives can and will change physician behavior.  But no system can respond to the complexity of an injured worker’s life and specific needs.  Each one of us becomes incredibly frustrated just dealing with airlines trying to make changes to a travel itinerary. Imagine having you’re medical treatment plan being altered against your wishes. These claims examiners are dealing with these workers entire life, including their ability to put food on the table.  My point is that any system cannot respond to the specific complexity of a given claim.  The better solution is to give the workers the tools to navigate their own way through the morass.

I am suggesting the following regarding the role of the claims examiners:

• Respect the injured worker and treat them accordingly.
  • It should be a major part of their orientation and ongoing in-service training.
• They should not be involved in medical decision making.
  • They should be able to approve reasonable care quickly and then ask for RN or physician input if they have questions.
  • This process should be expedited as quickly as possible.
  • How does delaying the ordering of tests save any money?  It would be different if there were no time loss.  The delay costs much more than the test.
• Their main role should be to make sure that the claim is run as seamlessly as possible.  Improving communication between all parties should be emphasized.
• They need to understand how trapped their claimants feel and not react when the worker is upset.  What would they do in a similar circumstance?  I don’t think any of us on the roundtable would react much differently.

There are many physicians who will not see worker’s comp patients due to the hassle factor.  Often, if a surgeon deals with worker’s comp, it is just to do a consultation and perform surgery.  By isolating out the worker’s comp variables, the decision making process regarding major surgery can become flawed.

I spend most of my time talking patients out of any type of spine surgery.  I specifically work just on discrete structural problems with matching clinical symptoms. I am diligent in trying to deal with all of the variables affecting the outcome of surgery, especially with a worker’s comp situation.  I will meet with nurse case managers as well as talk and meet with vocational counselors.  I will not close a claim until all parties have a plan in place.  I have one patient who had eight people involved in getting him back to work.  It took me ten months and at least five hours of phone calls and meetings.  After four years of chronic pain and disability, he is now working full time again.

I am one of the most interactive surgeons I know in getting a claim resolved.  I have learned how broken this system is.  I am not blaming the claims examiners.  It is a system that sets them up to fail.  Although I think the ultimate answer is to give the patients the tools to navigate their own way back to full health, there are many system changes that must be made.

I realize that there are several claims examiners on the roundtable.  I will be looking for their input with interest.  Right now, life in the trenches with my injured workers is intolerable.

BF

The post Examiners from the Worker’s Perspective first appeared on Back in Control.

The post Examiners from the Worker’s Perspective appeared first on Back in Control.