Interview with Howard Schubiner, MD
This interview will be published in three segments: 1. General information on Dr. Schubiner and PPD, 2. Developments in his research, 3. PPD treatment. Several prominent PPD practitioners participated in the interview including Eric Sherman PsyD, Alan Gordon LCSW, Barbra Kline LCSW, and Colleen Perry.
This interview was written primarily for practitioners. Some of the responses may have been different for a peer audience, and this interview should not be considered medical advice.
General Questions about Dr. Schubiner
TMS Wiki: Before beginning to study PPD, you had a successful career as a researcher in the fields of adolescent medicine, ADHD, and stress reduction. For example, you are on the editorial boards of the Journal of Adolescent Health and the Journal of Attention Disorders. I would think that switching your focus to PPD must feel like a big transition. How did you first learn about PPD, and what about the field led you to refocus your career in this direction?
Howard Schubiner: When I was in college, I was very interested in mind body interactions. After becoming a doctor, I studied hypnosis, meditation, and acupuncture. However, I had little time for those interests during my 30s, while I was working to build a career as a researcher. However, when I turned 40, I realized that I needed to get back to meditation. This led me to become a mindfulness meditation teacher, which opened the doors back to my roots. When I finally left the University for Providence Hospital, I happened to hear about a friend's experience with severe hip and back pain that was basically cured by the methods of Dr. Sarno.
This occurred at a time when I was ready for a new passion and I started reading voraciously. I read all of Dr. Sarno's books, worked with him for a few days, and found as much research as I could that related to the connection between the mind and the body. I began to realize how important this area is and how this is a key to understanding so much human misery that is unexplained by modern medical science. The vast majority of doctors do not understand that mental events can cause true and real physical pain. That simple statement, that simple understanding is missing in modern medicine. We call it modern medicines' blind spot. I started interviewing people and the more I paid careful attention to their stories, the more I really began to understand the depth and breadth of this disorder. Since I was used to teaching mindfulness meditation courses in small groups, it was only natural that I'd develop a TMS program that I taught to small groups once a week for several weeks. I have tried to be innovative by incorporating elements of mindfulness meditation, therapeutic journaling, and many concepts that I had learned from my earlier training.
I am not a strong believer in fate, but I do believe that when opportunity knocks, you should pay attention and respond. I feel that this work is the most important work that I have done.
Wiki: You have a strong background in mindfulness meditation. How do you think that your background with mindfulness informs your approach to PPD and to medicine in general?
HS: Mindfulness is a powerful tool for living. In my opinion, everyone should learn these techniques, and they are easy to learn and implement. The hard part is remembering to implement them, especially in times of stress. Mindfulness teaches being in the moment, being able to gain perspective, understanding that everything is transient, learning to deal with strong emotions and negative thoughts. Brain studies show that mindfulness practice activates the DLPFC area of the brain which is important in inhibiting pain. It is also associated with improved immune function and overall contentment.
With regard to pain and TMS, mindfulness is an invaluable component for recovery. Although pain can clearly be triggered by emotions that have been primed from stressful events in the past, the pain is occurring in the present. And it continues to be triggered by emotions in the present, even if they were learned in the past. Therefore, while it is important to understand the effects of the past and deal with them, it is also important to live in the present and deal with current stressors and current emotions. Mindfulness practice helps people to observe, accept, learn from, and let go of things that occur on a minute by minute basis. Therefore, when unwanted thoughts, emotions, or pains occur, this gives us an opportunity to observe them, accept them, learn from them and let them go. It allows us to not be afraid of strong emotions or pain because they are seen as transient phenomena and they can't hurt us or harm us if we don't let them. It teaches us not to resist these feelings, but rather to embrace them, become one with them, and allow them to pass.
Mindfulness also teaches us that we need to make good decisions—it is not enough to simply be passive and watch life go by, it is important to engage with it and decide how to improve our lives. It is frequently not enough to simply understand life stressors and write about them to recover from TMS. Often, people must make some changes in their lives and mindfulness practice helps people step back and make good decisions about how to proceed.
Wiki: You studied with Jon Kabat-Zinn and Saki F. Santorelli. Can you tell us about their work and its relevance to PPD?
HS: They were my first meditation teachers and I respect them greatly. They taught me that mindfulness is, at its core, an inquiry; an inquiry into the depths of our being and our reality. It's a simple process that when practiced seriously, can make huge differences in people's lives. During my years as a mindfulness teacher, I was impressed how many people found it to be helpful in resolving a number of stress-related problems in their lives. However, one thing puzzled me about it. During my sixteen years of teaching mindfulness, very few people had dramatic recoveries from TMS-like symptoms. It was only when I started to fully understand TMS and educate people about it that mindfulness became an approach that helped to create dramatic recoveries. The combination of education and interventions is powerful, while only one of the two is often not enough.
