“I know better”

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

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

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

Why is depression just the expression of sustained anxiety?

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

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

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

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

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

Anger – stepping it up a notch

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

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

Medicine has missed it

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

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

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

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

• Adequate sleep is a necessary requirement for healing.
• Insomnia is a cause of chronic pain, and it is not the other way around.
• It is almost always possible to experience a consistently good night’s sleep using a combination of approaches.
• Do not undergo any major invasive interventions until you have solved this issue.

Insufficient sleep is a major factor that compromises one’s coping capacity and increases pain. It is consistently solvable with a stepwise approach regardless of the level of your pain. The outcomes of the various treatments are easily assessed. The key is focus and persistence. It is a myth that you need less sleep as an adult and at least seven hours of sleep is the desired amount. Few patients suffering from chronic pain are getting adequate sleep.

Incorporating sleep into the treatment of pain was my first step in conceiving the DOC protocol. I felt I had a whole new weapon that was effective and yet simple. There was always some improvement in their sense of well-being if not also their pain.

 Sleep and pain

I had originally thought that people in chronic pain could not sleep because of their pain. But a large study out of Israel showed that it is lack of sleep that induces chronic low back pain. It also demonstrated that the reverse was not true – that pain caused insomnia.¹

Another study documented that lack of sleep was a bigger predictor of becoming disabled than the severity of back pain. Even more interesting to me was that this was also true for leg pain (sciatica), which surgeons generally feel is the most disabling problem.²

Successfully addressing insomnia is the highest priority. The DOC Journey will be marginally effective if you aren’t getting 7 or 8 hours of restful sleep. Not sleeping is NOT an option. No major decisions regarding your spine care should be made until you feel rested during the day. This is particularly true regarding spine surgery.

I had one businessman that had experienced chronic neck pain for almost two years. There was no specific injury. He continued to work as an owner of a small accounting firm but was miserable. He had been through multiple courses of physical therapy. I started him on a strong sleep medication, which immediately allowed him to sleep a full night. I saw him back at two weeks to check on how the medication was working. I was planning on starting aggressive physical therapy six weeks later. When he came back for his eight-week visit, I was surprised to find he was pain-free after being in pain for over two years.

Start sleeping – NOW

There are many ways to get a good night’s sleep. Most people can figure out a solution using a combination of the self-directed suggestions below. If you are still struggling after a few weeks, you should discuss it with your primary care physician. The details of each of these suggestions are outlined in the next lesson, which is the sleep chapter of my book, Back in Control. Please use this a reference to devise your own approach.

Approaches to Insomnia – self-directed

1. Sleep hygiene – well-known set of principles to optimize sleep.
2. Stress management at bedtime – i.e., don’t read business emails while you are trying to fall asleep.
3. Exercise – It is not helpful to exercise late in the evening, but overall physical conditioning improves sleep.
4. Expressive writing – has been shown to help decrease the time it takes to fall asleep.
5. CBT-I – stands for Cognitive Behavioral Therapy Insomnia. There are online resources that may be helpful in addressing some of the anxiety around trying to get a good night’s sleep.
6. Over the counter sleep aids – I do not have specific recommendations and they should not be used long-term. You also should make your physicians aware that you are using them.

Under the guidance of a physician

1. Prescription Medications – There are many medications that are effective in dealing with insomnia. I have observed that if you are suffering from chronic pain that you often need a kick-start with strong sleep meds. Once your nervous system quiets down you can and should come from them relatively soon. Using narcotics for sleep is not recommended and creates many additional problems.
2. Diagnosing a sleep disorder – there are over 100 sleep disorders with the most common one being sleep apnea. In sleep apnea your airway intermittently becomes occluded while sleeping and you are gasping for air. Sleep quality is poor, and you are tired the next day. More importantly it has an adverse effect on your heart. If simple measures are not working, it is important to diagnose and treat this. Restless Leg Syndrome is another common sleep disorder that is treatable with the correct medications.

Recap

A consistently restful night’s sleep is necessary for healing from chronic mental or physical pain. Insomnia causes chronic LBP and must be addressed as the first step of healing. It is generally solvable regardless of the level of your pain. Most people can improve their sleep with simple self-directed interventions, but you should not hesitate to seek help from your physician.

Use the sleep chapter from my book, Back in Control, as a reference. Read it carefully and implement the steps that are doable for you. As you layer on additional strategies, you will find a way to sleep.

References

1. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
2. 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.

The post Systematic Approach to Sleep first appeared on Back in Control.

The post Systematic Approach to Sleep appeared first on Back in Control.

