Part 2 Mind-Body Feedback Cycle: Cases (three of them)

Part 2 of 3

See Part 3 for treatments

Please share your opinion

• I agree with this including my personal health journey
• I agree with this theoretically or as a practitioner
• Interesting, but yet undecided
• 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.

Case 1 - Physical symptoms in the context of a psychological disorder

Panic disorder involves an idiosyncratic, and often meaningful, constellation of physical symptoms. It is telltale that the patient feels these episodes "come out of the blue," meaning they lack insight into the trigger, and the idiosyncratic meaning of the symptoms. As is classic to defense analysis, we want to rewind the entropy that occurs and regain the insight embedded but psychologically resisted within the symptom. One means is a somatic bridge: "what are the visceral feelings / symptoms associated with your panic? Can you focus on those parts of your body and try to recreate those symptoms? Let them get more intense and try to think about memories that come up - when are other or first times you recall feeling that way?" Almost ubiquitously, this intervention yields insights and memories the therapist and client will return to throughout the course of therapy - maybe the client remembers holding their breath and being unable to make themselves start breathing again as they experienced a car accident as a child - strapped into their child-safety seat, they felt so out of control of the situation, and now as an adult, they similarly brace themselves for what feels out of control in their social environment.

Let's take this a step further and consider someone with panic disorder who has an underlying intellectualizing cognitive style (cognitive styles being on a continuum from only having insight into emotions to only being aware of thoughts, events and most emotional experiences are displaced physically, aka somatically, or as anxiety). Alexithymia is frequently part of this cognitive style, as much emotional experience is distorted, language for it is limited and there is a dearth of experiences of "sitting" with emotions (allowing oneself to feel feelings is unfamiliar). Additionally, these individuals are frequently "super sensors" meaning they have a heightened awareness of physical sensations, which are consequently misinterpreted as more serious or even life-threatening than they are.

This individual experiences panic when they have normal bodily sensations - due to heightened sensitivity, they misinterpret it as life-threatening and become acutely anxious. Additionally, emotional experiences do not enter into, or are pushed out of, conscious awareness, and are displaced as physical symptoms. Likewise, these physical symptoms are misinterpreted as dangerous or life-threatening, and a panic attack ensues.

Gaining language for emotions and exposure to them in order to learn they are safe to experience helps break the chain reaction in which emotions cause panic. Accepting physical symptoms as not dangerous can help prevent the process in which physical sensations cause panic. Processing past traumatic memories, which shifts those memories from being recalled emotionally as if we are back in the situation to factual memories disentangles the past from the present and allows present experiences to have here-and-now rather than anachronistic meaning and reactions. Parasympathetic activating coping skills such as deep breathing, progressive muscle relaxation, mindfulness, imagery, splashing water on ones face, and grounding help to handle here-and-now triggers as well as to re-regulate the Hypothalamic-Pituatiary-Adrenal axis and Sympathic-Adrenal-Medulary Axis and gain a greater buffer before the panic threshold is crossed (a reduced baseline anxiety or physiological reactivity).

Case 2 - Co-occurring and intertwined medical and psychological conditions

 A client presented quite disenchanted with both medical and psychological treatment. They reported they tried everything and felt that Dialectical Behavioral (DBT) skills therapy was a last effort to manage their psychological distress. They were constantly anxious, had trouble not bringing problems home from work, felt compelled to perform well but had difficulty finding positive work relationships primarily with bosses, could not sleep, felt physically ill and remarkably anxious upon waking to the degree they could not start their day for a prolonged period of time in bed. This individual had physical health concerns including an arthritic autoimmune condition affecting their back, leg pain from a serious bone break in the past, and due to these conditions were unable to engage in pastimes they previously greatly enjoyed like jogging and hiking. They were on significant psychological medications including trazadone for sleep, compazine for anxiety (antipsychotics for anxiety is a sign of a last effort from the psychiatric provider), an SSRI for mood and anxiety, a biologic for the autoimmune disorder, and occasionally pain medications. The patient had a history of complex trauma from early-life bullying and likely personality disordered parents, namely a mother who could not engage in perspective taking, and was frequently belittling and domineering.

The patient made notable strides in therapy over several years including but not limited to recognizing when others mistreated her, setting boundaries and communication skills (interpersonal effectiveness), utilizing mindfulness to leave work at work, parasympathetic activation, dream analysis and trauma processing, and internal child work. She accessed artistic parts of herself that she had not engaged or expressed including writing for herself and in groups, and joining an improv group. However, significant symptoms remained and her reliance on seemingly heavy psychiatric medications considering her diagnoses and occupational functioning had not budged.

