This week, I wanted to write about mindbody medicine and particularly to acknowledge the National Association for the Clinical Application of Behavioral Medicine for its efforts in promoting mindbody medicine. I first came in contact with NICABM, its acronym, after my book, Coyote Medicine, was released. I confess to being somewhat "socially autistic" in those days. I was shy and didn't know how to interact with groups of people, especially with the successful and well-known. I remember my first NICABM conference in Hilton Head, South Carolina. It was a coldish, blustery, Atlantic Ocean winter weekend, though much warmer than Vermont, from where I'd come. I gave one of my first Coyote Medicine talks and made the mistake of using a videotape that had been made of me which was a bit too long. My ratings were not so great and I wasn't invited back for a number of years.
Nevertheless, I have been back and my ratings have improved as I became more and more practiced at the art of rhetoric. I met Joan Borysenko at my first NICABM along with other stars of our feel for whom I had the deepest respect. I was so moved that they would actually invite me to dinner with them. At that time Joan was married to Kurt Kaltreider, who became a dear friend as well. I can remember Kurt and I sharing a prayer smoking stick on the sandy beach in front of the hotel. We shared an interest in our Native American heritage and in exploring it. Kurt eventually introduced me to Sonny Richards, a Lakota elder, whom we brought to Pittsburgh numerous times (when I was at the University of Pittsburgh) and then later to Beth Israel Hospital in New York City. It was wonderful to bring yuwipi and sweat lodge and other ceremony to Pittsburgh and to the greater New York City area, and Sonny was a wonderful teacher. On one trip to New York City, the garbage collectors were on strike. Sonny and his entourage of helpers from South Dakota had never seen so much garbage. They walked around the city marveling at the stacks and stacks of bags piled on every street. It was August, so the smell was intense. While they appreciated New York City and bought miniature Statues of Liberty and Empire State Buildings with gorillas on top, I think they were ultimately grateful to get back to South Dakota where the garbage was smaller and more manageable.
This year I'm looking forward to reconnecting with NICABM at their annual meeting in December, again at Hilton Head Island. Its founder and leader, Dr. Ruth Buczynski, has built a marvelous and free teleseminar series that leads up to the annual meeting called Clinical Applications of Mind-Body Medicine: New Thinking about Stress and the Remarkable Power of Psychoneuroimmunology. These teleseminars happen every Wednesday at 5pm Eastern time and can be accessed through the NICABM's website at www.nicabm.org. This past Wednesday, Ruth interviewed Mark Starr, MD, on hypothyroidism and the metabolic issues that so often go undiagnosed or inaccurately treated. On Wednesday, August 4th, she'll be talking with Howard Schubiner, MD, on Modern Medicine's Blind Spot: The Mind-Body Syndrome of Pain. He will speak about neuroplasticity's unsuspected role in chronic pain and how mindfulness practice, along with a 6-step model to reprogram pain-pathways can relieve chronic pain.
I wanted to explore some of these ideas of neuroplasticity and chronic pain, beginning with the idea that the brain is created from the outside in. The brain is a socially constructed organ. Through our social relationships, our neural pathways are formed and reinforced as we continue to engage in the activities promoted by our relationships. We are relational selves. We are intimately connected and in relationship to everything in the Universe (albeit some of these relationships are quite distant and weak). These are basic indigenous concepts. Lakota elders with whom I have studied viewed the concept of individuality and of an autonomous self as flawed and misguided, perhaps even dangerous. Thus, neuroplasticity is how the brain converts social relationships into neural circuitry. This means that chronic pain and its maintenance by neural circuits is also under social control. The social context of pain provides the context or the background in which these neural circuits are built and maintained. Pain, therefore, is fundamentally social as well as neurobiological since our neurobiology is created by the social. As outside, so inside.
Instrumental in building our new understanding of pain and neuroplasticity has been Dr. Ronald Melzack and colleagues at McGill University in Montreal, Quebec , Canada. Melzack and colleagues showed that previous specificity theories of pain perception were incorrect. These theories held that pain involved a direct transmission system from somatic receptors to the brain. The amount of pain perceived was assumed to be directly proportional to the extent of injury. In contrast, Melzack and colleagues over 10 years ago showed that noxious stimuli actually sensitizes central neural structures involved in pain perception to be more sensitive to pain. Having pain reorganizes the nervous system to feel more pain in a kind of run-away, out of control, positive feedback loop. In this sense, positive means building upon itself like a runaway locomotive builds up speed as it travels downhill. During my medical and my psychiatric training, we talked about real pain and imaginary pain. We believed in real pain as pain that we could link to tissue injury a cut, a broken bone, surgery. We expected that pain should be proportionate to the extent of the injury. If it wasn't, we thought the person was faking pain, malingering, or "crazy", meaning that they had somatization disorder, hypochondriasis, or other "neurotic" difficulty. We said in a derogatory manner that the pain was all in their head.
