The ability to process anxiety in a healthy way is critical to maintaining your quality of life. It is even more important for someone who is experiencing chronic pain. Anxiety is a reflection of your body chemistry changes when you are in an arousal state. Your senses are heightened and your perception of pain is heightened. (1)

There are several principles I have learned from my own experience and working with my patients:

• Untreated disruptive anxiety always gets worse. It will NEVER get better on its own.
• Anxiety is the pain. It is simply indicating, “danger” whether it is real or perceived.
• Anxiety is highly treatable if it is acknowledged and treated as a physiological problem and not psychologically.
• Anxiety is both normal and necessary–it will never disappear. Every living creature is programmed to avoid situations that would potentially affect its survival.
• It is important to separate the threat from the chemical reaction (anxiety).
• Mental pain is more disruptive to people’s lives than physical pain.
• The harder you try to suppress fear, the stronger it will become. (2) White bears
• Avoiding anxiety becomes its own stressor.
• It is necessary to learn to live with anxiety; is it not solvable.
• The way to decrease anxiety is to utilize methods that lower the stress hormones. The ultimate answer is to learn to switch over to “play” chemicals. It is a set of learned skills and not “mind over matter” or “positive thinking.”

I think that unrelenting and uncontrolled anxiety is intolerable and the one of the worst aspects of being a human. It will infiltrate every corner of your life. I find it tragic that such a treatable problem is so often not adequately addressed because of the incorrect perception of what it represents. It is actually your gift of life.

1. Chen X, et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166-173.
2. Wegener DM, et al. “Paradoxical effects of thought suppression.” Journal of Personality and Social Psychology (1987); 53: 5-13.

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I talk about how the suppression of negative thoughts associated with chronic pain can really fire up the nervous system.  Dr. Daniel Wegner from Harvard published an elegant paper in 1987 demonstratng the impossibity of trying to suppress thoughts. I’ve talked about it before in White Bears and ANTS.

BF

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Gabriel Garcia Marquez

“It is not true that people stop pursuing dreams because they grow old. They stop pursing dreams when they are crushed by relentless anxiety…

Gabriel Garcia Marquez modified by David Hanscom

Life just beats us up—pain or no pain. Eventually many if not most of us gravitate towards a survival mode. Instead of living life with creativity and vigor, we’re just trying to get to Friday and recover over the weekend.

Chronic pain greatly magnifies this process. Instead of aiming for Friday, you are trying to just get through the day. As you become more anxious and frustrated, it becomes more difficult to engage in positive experiences with your family and friends. Good food, wine, and hobbies gradually disappear. In almost all cases, people suffering from chronic pain become increasingly isolated.

The major problem with this sequence is that an inordinate percent of your nervous system is focused on your pain, so you will feel it more. The reason that goal setting becomes such an important part of the DOC project is that it causes your thoughts to be somewhere else besides your pain. Goal setting is not positive thinking. Positive thinking is just another way of suppressing negative thinking and particularly in the context of chronic pain it is a disaster.

I was reminded about a poem I wrote in 2003 while attending a surgical training session sponsored by one of our instrumentation companies.  It was a remarkable weekend that altered my surgical approach to spinal deformity. Most of the three-day course was spent working on cadavers. I wrote this poem:

Whoever you were
You were generous
Giving yourself
To be my teacher
On your last day of
School

Remember the time of your life where your dreams were running free. Spend some time with it and re-connect with that energy. Reminisce with your partner. You have only one shot at this life. Give it your best shot!!

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I talk about how the DOC Project can relate to other aspects of our everyday life, including everyday stressors and suppression. This is related to some of what I talk about in “Memorization of Neurological Circuits.”

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• Not running a red light to avoid getting hit
• Treating our boss with respect to avoid getting fired
• Seeking food because you are afraid of starving
• Cutting away from yourself with a knife to avoid hurting yourself

Anxiety is the sensation that is felt when your brain senses danger (real or perceived), and creates a survival reaction. It is a “reflex” or link to your environment. 

Our modern world holds out the promise of happiness if we have enough of “X.”  One of the “X’s” is less anxiety. It appears to me that there is a lot of energy spent trying to rid anxiety from our lives. If you did this completely, you could not survive more than a few minutes. But we still keep trying and it’s ironic that the harder we work on eliminating anxiety from our lives, the stronger it becomes.

Some of our attempts are:

• Suppression/denial
• Rigid/structured thinking
• Avoiding anxiety-producing situations
  • Phobias
  • Decreasing the “size” of your life
• Direct control
  • Other people
    • Marriage
      • Control of household
      • Control of spouse
      • Control of children
    •  Boss
    •  Bully
      • Bullying is basically an anxiety reaction
      • Much of this behavior carries on into adulthood—just better disguised.
        • “All is fair in love and war”
        • “That’s just business”
    • Circumstances
    • Self

A universal strategy to decrease anxiety is to strive for more power and thereby increase your ability to control people and circumstances. I don’t know what percent of high achieving people have this as their motivation versus a vision based on love and excellence. My own obsessive drive to become a top tier spine surgeon was anxiety-based. Examples of ways we try to gain more power:

• Gain Strength
  • Physical
  • Mental
  • Spiritual
  • Financial
• More control over others
  • Intimidation
  • Guilt
  • Organizing others for your own agenda

It is not that many of the above behaviors are undesirable. It depends on the motivation and intensity and the effect on those close around you. The first and necessary step is to become aware of the effects of anxiety on you and those close to you. Then you will be able to process it in a way that allows you and others close to you to thrive.

