Your Hand Over the Heat

If you were to put your hand close to a hot burner on a stove, what would happen to your level of anxiety?

• It would quickly escalate.
• You would withdraw your hand.
• You would protect yourself.
• Anxiety would be alleviated.

What would happen to your anxiety if you were forced to leave your hand over the burner?

• It would go through the roof.
• You would feel trapped and extremely angry.

I don’t believe you’re OK.

Anxiety is a Programming Problem

The changes to the central nervous system during chronic pain represent a programming problem rather than a psychological problem.

• Anxiety gains strength with time and repetition.
• Anger is a powerful force that covers up the feeling of anxiety
• Anger spins anxiety-inducing neurological circuits more quickly.
• We deal with anxiety by exerting some form of control.
• If you are successful in controlling the situation or yourself, then your anxiety is alleviated.
• Without control, you become frustrated or angry. Anger = loss control

With chronic pain, you have, metaphorically, lost your ability to “withdraw your hand from the red hot burner.” How can you rate yourself as a zero on anxiety and irritability? If you had no other stress in your life, chronic pain alone would be enough to destroy the quality of your life.

There are several other stress factors to consider with chronic pain.

• People in chronic pain don’t see an end to their suffering. They lose hope in returning to a pain-free life.
• Chronic pain patients are truly victims of pain. So it’s more difficult to let go and not have anger run your life.
• When chronic pain patients suppress anxiety and anger, these negative feelings become much stronger. (2)  White Bears and ANTS.

Being Pain-Free is a Basic Need

We all deserve to live free of constant pain. Being pain-free is a basic need. It has been shown that the impact of chronic pain on a person’s quality of life is equivalent to having terminal cancer. (1) We cannot accomplish higher goals and flourish as human beings without first securing the comfort of being in our bodies. I discuss this in “Maslow’s Miss”  and in the video: “Your Hand Over the Stove.”

“The Link Between Pain and Anxiety”. Inspire, January 21st, 2013

1. Fredheim OM et al. “Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients.” Acta Anaesthesiologica Scandinavica (2008); 52: 143 – 148.
2. Wegener, DM et al. “Paradoxical effects of thought suppression. Journal of Personality and Social Psychology (1987); 53: 5 – 13.

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Anger

It is my observation that the whole system of care ignores the most significant factor that contributes to the development of chronic pain—anger. Anger is universal and part of the human experience. Some argue for the necessity of anger. In any case, it is not going away any time soon. Anger provides a useful survival mechanism. When you are threatened and feel anxiety, you will take evasive or avoidance action. When that ability to escape is lost, you will become angry, which increases your body’s physical reaction and mental focus to solve the problem.

Control

The antidote to anxiety is control.

Loss of control = anger.

The current disability system strips the worker of control. Additionally, at least in Washington State, the injured worker is at the mercy of a medically unsophisticated claims examiner. That examiner has final say in everything. As “enlightened” as I am, I cannot discuss a case with an examiner for more than a few minutes before I feel like I am losing my mind. I cannot imagine having my well being, as well as my livelihood, at the mercy of this system.

Dealing with the Anger

It will not matter what systems are designed to “incentivize” workers to return to work, unless this core issue of anger is addressed. You don’t have to incentivize any living creature to jump out of a cage. You just have to the door. Anger not only traps workers so they cannot fully engage in their care, but it also robs them of the ability or motivation to become engaged.

Although anger can be a useful survival mechanism, it is usually destructive to you and everyone around you.  Your anger imposes its own will on the immediate surroundings, and you lose all ability to rationally interact with your environment. The consequences are often disastrous. The most well designed programs are not going to be effective unless the wall of anger can be penetrated.

Anger and Frustration with Workers Compensation 

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“Not much I can do”

I prepared to walk out the door and have her referred to a primary care physician. He or she could offer some basic care such as medications and physical therapy. But I did not know a way to have this quickly done, and she seemed like she was in a crisis. I turned around and walked back into the room realizing that at least her husband spoke some English. I spent about 20 minutes explaining the relationship between pain and the central nervous system’s response to it and gave them a copy of my book. I asked both of them to at least engage in the expressive writing.