Dr. Sarno

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

Dr. Schubiner

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

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

The Neurophysiological Disorder (NPD) – Make the Right Diagnosis

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

My Experience with NPD

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

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

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

Terminology

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

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

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

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

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

As you more effectively process stress, your sleep will improve. As a lack of sleep is itself is a major stress, getting the ball rolling is a little tricky. Getting to sleep with meds may be the starting point. A simpler step would be to do the expressive writing exercises outlined throughout this website at bedtime. Many sleep specialists are encouraging these types of cognitive behavioral exercises at bedtime as a sleep strategy. It’s remarkable how quickly writing can slow down these whirlpools of obsessive racing thoughts. The writing has been shown to decrease the time it takes to fall asleep. (1) Personally, expressive writing is the only tool I find effective for getting back to sleep if I am experiencing a particularly stressful week.

Additionally, it is very helpful to keep a notepad by the side of your bed.  When you wake up at night, it is often effective to engage in the writing exercises at that time.  You may initially be doing this three or four times per night.  The alternative of just laying there and hoping you will fall back asleep seldom works. I received an email from a patient who discovered that using one finger to “write” on her other hand had the same benefits as writing on paper and she would fall back asleep quickly.

Sleep is a critical anchor point of successfully solving your pain. Using this simple risk-free strategy might be of great benefit.

1. Baikie K WK. Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment. 2005;11:338-346.

BF

The post Writing at Bedtime first appeared on Back in Control.

The post Writing at Bedtime appeared first on Back in Control.

Most patients with chronic pain sleep poorly and are tired during daylight hours. They often feel pain more keenly at night when they have fewer distractions. Without restful sleep, one’s quality of life is compromised and day-to-day stress and pain are difficult to handle. The actual intensity of the pain increases.

In 1997, I started to incorporate sleep treatment into my practice. If a patient had an acute problem such as a ruptured disc, I would use sleep medications in addition to pain medications. It was much easier for my patients to wait it out until the disc healed if they were able to sleep. Whenever chronic pain was involved, the results were consistent: over the course of two to four weeks, my patient’s mood and coping mechanisms would improve with consistent sleep. If they did not get to sleep, I would aggressively keep switching meds until we found the right treatment. Not sleeping was not an option. I was able to get most of my patients to sleep reasonably well within four to six weeks.

Sleep is the highest priority

The first step in the DOC program is to get at least a month of adequate restful sleep. It is an integral part of calming down the nervous system. The program isn’t effective unless you are rested. Many adults think they can get by on less than eight hours of sleep, but consider 7 hours a minimum. Most people, especially with chronic pain, do not get a full night’s sleep.

There was one study done in which female volunteers were measured in terms of the quality of their Stage V sleep, also called REM sleep, for a period of time. This is the stage where the most dreaming takes place. It was discovered that the less amount (and poorer quality) of REM sleep, the higher the sensitivity to pain. (1)

It is my first obligation to simply get my patients to sleep. Patients argue with me that it is impossible to sleep with the pain. However, there are few situations where the right combination of medications cannot be found to yield a consistent good night’s sleep in spite of the pain. If your physician is not addressing your insomnia, insist that he or she does. It is one of the first responsibilities you must take on to pursue your pathway to a better quality of life.

1. Karaman S, et al. Prevalence of sleep disturbance in chronic pain. European Review for Medical and Pharmacological Sciences (2014); 18: 2475-2481.

The post Sleep first appeared on Back in Control.

The post Sleep appeared first on Back in Control.

You have to sleep

I began to address sleep in my patients after I moved to Sun Valley in 1999, If it were an acute problem such as a ruptured disc, I would use sleeping medications in addition to pain medications. It was much easier for my patients to wait out the pain until the disc healed if they could sleep. In chronic pain, the results were consistent. Over two to four weeks, my patient’s mood and coping mechanisms would improve.  If they did not get to sleep, I would aggressively keep switching meds until sleep was attained.  Not sleeping was not an option. None of the rest of the DOC program will work without sleep.

I had one businessman that had experienced chronic neck pain for almost two years. There was no specific injury. He continued work as an owner of a small accounting firm but was miserable. He had been through multiple courses of physical therapy. I started him on a strong sleep medication, which immediately allowed him to sleep a full night. I saw him back at two weeks to check on how the medication was working. I was planning on starting aggressive physical therapy six weeks later. When he came back for his eight-week visit, I was surprised to find he was pain-free after being in pain for over two years.

Incorporating sleep into my treatment of pain was my first step in conceiving the DOC protocol. I felt I had a whole new weapon that was effective and yet simple. There is always some improvement in their sense of well-being if not also their pain.

Patients will argue with me that it is impossible to sleep with the pain. There are few situations where the right combination of medications cannot be found to yield a consistent good night’s sleep in spite of the pain.

BF

The post Early Sleep Concepts first appeared on Back in Control.

The post Early Sleep Concepts appeared first on Back in Control.