Exploring the Hidden Causes of Chronic Pain, with Dr. David Clarke

In this episode of Causes or Cures, Dr. Eeks chats with Dr. David Clarke about the hidden causes of chronic pain and something he refers to as "the biggest blind spot" in the healthcare community. He discusses how adverse childhood experiences, traumas and stresses create chronic pain in adults and how they makes changes in the body. He also shares remarkable stories of patients he has successfully treated with something called Pain Relief Psychology. 
Dr. Clarke is the President of the Psychophysiologic Disorders Association (PPDA), a nonprofit dedicated to ending the chronic pain epidemic. He earned his medical degree from the University of Connecticut School of Medicine, and is Board-certified in Internal Medicine and Gastroenterology. His organization’s mission is to advance the awareness, diagnosis, and treatment of stress-related, brain-generated medical conditions. You can learn more about him at EndChronicPain.org.

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Transcript

SPEAKER_00 0:00

Welcome to the Causes or Cures Podcast, your gateway to understanding health and groundbreaking medical research in a fun and easy to understand way. With Dr. Eaks as your host, join us as we sit down with the world's leading doctors and scientists to unravel the mysteries of health. For practical tips on well-being to the latest breakthroughs in medical research, we cover it all. Don't forget to subscribe. Now, let's ignite our curiosity and together dive into today's episode.

SPEAKER_01 0:32

Hi everyone, and thanks for joining in for this episode of Causes or Cures. I'm Dr. Eeks, your host, and I hope everyone is doing okay out there. Before we jump in, I'm going to ask anyone who is a regular listener, if you can and have a moment, to leave a review or rating of causes or cures on Apple, Spotify, or whatever podcast service you use. Also, if you have any ideas for guests or topics, to please email me at Aaron at BloomingWellness.com. I enjoy doing this podcast, but it does take up a lot of time. So I will be adding in some extra special episodes for subscribers just to help keep the podcast going and so I can keep the interview podcast available for everyone. So I'm working on that and stay tuned. Now on to today's topic. What causes chronic pain? A condition that afflicts millions of people. Could be back pain, fibromyalgia, migraines, irritable bowel, stomach pain. Chronic pain can show up and stick around anywhere on the body. It's probably safe to say many different things or a combination of things may cause it. But in today's episode, we are going to talk about what my guest refers to as hidden causes of chronic pain and the biggest blind spot in healthcare. The biggest blind spot in healthcare. My guest today is Dr. David Clark, a physician and president of the Psychophysiologic Disorders Association, an organization dedicated to ending what they call a chronic pain epidemic. In today's episode, Dr. Clark will talk about how adverse childhood experiences, traumas, and stresses create chronic pain in adults. He will explain how such events, particularly the false beliefs we have after experiencing such an event, the associated negative emotions we suppress, and hidden triggers from the past event, change nerve circuits in the brain and lead to chronic pain conditions. He will also share remarkable stories of patients he has treated with something called pain relief psychology. And when I say remarkable, some of these stories are mind-blowing. I must say, after I recorded this podcast with Dr. Clark not too long ago, I thought about all the people out there who are struggling with chronic pain issues and they try everything to get relief, right? They may not even be aware of this potential link to adverse childhood experiences and stress, or that an approach such as Dr. Clark's exists as an option for them. So it's something to keep in mind, you know, for you, for someone, for anyone out there who may have suffered a trauma or an adverse childhood event. All right. So let's connect to Dr. Clark and hear what he has to say. All right. All right, you ready to jump in?

SPEAKER_02 3:49

Let's do it.

SPEAKER_01 3:50

Okay. All right, everybody, we are connecting with Dr. David Clark. And we are gonna it's it's a really interesting topic. It's about, you know, past adverse childhood trauma and how this may be connected to some of these chronic issues uh impact a lot of people. But before we dive in, can you tell us a little more about yourself, Dr. Clark, and the things that you do?

