Mind-Body Feedback Cycle: Knot of Mental and Physical Wellness

Part 1 of 3

See Part 2 for cases and Part 3 for treatments

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• I agree with this including my personal health journey
• I agree with this theoretically or as a practitioner
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• I disagree with the ideas in this article

Da Vinci's Vitruvian man was his ideal of perfection based upon ratios, or in other words, balance. In this blog, a metaphor for mind-body balance.

The subject is divisive within the treatment community. On one side are providers who may be seen as overly reductionistic, while the other side faces criticism for being excessively (w)holistic, "woo-woo," or "hippy-dippy."

Reductionism can be thought of as a byproduct of shortcomings of the scientific method. The scientific method posits that, in order to understand something "scientifically," we must study it in a relative vacuum by limiting confounding variables or at least controlling for them, which can become complicated, costly, cumbersome and burdensome. But what if certain, especially complex things like human well-being, cannot be understood without a vast array of mediating, moderating and otherwise interacting variables? Is it altogether unscientific? Is it outside the realm of current technology for scientific study and consequently beyond the realm of treatment driven by an evidence basis? I think it would be a stretch to say that, but it is a concern with our current gold-standard model of scientific study, which is required to attain grant funding and achieve publication in peer-reviewed journals.

But that is scientific cultural context, not the focus of this blog article. A greater number of practitioners are starting to look at wellness from a more holistic and systemic standpoint. Even outside of the scientific community, we see signs of this change in news articles on the mind-body, or maybe even more common, gut-psychology connection.

Historically, we have treated physical health problems with physical health treatments such as pharmaceutical medications, lifestyle change like diet, and devices and surgery. Conversely, we have treated mental health conditions with psychotherapy and psychiatric medications, and sometimes with electroconvulsive therapy, or lifestyle change like increased activity. But what if your Irritable Bowel Syndrome and Generalized Anxiety Disorder stem from a common, shared underlying pathology? I mean, it makes sense - these two conditions are frequently comorbid (co-occurring), and I am a firm believer in parsimony or Occam's Razor unless we have a good argument that two co-occurring symptoms, syndromes or disorders are better explained and / or treated as separate conditions.

Well, what if? One answer is that we look for possible common underlying causes, and consequently common treatments that address that underlying cause, thereby treating both conditions. However, this can veer off the beaten path of the scientific method and evidence-basis toward treatments that are less studied and often less well-regulated which can pose safety risks. Sometimes to a point that there is little reason to believe the treatments work, and you find yourself in the back room in an off-grid cabin getting recommendations for homemade tinctures. This is the other polarity. And unfortunately, even supplements packaged neatly with nicely branded and marketed labels are not always much better regulated. You can search for information about any brand or product of that brand in terms of the rigor of the third-party testing of their product. And of course consult a medical provider before taking anything.

Sometimes the patients who find themselves seeking these alternative, holistic treatments have been unintentionally ostracized by the treatment community. They might present with a diffuse aray of symptoms, syndromes or disorders, many of which are not currently well understood in the medical community, possibly due to some of the limitations of the scientific method described above or simply because we are still in the infancy of studying these conditions. From a psychiatric standpoint, these patients may be labeled, correctly or incorrectly, as somatizing or having a somatic disorder. On one hand, there is no reason to believe somatic disorders do not exist - in other words, psychological pathology that presents as physical discomfort as much as or even rather than psychological symptoms. Non-epileptiform convulsive episodes are the most florid example: people appear to be having a epileptic seizure, but often with missing telltale features (they will respond to certain external stimuli, for example) and no physiological diagnostic criteria of epilepsy. These episodes often occur during psychosocial stressors, and if the person engages in therapy, the condition responds to treatment very similar to that of panic disorder.

We know well that physical symptoms are part of many, if not all, psychological conditions. Panic disorder is a good example as the physical symptoms are fundamental to the condition, and most people have some knowledge of what this condition is. Depression often involves changes to sleep, appetite, and causes fatigue, and while not part of the diagnostic criteria, may also correlate to (at least perception of) physical pain. Anxiety is going to be associated with breathing, tension, difficulty sleeping, heart rate and blood pressure.

For people who primarily somaticize (when using the term in this way, we mean experiencing psychological symptoms as physical discomfort as a primary means of coping with the underlying cause of the psychological problem), the problem comes up that they can be difficult to treat. The defense of displacing psychological stress into a physical form innately implies resistance to acknowledging the underlying psychological origin or context of the symptoms. More broadly, these individuals may present with a degree of alexithymia, or lacking language for emotional experiences, which can be related to underlying cognitive style and internalized coping such as growing up in a family system in which emotional communication was not demonstrated or acceptable. In the case of non-epileptiform convulsive episodes, these individuals have little confidence or ability to communicate social wants, needs or desires, and those needs are meet as a direct result of the episode - people demonstrate support, closeness and caring, which inadvertently reinforces the symptom.

