I had the great pleasure of seeing the presentation Interstitial Medicine - The Role of Psychiatry in the complex interactions between mental disorders and medical conditions presented by John Hopkins Professor Glenn J. Treisman, MD at the May 2024 Gold Lab Symposium last week. You can watch Dr. Treisman’s talk on YouTube at GoldLab Symposium 2024 DAY 1 - Live Stream starting at minute 17:20. This topic has been a main focus of my practice since beginning in 2011. I’m not as interested in psychiatry perse but I am interested in the “functional neurological” component of mind-body illness. The following is a sort of “book report” on Dr.Treisman’s talk introjecting with some of my own thoughts. People who have chronic pain often have what are called comorbidities. Comorbidity refers to the presence of one or more additional medical conditions co-occurring with a primary condition in a patient. These coexisting conditions can either be related to or independent of the primary condition. Comorbidity is common in both physical and mental health disorders and can complicate the diagnosis, treatment, and management of the primary condition. The siloed non-interdisciplinary nature of the mainstream health care system compounds this difficulty. Dr Treisman in his presentation says, “Everything in the human body affects everything else. We have this weird idea that you can get sick in some way, let's say diabetes, and it's just diabetes. It affects everything. It affects the nerves to your gut, it affects your microbiome, it affects the way in which you think. And we tend not to think about that in medicine, we tend to think about what is right in front of us. The division between mental illness and physical illness is an illusion. It's not true. Your brain is connected to every part of your body. If your foot is sick it affects your brain, if your brain is sick it affects your foot.” Chronic pain used to be thought of as “psychosomatic” meaning the person was simply focusing so much on “pain” that they were causing their nociceptors to fire. Nociceptors are nerves that detect when tissue is undergoing damage. The idea was the nociceptors were being caused to fire by the patient's neurotic obsession with pain and damage while no damage was in fact occurring. We now know this is false. Your pain system is constantly changing and resetting itself. Are you aware of the feeling of your shoes on your feet? Were you aware of this before you read the last sentence? Your brain subtracts the sensation of unimportant information so that you don’t get distracted from sensations and tasks that are a higher priority. When we are more fatigued, depressed, or depleted in some way, it is harder to subtract out unimportant sensations. There are many confirmed chronic pain mechanisms like central sensitization, or sensory amplification caused by nerve damage, but there is a category of pain patients who present with comorbidities of the following:
These disorders, along with chronic pain, are an indicator of the dysregulation of the autonomic nervous system. That means that the nerves, both going to (afferent) and from (efferent) the brain, are damaged in some way. Dysautonomia is often triggered by an infection like Mono or COVID-19. These patients are often told they are “functional” which in mainstream medicine often means “it's all in your head.” We have historically and continue to tell people with real illnesses that they are all made up because the medical field does not know how to treat them medically. We tell them it is something they are doing rather than something they have. More savvy practitioners know that functional means a problem with function rather than structure, i.e. a problem with the software, not the hardware. These patients, therefore, often end up in psychiatry and therapy. Psychiatry and therapy may help with some components of these illnesses, but in my experience, and according to Dr. Treisman, interdisciplinary support is needed for these patients to be successful. The following image represents the interconnectedness of the brain, immune system, gut microbiome, circulatory system, and gut-brain or enteric nervous system. This is a simplified model of how interconnected the brain and body really are. I love the quote from John Barnes: "Is the brain the innermost surface of the skin or the skin the outermost surface of the brain?” If something happens to any component in the system, all other components are affected on a spectrum. That means that someone’s gut microbiome disruption could cause significant migraines in some and minor migraines in others. This system is complex and still being studied with increasing interest. It’s easy to see how the siloed nature of the medical field can miss dysautonomia and other similar conditions since these conditions affect so many different systems at once. Here is another image provided by Dr.Treisman that describes the connection between systems and symptoms. He referred to this as his synthesis of the problem:
Dr. Treisman ends his talk by describing essential information to impart to dysautonomia clients:
Why did I bother writing this up? It is my belief that even as psychotherapists we need to consider differential diagnoses and advocate for our clients with other practitioners until the client sees an improvement in symptoms. Just because clients have been evaluated by medical professionals who have declared their issues to be “psychosomatic,” “functional,” or “all in their head” does not mean that this evaluation is correct. The way I handle this issue in my practice is I provide nervous systems regulation therapies, grief work, and parts work regardless of the medical situation. Nervous system regulation psychotherapy is never medically contraindicated and only helps clients become more resilient regardless of external factors. (*Nervous system regulation psychotherapies can be contraindicated due to certain psychodynamic factors like subpersonalities that do not want the patient to feel better, but that is not a topic that will be treated here.) However, nervous system regulation practices are not enough for many clients and they need medical support if they are to have substantial quality of life improvements. I have long believed that many clients need an interdisciplinary approach when it comes to complex psyche-soma presentations and I feel validated in my perspective by Dr Treisman. A final note: I disagree with Dr Treisman that someone is “well” if they are taking 6 - 12 medications to manage their condition. However, I do view taking medication to be superior to suffering unaided. If taking medication is a strategy that patients need to improve their quality of life, I’m all for it. I am still interested in the medical field at large working to discover ways to address these syndromes with increasingly less damaging interventions that have fewer side effects. I feel hopeful that people like Dr Treisman who promote interdisciplinary approaches are starting the process of uniting the medical field so that we can come up with more sophisticated less damaging treatment approaches.
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July 2024
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