SPEAKER_02 4:15

Well, I'm a gastroenterologist and internal medicine doctor as well. And I practiced for 40 years and was headed for a career as a garden variety practitioner in my specialty. Uh and then in the eighth year of my training, I unexpectedly encountered a patient I didn't know the first thing about diagnosing or treating, uh, which, you know, when you're eight years in, as you know, you kind of expect that you know everything you need to know. Uh, and then this patient had been referred by another university, and they had no idea what was wrong with her. And we did some specialized testing that we, my department chair and I were confident was gonna show what the problem was, because there really wasn't any other explanation that was possible as far as we were concerned. But that test was normal as well. And it was left to me to do her exit interview and basically to tell her, I'm sorry, but you're gonna have to live with this. And it was a pretty severe condition she was suffering from. And in the course of the interview, I stumbled on the fact that she had been severely abused as a girl. Uh, my really my first encounter with a patient who had what we call today adverse childhood experiences. And none of that had happened for 25 years uh in her case, but uh I it stood out so uh prominently that I thought, well, maybe it's related to her illness. Uh, I doubt it, but maybe. And there was a psychiatrist at UCLA where I was in training that I knew uh was also board certified in internal medicine and had an interest in mind and body uh connections. So I sent the patient to her, not thinking anything would come of it. But a few months later I ran into Harriet Kaplan, the psychiatrist in an elevator, and found out to my shock that uh she had cured the patient with less than three months of weekly counseling sessions, which absolutely upended my world. You know, the idea that you could alleviate a serious physical condition, you know, one that had been going on for a couple of years just by talking to somebody, that just didn't seem possible. Nothing in my training had even mentioned that you could even consider doing that. So I thought, you know, if I want to be a complete doctor, I should learn a little bit about how to do this. And I uh got Dr. Kaplan to teach me her framework, thinking, you know, a couple of patients a year, this will come in handy. Well, it turned out to be uh five or six patients a week, you know, 250 to 300 patients a year. And now we're 7,000 plus uh patients later. And I I learned how to do what Dr. Kaplan did, how to alleviate the physical symptoms of people uh just by talking to them. And sometimes the the best medical instrument uh is your own mind. Um, and that's what it turned out to be for these patients. And it was very rewarding work. I just I love doing it, um, being able to take patients who the rest of the healthcare system had uh basically failed and be able to uncover what was wrong and be able to alleviate their symptoms through a discussion. Um, it was wonderful to be able to do that.

SPEAKER_01 7:29

And so I think folks are probably wondering like, well, how how does that happen? You know, you get these physical symptoms and then you're talking to someone and they get cured when you try everything else in the book. So I know we're and we're gonna talk about this. You are the president of the psychophysiologic disorders association. Is that correct?

SPEAKER_02 7:48

That is correct, yes. And that's the my colleagues and I debated for you know a couple of months about what to call ourselves when we founded the nonprofit. And what we like about that term is that it's a blend of psychology and physiology. And these are absolutely real symptoms that can happen to anybody. Um, they typically happen to people who are pretty mentally strong, to be honest. It's not that there's you know people who can't handle their stress. These are, I think of them like uh Olympic weightlifters who are carrying, you know, huge amounts of stress. But if you give an Olympic weightlifter 50 pounds more than the world record uh weight uh for their weight class to carry, uh they're they're gonna struggle. And that's what's happening with uh patients with this um form of illness. And it's you know absolutely real form of illness. The uh most people assume that if you've got um pain or illness, it's caused by disease or injury. But it turns out there's a whole other group where the pain or illness are caused by um altered nerve circuits in the brain, and the uh brain is producing these symptoms in the body.

SPEAKER_01 8:58

Yeah.

SPEAKER_02 8:58

And the um uh key to it is to uncover the stress that was responsible for the change in nerve circuits. Um that we have numerous uh functional magnetic resonance imaging studies now that document that there are physical changes in the brain behind this.

SPEAKER_01 9:18

So can is there a strict definition for a uh psychophysiological disorder that is accepted, widely accepted in the medical community?