Wiki: Are there any ways in which your experience of studying with them affected the meditation portions of your PPD recovery program?
HS: Often meditation approaches tend to be cerebral and people tend to think of meditation as a relaxing, passive way of observing reality and our situation. However, Jon and Saki also emphasize that mindfulness practice requires us to engage in reality, in all of its ups and downs. A key concept in understanding TMS is that emotions are often suppressed and these emotions can be expressed as pain and other physical symptoms. Therefore, learning to recognize and express these emotions is part of PPD recovery. Mindfulness practice is one way to deal with strong emotions and I have recorded a meditation specifically for this purpose. It's entitled, Embracing Emotions, and is available at no cost at www.unlearnyourpain.com/mbs-book
Wiki: Have you found that people with PPD have any inhibitions or specific difficulties with practicing mindfulness? Also, how do you discuss meditation with patients, and have them agree to meditate?
HS: I have not had many difficulties in explaining mindfulness or in getting people to engage in it. The techniques are clear and easy to grasp. They don't contradict tenets of religious beliefs. Mindfulness exercises can be done while sitting in a quiet place or while engaging in any activities, such as work, leisure, or exercise. People who engage in mindfulness exercises generally benefit greatly. The difficult part is often getting people to remember to practice and continue that practice.
Eric Sherman PsyD: Did you ever encounter professional ostracism/ridicule/ or marginalization for espousing your views on psychophysiologic disorders? If so, how did you deal with it?
Howard Schubiner: I haven't been exposed to anything resembling ostracism or ridicule as yet. I hope I don't! Several professionals have questioned my ideas and we have debated them in a professional manner. This is an important way to sharpen my concepts and correct any areas that aren't clear or correct. One day, I was giving a lecture and after presenting a brief patient vignette, I asked what I thought was a rhetorical question, “Does that make sense?” Immediately, a physician in the audience shook his head “No”, and walked out of the lecture hall.
ES: What have you found to be the most compelling argument to pique the curiosity of fellow physicians who were on the fence, that is, not completely antagonistic to your ideas about psychophysiologic disorders?
HS: The most compelling arguments are the presentation of data. Some people immediately understand these concepts from powerful stories that describe PPD. However, others need to see the science. I try very hard to create a case for the legitimacy of PPD by presenting a cogent argument based on scientific studies. I have been fortunate to work with some excellent researchers to conduct studies that demonstrate that this approach actually helps people.
ES: Have any of the physicians who might have rejected your ideas in the past come around? If so, how do you understand their 'conversions'?
HS: I'm not aware of anyone in this category, but a typical “conversion” would occur when a patient responds completely to this approach or the physician sees this disorder in someone in their family.
Wiki: There seems to be several different treatment programs each of which has different approaches. As you were developing your own treatment program, what factored in to your methodology? In other words, why did you choose the techniques that you did.
HS: I have been a physician for many years and have worked in the area of stress reduction and management for a long time. Over the years, I've been exposed to many forms of treatment and these have informed my choice of therapies for PPD. In my program, I focus on therapeutic writing because there is solid research showing its benefit and it allows people to explore many issues in a safe and useful format. Mindfulness was a natural choice given my background. The affirmations were something newer to me, but I've found it to be an essential part of the program. Finally, moving forward in life, encouraging exercise, and emphasizing positive emotional health were aspects of the program that just seemed to make sense. I am constantly evaluating new forms of treatment that may help people with PPD because not everyone responds to the same interventions.
General Questions on PPD
Alan Gordon, LCSW: Do you think that the physical symptoms serve as a distraction from painful unconscious emotions or are simply a consequence of painful unconscious emotions?
HS: That is a difficult question, but both concepts might be valid. It's often difficult to understand the “motivation” of the subconscious mind! It seems clear that we are designed to protect ourselves. Pain and other symptoms seem to serve as an alarm much of the time, therefore they can easily be seen as a consequence of subconscious emotions. Fatigue typically occurs in the setting of someone who is totally overwhelmed in their life. Therefore it seems to serve to create a “time-out” for someone who needs it. On the other hand, there seems to be an interesting relationship between pain and anxiety. I've frequently seen people who have severe anxiety that reduces when pain occurs or vice versa. This suggests that pain can be seen as a way of covering anxiety when the anxiety is too uncomfortable. It is also an example of symptom substitution.
AG: Why do many people find it so difficult to let go of the physical/structural explanation for their pain even in the face of overwhelming evidence that it's psychophysiologic?
HS: This is a good and important question. Of course, everyone is different, but one of the problems that I frequently see is that the “evidence” for PPD may not be overwhelming to them. That evidence primarily consists of scientific studies, a paradigm that is often foreign and new, and connections between pain and psychological events. These are relatively easy to ignore or not fully understand. In addition, there is often “evidence” of a physical/structural problem from other doctors and from lab tests or X-rays/MRI's. It can be difficult to ignore that information. Secondly, there is the oft mentioned problem of “Are you saying that it's all in my head?” This line of thinking is powerful in resisting a psychological explanation because it is often perceived to place blame on the patient. In addition, it may be rejected because it also places responsibility on the patient. Now the cure is in their hands, rather than in the hands of the physician.