Surprisingly, she and her husband returned. She could walk and conversed with me through the interpreter. Her whole body still hurt but she felt a little better. Her husband had not really engaged in reading the book. I was encouraged by the little progress, but I felt that if I was going to teach her anything about chronic pain, it was going to have to be done by me in the office through the interpreter. I spent about a half an hour going through the relationship between pain, anxiety, and anger. I again asked the husband to assist her in learning and translating the concepts. I also requested that she further commit to writing down her thoughts and immediately destroy them.

It was anxiety

They returned two weeks later and her pain was markedly improved. As I talked to her it became crystal clear that she was being tormented by extreme anxiety. She stood in the opposite corner of the room with her arms wrapped around herself and her whole body was quivering with fear. They had decided to move their family back to Puerto Rico so she could be with her mother. I realized that this was the last chance to turn this around.

I explained to her that although she might have a temporary decrease in her anxiety, she was not going to completely outrun it by being around her family. It was fine to move back home if that was what she wanted to do. If it was to escape anxiety, I felt that was a bad idea and it would follow her. I became very blunt with her and her husband about the whole situation. He needed to engage. She needed to address her anxiety as its own issue and commit to the writing process. I re-explained some of the central nervous system concepts. I was fairly sure they were headed back to Puerto Rico.

Better

Two weeks later they returned. She and her husband were both smiling. Her pain and anxiety were much better. They were not moving to Puerto Rico and were excited about how the situation was turning around. Her husband was more engaged and she had pursued her expressive writing with a vengeance. It had been extremely helpful. Her husband’s comment was, “I have my wife back.”

I have no illusions that she is yet home free. Recovery is not a straight-line endeavor.  But she now had tools and more importantly—hope. Her problem was not chronic pain; it was anxiety. I did not order any tests. I prescribed some medications for sleep and pain. I spent about two hours of my time talking to her. She engaged in the simple but powerful tool of expressive writing and has a high probability of continued improvement.

Back in action

What is this worth? There are two adults and two children in this family who have a higher chance of being contributing members of society. There is less family stress, which improves the behavior of the children, who are going to school with your children. The wife has a better chance of being an effective mother and getting back into the workforce. Minimal medical resources were expended and less will probably be spent in the future.

Four lives affected. Minimal medical resources expended. With her severe language barrier, writing down her anxieties was her only choice of tools. This occurred relatively early in my presenting the DOC process to my patients. I did not anticipate this outcome. Treating chronic pain has become one of the most rewarding parts of my practice.

BF

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Caroline Myss-Taking Back Your Spirit

Anger and chronic pain are linked pathways. It is not possible to release yourself from your pain and move foward with your life until you can experience true forgiveness for the people who have wronged you the most. This remarkable video was passed on to me by a friend this weekend. Caroline Myss is a medical intuitive who has a remarkable ability to diagnose and heal disease through her ability to connect with patients. She relates a powerful story about forgiveness. The Navajo indians have a deep connection with the spirit that seems to be lost in our modern world.

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Anger

Nonetheless, there are obstacles to becoming pain free. The absolute biggest block that I encountered daily was anger. I honestly didn’t know how to help a patient get past it. He or she becomes irrational. When you are chronically angry, it is your baseline, and you cannot even recognize that you are angry. I personally had no clue that I had any anger issues until I was 50 years old. In fact, one of the first lines to my wife when I first met her was that I was a “good catch” because  I had dealt with all of my anger issues. I am glad that neither of us had any idea that I had not even opened the door to my frustrations, as we never would have made it.

Noncompliant

The problem with anger is that you cannot listen and accurately assess a given situation. The conversation I have with a patient who is noncompliant goes like this. “Doctor, you mean to tell me that there is nothing wrong with my back? I have been in pain for several years and I know that this pain is not in my head. You must be missing something.”