SPEAKER_02 9:28

Um what our definition is that it's pain or illness um that is linked not to disease or injury, but to stress. And most often the stress is, you know, it's a psychosocial stress that most often the patients don't fully recognize that they have. It could be stress in their life at the moment, it could be uh long-term impact of adverse childhood experiences, which is okay because we can treat those long-term impacts. We can't go back and change the adversity that the person suffered, obviously, uh, but we can change the long-term impact and benefit the patient that way. And it's also can be linked to mental health conditions that are manifesting in the body rather than with mental health uh symptoms. So depression, anxiety, post-traumatic stress. Uh, a very large number of patients with those conditions present themselves to the healthcare system uh with a physical symptom instead of a mental health concern. So it's it's all of those things. Uh, but it's, you know, they all have the same common denominator of a psychological process that is manifesting physiologically.

SPEAKER_01 10:43

And uh so like the I'm gonna say the layperson term, just so folks might be can relate to this a little bit more, is uh is a mind-body disorder.

SPEAKER_02 10:52

Yeah, mind-body is another term that's widely used. Um my first book, um, I use the term stress illness. So there are um, you know, over a dozen synonyms for this. Uh used to be called psychosomatic, but nobody likes that term because it uh it puts the entire blame for the condition on psychology. And a lot of um medical clinicians uh kind of separate themselves from responsibility for patients with that. And um my colleagues and I don't think that's right. We think that it the best outcomes are achieved with uh collaboration between medical clinicians and mental health professionals.

SPEAKER_01 11:34

And I I went to your website, uh, which I really I spent some time on there this morning. Uh thank you. Yeah, yeah, preparing for this. Uh and some I I just for some people out there, uh you do give specific names of uh diseases that they might be familiar with, like fibromyalgia, you mentioned migraines that you can't fix, chronic fatigue. I saw long COVID on there as well.

SPEAKER_02 11:59

Yeah, maybe uh, you know, not every case of long COVID, not every case of chronic fatigue or myalgic encephalitis. I mean, I I think it's uh fair to say we don't have the causes of those conditions uh thoroughly pinned down. But uh there was a study published out of Harvard recently that used um the psychophysiologic uh treatment methods, what I've called uh pain relief psychology. Uh it's already been successful uh with people with chronic back pain, uh, in older veterans with uh chronic pain pretty much anywhere. And now it's been used with uh a small group of long COVID patients who had been suffering for an average of nine months, and they got dramatic benefits uh in a matter of weeks uh from using these same techniques. So uh again, not necessarily everybody with long COVID uh has a psychophysiologic process behind it, but it at least some of them do.

SPEAKER_01 12:58

So, what do you think, in general terms, the prevalence of you know these mind-body disorders are?

SPEAKER_02 13:04

Yeah, there's a uh an excellent study from 2015 that reviewed uh 32 papers from around the world. I think they came from two dozen different countries. And on average, they found that it was 40% of primary care patients. So it's a huge number. I mean, we're looking at an estimate in the general population of one in five people. Um, so it's uh 80% larger than the diabetic population, and yet very few healthcare professionals have had any formal training in how to diagnose or treat this condition. So it's a giant, probably the biggest blind spot uh and the biggest source of needless suffering uh in the healthcare system right now.

SPEAKER_01 13:46

And it's that's a lot that's pretty big, 40%. That's uh that's a huge number. So how are these diagnosed? It sounds like based on the you know, the first patient you described, that was you tried everything, you looked at all these tests, nothing was coming up positive, and then it almost sounds like it's a I don't uh diagnosis of exclusion, but I don't know if that would be correct or how it uh you know, I used to approach it as a diagnosis of exclusion.