Wiki: Have you seen any pediatric cases of PPD, and would you diagnosis them in a different manner than adult patients? Does PPD appear in different ways for children than in adults?
HS: PPD is a common phenomenon in all people and therefore we see it in children, adolescents, as well as adults and the elderly. The manifestations are generally the same at all ages, but children may not be as capable of looking at their emotions and their subconscious motivations as are adults.
Wiki: Can anxiety and depression be manifestations of PPD or are they the cause of PPD? Have you had success treating them with this approach? What about insomnia?
HS: In working with people with PPD, I encounter anxiety, depression, and insomnia on a daily basis. It is clear that these issues can create augmented pain responses and increased pain often increases anxiety, depression, and/or insomnia. I also see that these disorders can alternate or substitute for pain on a regular basis. In addition, anxiety, depression, and insomnia are triggered by the same life events as are PPD pain responses. It is these experiences that lead me to state that anxiety, depression, and insomnia are commonly manifestations of PPD. Just as with pain, it is essential to rule out medical conditions that can cause these disorders. However, when no medical condition exists to create them, I treat them in the same way that I treat pain due to PPD.
Wiki: I read several statistics that say more women then men suffer from PPD, specifically in cases of Fibromyalgia where women make up almost 90% of the cases. In your opinion why is this? Is the reason more genetics or cultural? How could understanding this help in understanding PPD as a whole?
HS: There may be some genetic factors involved, but those have not been shown to be a significant factor in this discrepancy. There are data to show that women are more likely to have been victims of sexual abuse and other forms of abuse. Women are also more likely to be conscientious, to worry, and to be less selfish than men in large international studies. They are more likely to be primary caregivers for children and aging parents. In my opinion, these factors combine to produce PPD in a higher proportion in women. Understanding this helps us to realize that the people most likely to be affected with PPD are the “good” people of the world who care for others, try hard to please, and are responsible. It should help to decrease the stigma of having PPD.
Wiki: I'm interested in some of the specifics of various "PPD equivalents," such as TMJ, knee problems, dizziness, GI conditions, dermatological conditions etc. Are the same central sensitization mechanisms at play here or are there different mechanisms? Is there a structural (i.e. non mind-body) component for some of the diagnoses? Do you find yourself using different approaches in treating them?
HS: For all symptoms, a medical work-up should be completed. This will include a good history and physical exam, and necessary lab tests and imaging procedures. When these data are reviewed, one can make a determination about the cause of the symptoms, i.e. whether each symptom is purely PPD, purely a structural/physical cause, or a combination of the two. Central sensitization mechanisms are the cause of PPD, no matter what specific symptom is manifest. The approach to treating PPD is the same, no matter what symptoms have been produced.
Survey Response: Barbara A. Kline, LCSW-C: Since current theory supports a genetic/biological cause of bi-polar disorder, do you agree with this or do you believe bipolar disorder is another manifestation of PPD? I haven't noticed this mentioned in any of my readings or lectures I've attended.
HS: That is a difficult question. I have avoided it for some time, but it's an important issue and I'll try to give a reasonable answer. Many people have a tendency to describe potential PPD symptoms in dichotomous terms, that is, either it is PPD or it's structural/genetic/physical. There are obviously many disorders or symptoms that are a combination of the two. These can present complex issues for both the therapist and the patient. It may be that bipolar has components of both PPD and a genetic problem. On the other hand, it is my belief that psychiatrists are currently over-diagnosing bipolar disorder and therefore many people who carry the diagnosis do not have the “genetic” version of it, but rather a “learned” version that is caused by the same underlying events as PPD. This will have to be sorted out on a case-by-case basis to understand how to best treat people with bipolar disorder. Of course, treating bipolar with a combination of medications and PPD therapy can make a lot of sense as well
TMS Wiki: Are Randomized Controlled Trials (RCTs) important to the wider acceptance of the TMS/PPD approach? If so, why?
Howard Schubiner: There is no question that research findings will be necessary for this approach to be validated and accepted. There are a variety of types of research studies that will be needed, including case studies, outcome studies and RCT's. RCT's are recognized to provide the most valid scientific data, so those studies are most important in moving this field forward.
Wiki: In 2010 you published a study called "Sustained Pain Reduction Through Affective Self-awareness in Fibromyalgia: A Randomized Controlled Trial." Would you please give an overview of this study?