However, the stars aligned at a fortunate point. Her self-esteem had improved and she was ready to make decisions for herself. She recognized occupational problems were not her shortcomings, but a culture that could be described as toxic and at least a poor fit for her disposition and childhood. She figured out the finances and left for a meaningful job in which she would not face the same kind of bullies as she consistently had in a corporate setting. We had been discussing medications that might target symptoms better such as duloxetine for energy, anxiety, pain and mood in one treatment (I believe we explored information about Wellbutrin and buspar as well). Her biologic was no longer covered by insurance, and she had to switch to the generic at the same time as gaining access to a GLP-1 to help with metabolic sequelae of other conditions. She was able to her other medications (trazadone, compazine and SSRI). Her inflammation symptoms quickly declined, she lost weight and her pain was managed, so she was able to start engaging in physical pastimes again. She loved her job and could manage interpersonal conflict without serious psychological sequelae or bringing work home. She felt mindfully engaged with her family. She was sleeping and able to get up without nightmarish anxiety and stomach discomfort.

While therapy clearly made a huge difference and was a necessary piece of the puzzle that could not have been addressed by medical or occupational changes alone, it also had a hard ceiling due to medical conditions. Her progress in medical treatment was also barrackaded by psychological symptoms - making a change would have been terrifying considering the risk of toppling the seemingly fragile stability she had. The two approaches were necessary, just like untying a knot involves working both ends of the string, not just pulling one. However, it is undeniably evident in my mind that a significant portion of psychological distress was generated by systemic sequelae of medical conditions. During the latter half of therapy, it became a mantra to label discomfort as medical even if it felt like anxiety and consequently she did not go on a wild goose chase to figure out what psychosocial threat was looming. The scientific and treatment community has increasing indications that inflammation can cause depression, dysregulates our sympathetic nervous system causing anxiety, ravaging sleep which in turns causes inflammation and sympathetic dysregulation, fatigue and low mood. It was a cascade, cycle or snowball effect that could easily leave patient and care provider both bewildered and frustrated. I am appreciative the client stuck to our work and worked hard despite her exhaustion physically and emotionally having tried multiple treatments in the past. I think we were lucky that several medication changes occurred at once and one or more of them seemed to halt the cascade of inflammatory response.

Case 3 - Medical disguised as psychological

I started to have serious heartburn in the latter part of high school, with stabbing, burning and dull pain in my stomach. Medications didn't help much and family thought the side effects - possibly preventing calcium absorption - wasn't worth it. "Besides," they said, it was probably just diet and alcohol causing the reflux. There may be truth to this, but also highlights the invalidation people experiencing these health processes face from that start, which inadvertently discourages seeking help.

As a disclaimer, the following is circuitous, not-quite-chronological, and a bit difficult to follow, admittedly. However, I think this is directly related to and embodies the confusing experience of someone learning to understand a subsyndromal (ie., not having the florid and discrete symptoms of a recognized autoimmune disorder) inflammatory disorder. It is immensely confusing and distressing. All the symptoms are cyclically related, and finding a starting point of the pathology seems nearly or literally impossible.

By the end of college, the symptoms were becoming more diffuse including chronic fatigue, anxiety, and decreased alcohol tolerance. I dropped out of my major, music, because a hand injury sustained during high school never healed - I now, in retrospect as it is finally healing, believe was possibly caused by (and certainly halted from healing by) inflammation. I stopped playing music all together by the time I was a father, I could only play for minutes before the discomfort would become too distracting.

The symptoms continued to worsen through graduate school. As a director at the hospital, I recall having such inflammation in my belly that I could not bend over my belt, having to grip my gut like an elderly, cirrhotic alcoholic and spread my legs like a giraffe to bend down. I would wake up multiple times a night because my hands would be so numb I'd have to get out of bed and shake my arms. Any excessive use of my hands would result in such swelling, my mobility would be significantly limited and I'd have to stretch for my wrists for hours before bed in the evening. I happened across an article stating that treatment refractory reflux was cured in 80% of a small pilot study by eliminating dairy. I did so and my reflux was gone in days. I lost 30 pounds in a month and no longer had a distended gut to hold every time I bent over. The numbness in my hands and swelling in my arms went away. And the doctors seemed to think I was crazy when I told them, but referred me for an endoscopy seemingly out of fear of overlooking something that would be a liability, and solely related to the concerningly rapid weight loss (not the symptoms that bothered me). The endoscopy had no finding. I did have a lot of grief about my new diet, awful dreams about pizza that I couldn't eat, and a lot of fear of the symptoms returning if I didn't maintain the strict diet. While in part ecstatic about the weight loss and no-longer distended stomach, I was also self-conscious of the weight loss as I had recently been assigned to oversee program direction of the inpatient eating disorders program.