Melzack paradoxically showed us that the pain perception is all in our heads. Without the brain, of course, we would perceive no pain. Chronic pain is a disorder of perception and not necessarily at all correlated with the extent of tissue injury or any objective measures that we can create. Dr. Robert Bennett of the Oregon Health Sciences University wrote about the often complete absence of tissue injury in relation to chronic pain, which is diffuse and often spreads to areas well beyond the site of the original acute injury. He noted also that the ways in which acute pain are usually treated do not work for chronic pain.
University of California at San Diego neoroscientist Ramachandran showed that phantom limb pain arose from central brain maps that continued to maintain the pain present before the amputation and not from any peripheral nerve sensitization or other observable phenomena. Ramachandran found creative ways to eliminate phantom limb pain by tricking and encouraging the brain to remap itself in such a way as to eliminate the phantom limb and its pain.
Similarly, Melzack and other researchers showed why preventing post-surgery patients from feeling pain by giving them more than adequate analgesia before they feel pain actually allows them to feel less pain and use less overall analgesia. When surgical patients are allowed to feel severe pain, the brain remodels itself to feel even more pain and to exagerate the pain perceived. The consequence is that the doctor is always chasing pain that cannot be controled. When adequate analgesia is produced to prevent the experience of pain (and hypnosis, of course, or mindfulness training can be part of this prevention), then this remodeling process does not happen and paradoxically the amount of pain felt is minimized as is the patient's use of analgesia.
The presence of pain and the activation of pain circuits sensitizes, winds-up, and expands the receptive fields of CNS neurons involved in pain perception. Thus, the perception of pain also involves a dynamic process influenced by the effects of past experiences which shapes the experience of present and future experiences. Sensory stimuli act on neural systems that have been modified by past inputs, and the behavioral output is significantly influenced by the "memory" of these prior events.
Both Native American philosophies and Buddhism teach us to focus in the present to reduce pain and suffering and this is, of course, what mindfulness meditation allows us to accomplish. Buddha said that clinging to what we desire and aversion to what we don't want is the cause of much of our suffering. The hypnotherapist Milton Erickson wrote that one-third of the pain that people feel is the memory of pain they have felt and one-third is the fear of pain they will feel. If we eliminate dwelling in the future or the past, we eliminate 2/3s of the sensation of pain.
I believe we are on the verge of discovering that a number of our contemporary afflictions are disorders of central mapping and processing and not illnesses that exist outside the body independent of the brain. I suspect that fibromyalgia is such a disease. The multiple painful spots that are found on the surface of the body are often migratory and evanescent. We are wiser to search for the disorganized maps and exagerated neural circuits that perceive pain within the brain. I think many of the post-Lyme disease syndromes operate on the same basis. The brain learns to experience symptoms and continues to do so long after the Lyme Disease is eradicated. The person does not require years of intravenous antibiotics or complicated antibiotic, herbal, and/or other potion remedies, but rather, a sensible way to teach his or her brain that the illness has ended and it's all right to stop feeling the symptoms of the illness. Perception can also be illusion.
The danger in all this is that we pathologize human experience. We do this when we create diagnoses. Then people have to meet so-called objective criteria to fall into these diagnoses and we insist upon proof. Pain is a story, not a disorder. Pain is a dynamic performance which has a beginning (often the actual tissue injury or an inciting event), a middle (it builds upon itself) and an end (the pain resolves or it becomes completely unmanageable). Pain happens to someone (the main character of the story) and involves many supportive characters (doctors, family members, friends, co-workers). Denouements and resolutions occur. A plot unfolds, often of valiant suffering against the implacability and insensitivity of the medical system. Meaning and purpose is found occasionally in bearing up against this adversity or in overcoming it. As is true with any large story, multiple smaller stories or vignettes exist that together comprise the larger pain story. And, there is definitely an audience who watches the characters fulfill their roles. This audience and the sense of their appreciation of the story and its plots and meanings contributes to the dynamics of pain perception by reorganizing the brain and its neural circuitry as surely as learning to read creates circuitry that was never there before (See Boston neuroscientist Wolf and her excellent book, Proust and the Squid, for a description of how this works).
These are ideas that I discuss in more detail in my newest book, Healing the Mind through the Power of Story: the Promise of Narrative Psychiatry, ideas that will be discussed by Dr. Buszynski on Wednesday in the teleseminar, and during at the actual conference during the second weekend of December. For more details, of course, see www.nicabm.org.