HS: In this study, we enrolled women with fibromyalgia and randomized them into an intervention group and a wait-list group. The intervention group received an initial visit with me of 2 hours in duration followed by the treatment program that I have developed (and published in my book, Unlearn Your Pain) in a small group format. The initial visit consisted of a medical history, a physical exam, a detailed psychological history to elicit connections between stressful events and the onset of PPD symptoms, and an explanation of PPD. This interview is also published in my book (Chapter 5). When you conduct this kind of interview, it is almost always successful in obtaining a clear understanding of the life events and stressful situations that triggered the onset of PPD symptoms, including fibromyalgia.
Wiki: Can you describe the treatment techniques that were used in the study and why you chose those specific techniques? Clinicians may wish to use this study to validate their own approaches to colleagues and patients. To do so, they need as clear an understanding of the differences between this program and their own treatment as possible, so please be specific. Also, how did the program in the study differ from the program in Unlearn Your Pain? Do you have advice for anyone who would want to set up a program similar to the one in the study?
HS: The treatment approach can be broken down into seven steps and is taught in a 4-week program (see Chapters 7-11 of Unlearn Your Pain). The program that was tested in the research study was of 3 weeks duration. These are:
1) Understanding PPD: The body is normal and does not have a physical/structural disease process. The symptoms are real and can be severe, but are caused by learned nerve pathways that have been triggered by subconscious processes.
2) Hope/Positive Expectations/Confidence: Hope and positive expectations that resolution of symptoms is possible and confidence that one can accomplish this.
3) Writing: A series of therapeutic writing exercises were designed to help participants learn more about their underlying thoughts and emotions about life events and cope with them better.
4) Meditations: Mindfulness practice is taught and other meditations were developed to heal both mind and body.
5) Self-talk: A series of powerful affirmations are used to help align the mind and body towards health and empowerment.
6) Changes: Looking carefully at one's life to discern what changes are necessary to create health and well-being.
7) Love: Participants are asked to practice kindness to self, increase self-worth, take time for self, and be assertive.
Wiki: How did you measure the effectiveness of the treatment? What made you choose those measures? Did you do a follow up after the treatment was complete?
HS: We measured a variety of outcomes, such as pain, overall physical health, locus of control, sleep, fatigue, number of painful regions, and tender point sensitivity. There were dramatic decreases in pain, number of painful regions, and in physical health. Locus of control shifted from reliance on physicians to reliance on self. The sensitivity of tender points was reduced thus demonstrating an objective measure of efficacy. There were no changes in sleep or fatigue. The measures that improved showed statistical significance at a 6-week follow up and that level of improvement persisted to the 6-month follow up even though there was no additional treatment after the 3-week program. This finding suggests that the treatment induced a lasting effect.
Wiki: Were there any limitations to the study that readers should be aware of?
HS: One limitation of the study was that the sample size was relatively small, however given the small sample size the fact that the results were strongly statistically significant shows that the intervention was powerful. Another limitation was that the control group did not receive an intervention of similar intensity.
Wiki: What were the overall findings of the trial? Given the study's strengths and weaknesses, what do you believe this teaches us about the PPD treatment approach?
HS: This study is the first randomized, controlled trial to study a PPD treatment approach. It demonstrates that this treatment approach is effective for a disorder that is generally considered to respond poorly to any form of treatment. Since individuals with fibromyalgia are likely to suffer with a variety of other psychophysiologic disorders, it shows that this approach is also effective for those disorders, i.e. irritable bowel syndrome, headaches, back and neck pain, etc.
Wiki: Some may argue that exercise helps fibromyalgia independent of psychological interventions. How would you respond to people who said that the psychological interventions merely made people more willing to exercise, and that it was the exercise that led to the improvements?
HS: My clinical experience suggests that exercise is only effective when it is combined with the other elements of the PPD program. Exercise alone may have limited value, but the key to dramatic improvement is understanding why one is exercising, i.e. to undo the emotional fear, to break the conditioned responses of pain that have been associated with exercise, and to prove to oneself that one is strong and healthy.
Wiki: Fibromyalgia can create different symptoms in different people. Did you find any difference in outcomes between participants who also had IBS and ones who had migraine headaches? The study mentions that you did not exclude patients who were in psychiatric treatment or who had other psychiatric disorders, such as anxiety, post-traumatic stress disorder, or depression. Did you find any difference in outcomes for patients receiving other treatment or who had a comorbid diagnosis?
HS: In an attempt to understand some of the factors that might predict successful treatment, we expanded the study to 40 individuals with fibromyalgia who were treated with this program. However, we did not find any useful factors or predictors so we abandoned that additional study.
Wiki: You have recently been awarded a grant from the NIH. How will the new study differ from the study that we have been discussing above? Should we expect one study or a collection of them?
HS: The new study will compare 3 groups of women with fibromyalgia in a randomized fashion who will receive an 8-week intervention in a small group format. Group 1 will be a control group and will consists of an educational program to explain fibromyalgia. We will use the traditional medical model for fibromyalgia. Participants will learn that fibromyalgia is a chronic painful condition with no known cause and no known cure.