Some literature associates somatizing with passive aggression - this association may be useful and accurate or code for a difficult client who won't let a care provider help. The latter is referred to as "help seeking rejection" and is manageable by knowledgeable, self-aware care providers. We can understand that through the analogy of "hot potato," in which someone says "here is my problem, now it is your problem to solve and if you don't fix it for me, you are to blame." Rarely is anyone truly or intentionally saying that to a care provider, but somewhat frequently this sentiment can arise. And when that is the unconscious sentiment, it is not malicious, but due to lack of skill to get that need met more effectively and directly through communication.

Consider a patient who goes to a medical doctor with symptoms they cannot understand, explain or at least successfully treat with our current medical technologies. The doctor feels like they are not a good provider, but wish not to acknowledge this and pushes it out of consciousness, which ultimately only leaves the patient to blame for the lack of progress and frustration. The patient is frustrated by frequent appointments, lack of progress with symptoms, compiling copays, and possibly subtle but increasing non-verbal communications of frustration from the provider. The medical provider refers the patient to mental health services, but even with the best tact, may have difficulty doing so in a manner that does not feel dismissive or shaming, especially if the care provider still has not acknowledged and processed feeling inadequate to help the patient. The patient feels the twinge of social stigma, and that they are seen as "just crazy." They might ambivalently follow on the referral to mental health care, and may or may not be engaged in treatment. The symptoms might not improve, and the therapist or psychiatrist may be similarly distressed to the medical care provider - frustrated about the patient's engagement and progress, and left feeling inadequate.

We can assume there is a continuum from completely physical health problems to completely mental health problems, with a number of presentations in the gray area. Examples are as follows, ranging from primarily physical to primarily psychological:

• Physical health problems that cause secondary mental distress such as a life-long running who feels depressed because they can no longer run after a knee injury. The mental health symptom is indirect - an emotional reaction to the physical health concern.

• Someone develops a tumor and while very treatable, the medications cause an array of mental health symptoms including low mood and fatigue. In this example, the pathology is clearly medical, but directly via treatment causes psychological symptoms.

• Some conditions seem to sit squarely between mental and physical health. While any physical (and possibly mental) health concern likely involves inflammation, conditions primarily understood as inflammatory almost always involve psychological symptoms like low-mood, fatigue, sympathetic dysregulation resulting in anxiety, and sleep symptoms.

• Nearly every psychological disorder has physical symptoms, but I suspect we will see more literature understanding direct connections. For example, we are starting to see publications about the role of inflammation in depression. This, of course, brings up the "chicken or egg" question: which one starts first, mood or inflammation, and causes the other. Chronic Fatigue Syndrome (CFS) can occur more frequently than coincidentally with depression, and may be better considered a differential rather than comorbid diagnosis.

• Some psychological conditions are, while possibly influenced by underlying physical factors, very clearly primary. For example, post-traumatic stress disorder in people who witnessed an event like the September 11th plane crash attacks. We know that risk of developing PTSD is associated with existing Hypothalamic-Pituitary-Adrenal Axis dysregulation and increased cortisol levels (stress hormones produced by this dysregulation), such as the offspring of a trauma survivor, but the trigger for the condition was very clearly psychological / experiential and not an assault or injury to the physical tissues in the body.

Even when psychological conditions might be secondary to primary medical problems, they do not occur in a vacuum. The way those psychological conditions present is shaped by that person and their past experiences. Each depression or anxiety is idiosyncratic. While schizophrenia requires a genetic predisposition (the origin in biological or in other words medical), the delusions and hallucinations are highly individual. Consequently, regardless of the origin of the pathology, psychotherapy can help the patient to understand the specific nature of the symptoms and thereby lessen their severity and impact on functioning. However, it would be important that the therapist and patient understand that therapy would not be curative if the underlying pathology is medical. Co-occurring, and hopefully cooperative (as in a teams approach) medical treatment would predict the best outcome.

But what about the conditions that might share a pathology that isn't yet well understood medically? I suspect a notable portion of individuals who might be described as heavily relying on somatic coping mechanisms might have medical conditions we do not well understand. Anecdotally, it seems many of these individuals have inflammatory disorders or syndromes. I'd like to explore some cases below, but prior to going into that, it is worth noting a few things. A primary part of my background as a psychologist is rooted in psychoanalytic therapy, which was fathered by Sigmund Frued, a physician, who not surprisingly wanted to understand psychology as tangibly as medical conditions and applied reductionist ways of thinking to his theories. Psychological conditions were not thought of as related to other body or physical conditions and needed to stand on their own. Some would say it is incompatible to think of conditions that presumably hinge on something like somatic defense mechanisms as also having medical causes. I do believe somatic defenses are common and frequently the primary driver of psychological presentations, but I also believe there is an intersection in which mind and body overlap in ways we need to better understand.