I finally had enough money to seek out health care, and scheduling with a GI doctor. He said my symptoms didn't fit with any diagnosis, could be something with microbiome, and this wasn't uncommon, but he could label it as Irritable Bowel Syndrome as a catch-all and prescribe a tricyclic antidepressant (TCA). I appreciated the honesty, but was frustrated and discouraged by the lack of support in finding a treatment. TCA's have lots of side effects and only treated some symptoms while probably causing a host of others. I wondered if it was also code for "maybe this is psychological."

I met with a dietician and had a blood test for food sensitivities. It showed many things including dairy (not lactose), wheat and related products (but not gluten), pineapple, eggs, pine nuts, and a few others. The dietician put me on an elimination diet and discussed moderation, describing my condition as leaky gut. This is an inflammatory syndrome in which the intestine becomes inflamed, tissue damaged and consequently more permeable. Things, proteins, that should not pass through the gut lining do pass through, and the body responds to these things as foreign threats, causing an immune response and more inflammation. Again, (as the case study above), a cascade.

I moderated my eating, but with life stressors (a new, protective, father and director of grossly mismanaged hospital programs) and some level of inflammation, I experienced what I thought of at the time as anxiety and dysthymia, which lead me to seek mental health treatment. I started an SSRI and therapy. While it was immensely helpful for anxiety, the psychiatrist arguably over prescribed the SSRI, which caused what I would label as disinhibition: I grew my hair and beard out long, had intense cravings for alcohol (and with no anxiety about the risks of drinking, there was nothing to stay my hand), and had no tolerance for my wife's perspective in arguments, many of which were caused by the alcohol. Therapy was helpful to process grief about losing music as a major part of my life, my sense of loneliness and isolation that I associated with dysthymia (and a massive creative rut), and as a resource to vent about my frustrations in my marriage. In terms of my marriage, I felt victim to my wife's anger and with little to no sense of hope to change it. Therapy gave me space to explore how I associated this with a family-of-origin member's hostility in which I also felt little agency other than to avoid or bullheadedly stand my ground out of a sense of principle. Therapy was truncated when the birth of our second child took priority, but clearly even if my psychological symptoms were seated in an inflammatory disorder, they were highly idiosyncratic and shaped by my past, present relationships and personality.

Likely both caused by and worsening the inflammation, at some point I developed sleep apnea. This causes inflammation and sympathetic dysregulation, in other words caused anxiety, and fatigue which was likely a major part of what I experienced as dysthymia, as well as difficulty with focus and concentration (for which I intermittently have received treatment under the diagnosis of ADHD). The SSRI, alcohol and apnea all can cause, and for me did cause, a sleep movement disorder. The alcohol, sleep movement disorder, fatigue, lack of motivation, and lack of anxiety response because of the SSRI negatively impacted by marriage. This in turn caused stress, which causes inflammation, and influenced my poor coping (alcohol cravings) - all of which worsen sleep apnea, and so on. You get the point.

My psychiatrist felt my anxiety was well enough managed to refer care to my PCP, but I recognized the need to decrease the SSRI and sought treatment from a psychiatric nurse practitioner. We tried treatments for energy, motivation, focus and concentration, and alcohol cravings which included first Wellbutrin, and then Modafinil. Both triggered Raynaud's syndrome, and while Wellbutrin did wonders providing consistent energy and focus, its noradrenergic effect was a major culprit in Raynaud's and became untenable. She recommended L-Theanine with the modafinil to help with anxiety, focus and blood flow (to treat Raynaud's). This helped moderately, including allowing me to almost fully taper off my SSRI (and I realized it caused much of my drowsiness), but what it did do was open the door to my focus on anti-inflammatory medications.

My PCP diagnosed me with chronic fatigue (CFS) while awaiting the sleep test that would eventually diagnose the apnea I discussed above. The psychiatric nurse practitioner recommended Low Dose Naltrexone to treat inflammation causing CFS. I got off all psychiatric medications, adding Coenzyme Q10 for energy, inflammation and circulation, which was profound for me (this article would not exist without the energy it gives me). The inflammation is slowly improving, my anxiety is in remission and dysthymia is improving, namely the energy, motivation and focus.

Part of my journey has been combatting both the social stigma and my internalization of this. Part of this process is talking openly about the experience. I have found most people are combatting symptoms they, and their care providers, cannot fully understand. I recall standing with a group of my friends on a weekend we all got together, several of them from out of town and across the country, and each of us was engaged in some new health behavior to reduce symptoms inflammation. I hope to follow this article with thoughts about what we can do holistically.