Group 2 will consist of a cognitive-behavioral therapy intervention. The model will consist of graded exercise, learning to cope better with pain, and reframing anxious and catastrophic thoughts.
Group 3 will consist of an emotional expressive intervention. This model links pain to emotionally difficult life events and asks participants to uncover and process emotions in order to recover from painful symptoms.
Wiki: People will want to know when they can hope to see a new article being published. What can you tell us about when you hope to be conducting the trials? Could you give an estimate of how long it might take before results begin to be published (or at least a lower bound)?
HS: Patience will be required. This study will last for 5 years, so we won't have any results for quite a while.
Wiki: Do you have any thoughts for research that you would like to conduct in the future, after the grant?
HS: We are currently analyzing data from an outcome study of patients who have been enrolled in the 4-week treatment program that I run in Michigan. We have enrolled about 60 patients to date and we expect to publish that data soon.
Treatment and Therapy
Wiki: During patient meetings, what are the most important ideas that need to be communicated to a PPD patient? What language do you find helpful in communicating these ideas?
HS: There are several critical concepts to convey to patients. They may have been told that their pain isn't real, that it's all in their head, or that they are just anxious or depressed. They are often very sensitive to feeling invalidated and stigmatized. These are the points I try to make:
- Their pain is absolutely, 100% real. All pain is real, of course, so that should be clear to everyone. I let them know that I know how much they are suffering and that I truly want to help them. I tell them that the most important thing we can do is identify the true cause of the pain, in order to reverse it. Covering up pain with medications and injections can be necessary, but it's certainly not ideal. Most people are happy to know that you take their pain seriously and you want to help them get rid of it.
- Pain is often caused by learned nerve connections. If the doctors they've already seen haven't been able to help them, it may be because they are looking in the wrong place. In other words, pain can occur in a part of the body even though there is no disease process going on there. I tell them that we are going to work to identify the underlying cause of the pain and that if we do, they will have a good chance to conquer it.
Wiki: Using the following diagram, please explain the roles that you believe the depicted brain structures play both in PPD pain and in PPD pain relief.
Diagram credits for both diagrams: Howard Schubiner, MD.
HS: THE PATHWAYS THAT PRODUCE AND PERPETUATE MIND BODY SYNDROME: These pathways can begin due to an injury or stressful event that produces strong emotions in the amygdala. Once the pain begins, nerves that send pain signals to the brain become sensitive over time and send repeated signals even when there is no tissue damage in the area where the pain is felt. These signals go to the amygdala and then get amplified by both conscious and subconscious emotions, which trigger activation of the anterior cingulate cortex (ACC). The autonomic nervous system (ANS) activates the fight, flight, freeze, or submit mechanism, which produces nerve activation, muscle tension, GI/GU spasm, and/or CV activation that worsens the physical symptoms. These pathways get reinforced over time, and this creates a vicious cycle of pain and increased emotional responses. A variety of triggers (such as certain physical movements or positions, places, weather changes, foods, or situations) can act as conditioned responses and add to the neurologic pathways that perpetuate pain. In the conscious portion of the brain, the dorsolateral prefrontal cortex (DLPFC) area can act to diminish and break the cycle by overriding the activity of the ANS and by deactivating the ACC.
Wiki: I've heard that in brain science, what we know is dwarfed by what we don't know. I know that there is some controversy around the exact mechanism behind PPD. However, many medical conditions are successfully treated before the underlying mechanism is completely understood. How confident can we be about the models described above? Which rest on the most solid foundations and which rest on the least solid foundations?
HS: I definitely agree that there is a great deal of controversy in many different arenas of mind body medicine and what are sometimes called “medically unexplained symptoms” in the medical literature. For example, fibromyalgia is clearly a form of PPD from my point of view. However, the literature is full of many divergent theories on the etiology of fibromyalgia. Of course, most people are going with some sort of physical disorder, which is common in the era of modern medicine's blind spot to the fact that psychological issues can (and often do ) cause real physical pain.
Anyway, it is difficult to know the exact mechanism of PPD and I will address that topic in the next question. However, I think we can be very certain that psychological mechanisms underlie PPD. From a psychological point of view, we don't know if emotions are suppressed or repressed; we don't know if PPD is a distraction or an alarm signaling danger; and we don't know if the Id and the Superego are playing major roles. We also don't know to what extent social factors play a role such as social contagion. Cultural issues may also be very important, as seen in so-called “culture bound syndromes” such as voodoo and, I would add, whiplash. But we do know that some or all of these psychological, social and cultural mechanisms are the cause of PPD symptoms. I happen to believe that PPD has the same underlying psychological mechanisms to PTSD and to what is known as conversion disorders (such as psychologically induced paralysis or inability to speak). And virtually all physicians and psychologists agree that psychological mechanisms are the cause of PTSD and conversion disorders. Another area of controversy is the role that genetic factors play, but that is the topic of yet another question (that I cover in the book).