I reply, “The pain you are experiencing is not imaginary pain, nor is it psychological. We know that if we did a functional MRI of your brain right now, the part of your brain that corresponds to your area of pain would light up brightly. All that matters is what is happening in your brain. We also know that the brain can fire spontaneously without an indentifiable source of the pain. I don’t just believe you have pain–I know you are experiencing pain and are frustrated about being trapped.”

I also explain to them that degenerated discs are normal as you age and that there is no correlation between a degenerated disc and back pain. The surgical success of a fusion for LBP is less than 30% with a significant downside of a failed surgery. They then say, “I don’t want surgery. I just want to be fixed and get my life back.” When I reply that we have had very consistent results following the steps outlined in this book, they explode saying, “I don’t want to read a book or anything like this. Just do something to fix my back.” They will then start ranting and often even yelling that no one will help them. Occasionally they will walk out of the room.

Anger is an absolute block to moving on

This is a frequent scenario. I would estimate that at least 50% of my patients fall somewhere in this part of the spectrum. They are noncompliant actually not by choice. I realize that chronic pain causes anger, but It is this anger that is also a complete block to engagement in effective treatment. Anger is destructive and it is multi-directional. It is particlurlarly self-destructive. You also have a strong sense of “being right” when you are angry and an even stronger sense of everyone else “being wrong.” I honestly do not know what to do to break this mind set.  I have tried everything from being confrontive to being incredibly patient. Nothing has worked. In fact, I have found that the longer I spend trying to convince someone to engage, the angrier they become. Angry people become upset when trying to be convinced to give it up. They just cannot hear me.

Address Your Anger

If you are angry or living in one of the above disguises of anger, be careful. You are trapped. You are truly stuck, and no one can even throw you a lifeline. What you cannot see is the havoc you are wreaking on those around you and onto yourself. I do not know how best to quell the anger rooted in chronic pain. I am open to suggestions.

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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

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Abraham Maslow

Abraham Maslow (1908-1970) was a brilliant professor of psychology. He founded a branch of psychology known as “Humanistic Psychology,” which focuses more on psychological virtues or excellences rather than on psychological disorders. Maslow is best known for his conceptualization of “man’s hierarchy of needs.” This hierarchy is usually represented as a pyramid, which is depicted above. Maslow thought that meeting one’s basic needs in the lower part of the hierarchy was necessary before progressing to the needs at the top. He also recognized that getting to the very top of the pyramid, what he called self-actualizing–flourishing as a human being, was not commonly attained.

Basic Human Needs

The most basic needs are physiological:

• Air
• Food
• Water
• Sleep
• Sex

According to Maslow, it is impossible to progress up the pyramid if you cannot obtain air, food, water, sleep, and sex.

Where is Pain?

A thought struck me as I looked at his hierarchy: where is the need to be free from pain? I believe this need belongs on the bottom row. Any time a basic human need is not met, anxiety quickly results. If the basic need remains unmet, then the anxiety will progress to anger, disrupting your quality of life and compromising your ability to function. When you are in pain, your body will flood you with anxiety in an attempt to protect itself from harm. (I talk more about the relationship between pain and anxiety in “Your Hand Stuck Over the Stove.”)

Will you have the wherewithal to progress up the hierarchy of needs when you are consumed by pain? You won’t. I believe it is impossible to flourish as a human being without first absolving yourself of your pain. Maslow simply missed including this basic need in his paradigm.

A.H. Maslow, A Theory of Human Motivation, Psychological Review 50(4) (1943):370-96.

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BF

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Consider a situation where you are forced to hold your hand next to the hot burner of a stove.  What would happen to your anxiety?  What would be your next response?  In chronic pain, you “can’t get your hand away from the stove.” I talk about this in depth in Your Hand Stuck Over the Stove.

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