The post Decreasing Anxiety with Control first appeared on Back in Control.

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80 Hours a Week???

I have witnessed the downside of thought suppression firsthand in the medical profession. In medicine, suppression is a way of life — it is the way we “succeed.”  We have extreme training conditions, infamously long hours, and harsh demands. A law was passed a while ago limiting residents’ hours to 80 hours per week.  Those hours are still too many for a given workweek. Think what it was like before those laws were passed. Complaining is not an option, though. What can we do?  Nothing. So we just put our heads down and go to work.  We learn to be “tough.” However, the price in terms of mental health is high. Various variations of this problem are present in all high-level/ performance professions.

Physician Burnout

The rate of physician burnout is over 60% and climbing. It is considered a major crisis affecting every aspect of health care. (1), and there is a higher prevalence of psychiatric disorders, drug abuse, and alcoholism among physicians compared to the general population. (2) The suicide rate for male physicians is 40% higher than men, in general, and 130% higher in women doctors.(3) I personally have four out of 80 medical school classmates and two close spine surgical colleagues who committed suicide. The most recent one occurred with a close friend of mine who was assisting me in two surgery cases.  Each case had gone extremely well. Afterward, he shook my hand, said “nice case,” and shot himself three hours later.

Over the years, I had watched my friend slowly fold under the stresses of being a spine surgeon. He suffered the deadly combination of suppressed anxiety and extreme perfectionism. At the time of his death, however, he appeared to have finally gotten a handle on it and seemed like he was pulling out of it. None of us saw it coming.

Patients tend to think of their doctors as somehow stronger than they are, and many physicians take on that projection. They don’t admit to themselves how much personal damage that poorly processed stress is doing to them.

Effects of Suppression

Trying to suppress or not think about negative thoughts is a disaster – in my opinion, it may even be more damaging than suffering. When you try to not think a negative thought, the thought is stronger when it reoccurs. It also takes a significant amount of additional mental and emotional energy to keep thoughts under wraps. For example, you might be upset at your spouse, partner, or child because they routinely don’t pick up after themselves. The first approach is usually to quietly ask them, which often progresses to nagging, and so on. You also might respond fairly aggressively to effect a change. As you know it usually doesn’t work.

As you are closely connected to this person, you also don’t want to be frustrated. So you aren’t. You try to ignore the untidiness. Your rational brain kicks in and starts to “keep score.” You rationalize that this isn’t that big of a deal. There is now a lot of mental energy being expended. You know the rest of the story.  The longer you try to ignore the problem, the higher chance you will be irrational when you finally do decide to deal with it.

There are other adverse effects on the brain with thought suppression.

• It is a mediator between depression and opioid craving in patients suffering from chronic pain. (4)
• It causes amnesia through damage to the hippocampus of the brain (memory area). (5)

Positive Thinking

There has been a movement for decades encouraging people to think positively. In my opinion this philosophy represents a global form of thought suppression. If a situation is bad, it is bad. Pretending otherwise does not help. The energy spent suppressing the negative emotions could be better spent solving the problem. Positive thinking was the one biggest factor in precipitating my burnout. My approach was that of being fearless and “bring it on.” It worked until it didn’t.

A simple but elegant experiment conducted in regard to suppressing negative thoughts published in 1987 showed that suppressing thoughts is not only ineffective but there is a trampoline effect and you experience them a lot more. I think it may be one of the most key concepts relevant to human’s mental health. Allow yourself to feel and embrace what is right in front of you.

1. Jha, AK, et al. A Crisis in Healthcare: A Call to Action on Physician Burnout. Massachusetts Medical Society, Waltham, MA.
2. Rath K, Huffman LB, Phillips GS, Carpenter KM, Fowler JM. Burnout and associated factors among members of the Society of Gynecologic Oncology. Am J Obstet Gynecol. 2015;213(6):824.e821-829. 
3. Shanafelt TD, et al “Suicidal ideation among American surgeons” Arch Surg 2011; 146(1): 54-62.
4. Garland, EL, et al. Thought suppression as a mediator of the association between depressed mood and prescription opioid craving among chronic pain patients. J Behav Med (2016) 39:128–138.
5. Hulbert, JC, et al. Inducing amnesia through systemic suppression. NATURE COMMUNICATIONS | 7:11003 | DOI: 10.1038/ncomms11003.
6. Wegener, D.M., et al. “Paradoxical effects of thought suppression.” Journal of Personality and Social Psychology (1987); 53: 5-13.

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