Wiki: What is your view of the exact mechanism of PPD? Is it an overactive ANS? Oxygen deficiency? Allostatic load? Central sensitization? Could you tell us a little bit about each of these models and help us understand the differences between each?
HS: Now you're really asking difficult questions. But here goes. The ANS is clearly overactive in animals who were abused in infancy and people with histories of abuse tend to be “hyper-vigilant” and to respond to perceived danger with heightened anxiety. However, the data on the ANS in disorders such as fibromyalgia does not support the ANS being “overactive.” In fact, there are lower cortisol responses to stress in people with histories of abuse. Studies of the ANS in fibromyalgia patients suggest that it is actually dysfunctional in some ways, not necessarily over- or under-active. Furthermore, an overactive ANS implies an “all or none” phenomenon. In reality, the ANS is very specific in terms of which pathways are activated to cause differing PPD manifestations.
I have not found evidence for the oxygen deprivation theory. There is one study which supports that in fibromyalgia patients, but that hasn't been confirmed. In addition, oxygen deprivation would theoretically occur on a micro-level caused by vaso-constriction. Stress doesn't always produce vaso-constriction, for example, having one's face turn red with embarrassment is due to vaso-dilation. Oxygen deprivation is purported to explain musculo-skeletal pain, but if that's the cause of PPD, one would have to find different explanations for fatigue, tinnitus, diarrhea, urinary frequency, anxiety, tachycardia, and other symptoms that I see as being all part of the varied manifestations of PPD. Furthermore, when one invokes oxygen deprivation, people often get the idea that they need to breathe more deeply or somehow increase their oxygen levels and neither of these is true from my point of view.
Allostatic load is an attractive theory as it suggests that stress builds up and finally boils over to create physical symptoms. In many ways that makes sense, but I haven't found that a good fit with what I see in my patients' lives. Allostatic load theory might work for disorders like asthma or inflammatory bowel disease where there is pathology induced by the buildup of stress. However, I don't see PPD that way. I see PPD as being induced by very specific stressors that psychologically trigger emotional and pain memories from earlier in life. It's not an accumulation of stress, but moments when certain situations create the onset of specific symptoms and then these symptoms can quickly disappear. The allostatic load model is really a disease model and I don't see PPD as fitting a disease model.
Central sensitization is closer to the model that makes sense to me. People like Yunus who have written about central sensitization suggest that a wide variety of disorders can be lumped under this mechanism, which makes sense to me (including fibromyalgia, fatigue, PTSD, and other PPD syndromes). However, the people who write about central sensitization have not linked the onset of these disorders to stress and emotional reactions. They just consider the central sensitization to occur for unknown or genetic reasons. If you combine central sensitization with the psychological mechanisms that I discussed in the last question, I think you have a pretty good model for PPD.
Yunus, Muhammad. “Central Sensitivity Syndromes: A New Paradigm and Group Nosology for Fibromyalgia and Overlapping Conditions, and the Related Issue of Disease versus Illness.” Seminars in Arthritis Rheumatism. 2008. 37: 339-352. [Abstract] [Cited By]
I think of PPD as being caused by learned nerve pathways. This is similar to the nerve pathways we learned in order to ride a bicycle, speak a language, or throw a ball. These pathways can learn pain or any other PPD manifestation. They can be initiated by an injury or can be induced simply by emotional reactions. The manifestations can be present one minute and move or disappear in the next minute because the nerve pathways can be activated or deactivated by the brain very quickly, as described in one of the earlier questions.
Wiki: From the psychological point of view, what do we know about why people develop PPD symptoms? Is it to distract them from emotions? To suppress emotions? To alert them to danger? Scientifically speaking, what do we know about how we get from the unconscious mind wanting something to actual physical changes in the body? How does this relate to the mechanism and structures described above?
HS: As I mentioned above, we really don't know too much about the psychological mechanisms. I tend to think that the body reacts to danger with an alarm system that is built in from our evolutionary heritage. I don't think that the majority of PPD symptoms occur when the body is reacting in order to protect us from emotions or to distract us from them, however there are times when these theories seem to fit pretty well. It does seem pretty clear that people who tend to suppress or not even notice emotions are more likely to experience PPD. However, the body can react incredibly quickly to an emotional event that we don't even have time to recognize the emotion. This is also part of our evolutionary heritage and has been shown by Joseph LeDoux in The Emotional Brain. How the mind produces PPD symptoms appears to be related to activation of very specific pathways from the ANS to the body and activation of very specific brain pathways. These pathways can produce activation of the nerves, muscles, GI tract, GU system, cardiovascular system, blood vessel constriction or dilation and these fibers can create all of the PPD symptoms. ANS activation can also produce a submit or freeze reaction (as it does in animals who freeze or play dead in the face of danger) and it seems to me that these reactions are what causes fatigue and depression. The bottom line is that the brain is pretty complicated. It has long term memory for specific childhood events and emotional memory that lasts forever. Most of our thoughts and emotions actually reside in subconscious portions of the mind and the body is controlled (via the ANS) by the subconscious part of our minds. When we encounter situations that trigger our emotional speed dial, responses occur with lightning speed in the brain and the body can react even before we can be aware of our emotions.
Wiki: Is it important to believe in the PPD concept? Can one be skeptical or doubt PPD and still recover? What does this tell us about the mechanism behind PPD? Can you relate your answer to the structures described above?
HS: As I mentioned above, it is generally not enough to engage in the therapeutic tools for PPD (such as mindfulness, expressive writing, affirmations, and counseling) without the understanding about PPD. I think that people need to understand that they have PPD rather than a medical disease and that they can recover. I understand that many people find it very difficult to believe that PPD can cause such severe pain or such varied symptoms. But it's a critical element of recovery. When people doubt the diagnosis and continue to worry that they have a physical problem, it impedes their recovery because doubt leads to fear and fear leads to persistent pain by activating the ACC. It's common to be skeptical that the program will work, but usually people begin to see responses when they start it and that helps to convince them. Since the mind controls the PPD symptoms, it is helpful to believe that you have PPD, that you are capable of getting better, and that you can cure yourself. A positive attitude activates the part of the brain that decreases pain, the DLPFC. The other activities that activate the DLPFC are kindness, love, hope, confidence, laughter, and awe—all good things to cultivate.
Wiki: What research studies do you find helpful to summarize during patient meetings?
HS: 1. There's an important study done by the U of Michigan group that clearly show that the pain of fibromyalgia is real.
- Gracely, Richard H.; Petzke, Frank; Wolf, Julie M.; Clauw, Daniel J. "Functional Magnetic Resonance Imaging Evidence of Augmented Pain Processing in Fibromyalgia." Arthritis & Rheumatism. 2002, 46(5): 1333–1343. [Abstract] [Full Text PDF] [Cited By] [About Richard Gracely] [About Julie Wolf] [About Daniel Clauw]
2. The same group has also shown that the pain of fibromyalgia is caused by central sensitization or central amplification; and that people with low back pain also have central sensitization/amplification of pain.
- Giesecke T; Graceley RH; Claw DJ; et al. “Central Pain Processing in Chronic Low Back Pain. Evidence for Reduced Pain Inhibition.” Schmerz. 2006 Sept. 20(5): 411-414, 416-417. [Abstract]
3. Studies of phantom limb syndrome indicate that pain can occur in a part of the body with no disease and that this pain is associated with cortical reorganization.
- Flor H, Elbert T, Knecht S, Wienbruch C, Pantev C, Birbaumer N, Larbig W, Taub E. "Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation." Nature. 1995, 375: 482-4. [Abstract]
4. A study by Derbyshire, et. al., demonstrated that pain created via hypnosis was identical in terms of brain structures activated (ACC, insula, somatosensory cortex) as pain induced by placing a hot object in a participant's hand. And pain that is imagined does not share those structures. The brain can create real pain.
- Derbyshire SWG, Whalley MG, Stenger VA, Oakley DA. "Cerebral activation during hypnotically induced and imagined pain." Neuroimage. 2004, 23: 392– 401. [Abstract] [Cited By] [About SWG Derbyshire]
5. Studies of MRI's in people without back pain show abnormal MRI's.
- Borenstein, G; Boden, SD; Weisel, SW. "The Value of Magnetic Resonance Imaging of the Lumbar Spine to Predict Low-Back Pain in Asymptomatic Individuals: A 7-year follow-up study." Journal of Bone and Joint Surgery [American]. 2001. 83-A: 1306-11. [Abstract] [Cited By] [About the Author]
- Boos, N.; Rieder, R.; Schade, V; et al. "The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying symptomatic disc herniations." Spine. 1995, 20: 2613-2625. [Abstract]
- Jensen, MC; Brant-Zawadski, MN; Obuchowski, N; Modic, MT; Malkasian, D; Ross, JS. "Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain." New England Journal of Medicine, July 14, 1994. 331(2): 69-73. [Abstract] [Full Text] [Cited By]
6. A sham car accident caused neck pain in 10% of people 4 weeks later; those with the most stress. Castro.
- Castro, WH; Meyer, SJ; Becke, ME; Nentwig, CG; Hein, MF; Ercan, Bl; et al. "No stress - no whiplash? Prevalence of "whiplash" symptoms following exposure to a placebo rear-end collision." International Journal of Legal Medicine. 2001, 114: 316-22. [Abstract] [Cited By]
7. Subconscious mechanisms control the body and alert us to potential danger.
- LeDoux J. The Emotional Brain: The mysterious underpinnings of emotional life. Touchstone Books, Simon and Schuster. 1996. New York, NY. [Amazon.com Page] [About LeDoux]
8. Most thoughts and emotions are subconscious and these trigger brain structures (ACC and ANS) that cause and amplify pain and other PPD symptoms. We can activate the DLPFC, which inhibits the ACC and pain, by understanding the underlying causes of pain, by mindfulness, by therapeutic writing, by affirmations, by enhancing gratitude, love, forgiveness and by enhancing self-esteem and self-efficacy.
- deCharms, R. C., & Zador, A. "Neural representation and the cortical code". Annual Review Neuroscience. 2000. 23: 613–647. [Abstract] [Full Text PDF] [About deCharms]
- Schmahl C, Bohus M, Esposito F, Treede RD, Di Salle F, Greffrath W, Ludaescher P, Jochims A, Lieb K, Scheffler K, Hennig J, Seifritz E. "Neural correlates of antinociception in borderline personality disorder." Archives of General Psychiatry. 2006, 63: 659-67. [Abstract] [Full Text] [Full Text PDF]
- Lieberman MD, Jarcho JM, Berman S, Naliboff BD, Suyenobu BY, Mandelkern M, Mayer EA. "The Neural correlates of placebo effects: a disruption account." NeuroImage 2004, 22: 447–455. [Abstract] [Full Text PDF] [About Lieberman]
Colleen Perry: As a physician, how do you help the childrenwhen you suspectthe parents are the main cause of the PPD? How do you explain PPD to parents?
HS: Children get PPD of course, just as adults do. I explain the process in the same way, i.e. as real physical symptoms triggered by stress and emotions. PPD commonly occurs in children after traumatic events or difficulties with teachers, siblings or other children. However, the most common causes are difficulties with parents. If the child is old enough to separate from parents and begin to make their own decisions (usually at least a teenager), then I may primarily work with them. For younger children, it is necessary to help the parents change their behaviors.
Wiki: There are several people on the wiki now who are in the 70s, and have chronic pain. What are the challenges in diagnosing elderly patients, and do you adjust your treatment for these patients.
HS: Older patients can present difficulties for several reasons. They are more likely to have medical and structural disorders that can make the diagnosis of PPD less certain. They may be more “set in their ways” making significant changes more difficult. They may have to deal with isolation and mortality. These issues can complicate treatment considerations. It is important to go slowly, review all of the medical information and make decisions carefully about the diagnosis. Similarly, treatment often takes longer and requires a significant amount of effort on the part of the patient.
Wiki: I have found that a large percentage of people who recover from PPD have, at some point, a relapse and gain new chronic symptoms many years after the initial recovery from PPD. Do you find it more difficult to treat patients with PPD relapses? Are there any unique problems or issues that people having a PPD relapse have, either accepting the diagnosis or in treatment, that are not prevalent in people just learning about PPD?
HS: One might think that someone who has successfully overcome PPD in the past would have an easier time when a “relapse” occurs. This is often the case; however, at times people in this situation can struggle to get better. Sometimes they begin to worry that they aren't getting better quickly enough and begin to “count days,” which only leads to more worry. The PPD symptoms are often different from the original ones and this can lead the person to a fruitless medical workup. The most important thing to offer people in this situation is reassurance.
Wiki: How do you approach a patient who rejects the PPD diagnosis?
HS: Sometimes people in this situation need more medical testing or a more thorough explanation of the lack of medical findings to explain their symptoms. Sometimes they need patient explanation of the neurological mechanisms that underlie PPD. Sometimes they need to hear stories of others who have overcome similar problems. And sometimes there is little one can do but wait until they decide to take the PPD path or another path.
Wiki: Should patients stop taking all medications? Can that be difficult or even dangerous? Must patients also stop physical therapy?
HS: Regarding physical therapy, I never mind if patients continue that as long as they see it as building strength and flexibility. I have problems with physical therapy if the patient is frequently reminded that there is something wrong with their body. I never recommend stopping medications early in the course of PPD treatment. I prefer to allow patients to stay on their medications while they work at getting better. Once they are better, it is much easier to wean off their medications. If one stops the medications too early, it can lead to increased pain for a couple of reasons. One, the medications may have been helping to alleviate the pain and two; the mind can “use” the lack of medication as a reason to ramp up PPD pain.
Wiki: Once people discover how the PPD approach can change people's lives, they tend to see it everywhere. It's crucial, of course, that practitioners don't leap to a diagnosis of PPD when something more serious is going on. What are some important conditions to rule out with someone complaining of back pain? Of FMS? Of RSI? Of TMJ?
HS: It's too complicated to delineate all of the potential medical disorders that need to be ruled out in various conditions. In general, if a reasonable medical workup doesn't demonstrate a serious condition, the diagnosis if likely to be PPD. Once a diagnosis has been made via the traditional medical route of fibromyalgia, migraine or tension headaches, irritable bowel or bladder syndrome, or chronic fatigue, the actual diagnosis is PPD.
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