SPEAKER_02 14:15

I wouldn't ask people about this until I'd done uh all the biomedical tests. I mean, 65% of my patients had garden variety gastrointestinal uh disorders. They they didn't have uh a stress-related illness or a mind-body condition. And in my early years, I used to do the you know full diagnostic evaluation before I would even mention uh that there might be stress involved. But I learned that it's better to mention stress at the beginning as uh just put it on the list of possibilities. You know, if somebody's got upper abdominal pain, I'll talk to them about maybe it's a gallstone, maybe it's an ulcer, maybe your pancreas is inflamed, but maybe it's stress that's going on. And patients appreciate uh uh the thoroughness of that, you know, taking a holistic approach, not trying to um eliminate any possibility uh off the bat. And, you know, I'll do a little bit of a screen for um the psychophysiologic issues um even on the initial visit now. And uh what I'm looking for, I do a systematic uh review of uh different kinds of psychosocial stresses, which are you know, stress in your life at the moment. One of my patients was getting his pain, and and nobody else had gotten this history. He only got his pain while he was driving to work. Um, you know, if he drove, was driving home from work, he was fine. On the weekends when he didn't work, he was fine. Uh so you know, that kind of gives you a clue. Uh, and sure enough, he had a huge stress in his workplace. Um, second area is the ACEs. Uh, you know, were you under stress as a child? What kinds of things happened to you? Um, how severe were they? Um, and if if there was a lot that went on, if a person looks back and they had experiences they would never want for a child of their own, and they can be subtle. I mean, it doesn't necessarily have to be sexual abuse or physical abuse. It can be uh neglect, it can be lack of emotional support. Uh, a number of my patients have simply been told over and over that they're never going to amount to anything. I mean, anything that shreds your self-esteem uh can have long-term impacts in uh any of several areas that can be highly stressful. And then finally, just to make sure that there's not depression, anxiety, or post-traumatic stress, because it it's you have to dig a little deeper than just asking somebody if they feel depressed, because a lot of my patients said no to that. Um, but when I asked them, you know, how's your sleeping? How's your energy level? How's your appetite? Have you lost interest in activities you used to enjoy? Uh are you crying for a little or no reason? Have you had thoughts of harming yourself? Does your life seem no longer worth living to you? I mean, then I'd get lots of yes answers to questions like that. And the the diagnosis became fairly clear. Same with anxiety and PTSD. It can be um subtle enough that you have to dig a little deeper.

SPEAKER_01 17:11

And so it sounds like there can be a wide variety of symptoms that they can present with.

SPEAKER_02 17:16

Yeah, literally from head to toe. I mean, migraines, ringing in the ears, uh, dizziness, visual disturbances, trouble swallowing, um, temporomandibular joint pain or stiffness in the jaw, trigeminal neuralgia, which you know, facial pain, uh spine pain, low back pain is huge. Probably uh 70% of low back pain is actually psychophysiologic uh in origin. And you know, one way to tell that is that the success rate of spine surgery for chronic pain is about 25%. And it's because they're focusing on the wrong thing. Um, irritable bowel, fibromyalgia, um, 80% of pelvic pain and genital symptoms and bladder spasms uh is psychophysiologic. Um I just gave a a five-hour presentation to um the International Pelvic Pain Society. And, you know, they were all nodding their heads that you know this was uh absolutely a part of their uh their practice. Um uh joint pains, numbness and tinkling, even certain rashes, you know, that one of my colleagues is a dermatologist, and you know, he sees patients all the time who get, for example, hives and they're going through a uh a highly stressful time in their lives, uh, not infrequently um planning a wedding in his case, he tells me.

SPEAKER_01 18:47

It's so interesting because uh you hear a lot about people, you know, when they they'll they'll you know say, Hey, I've been I've been having these stomach issues or this back pain forever, and they go to doctor, traditional medical doctor after doctor, and they can't seem to find you know a cure, and they they start looking in other places um to just to try to find any relief. And that's what's I always tell tell that to you know a lot of doctors who practice medicine. I'm like, you know, you shouldn't just say that person is seeking out, you know, uh non-evidence-based medicine or you know, going to an alternative practitioner for no reason, uh, they're suffering and they can't find uh a cure. So it and I just feel like maybe this something like this just needs to be on the radar of more folks.

SPEAKER_02 19:31

Um I I was not expecting to find this um at all when I started in practice. You know, I thought this was gonna be two or three patients a year that had this, but I had this framework that Dr. Kaplan had taught me that when I did all my endoscopies and scans and ultrasounds, that I should be looking for this. And these are people that um, you know, they look like anybody else. They could be your neighbor, your coworker, your friend, your relative. Uh, they don't look like they're suffering from a whole lot of stress because they're they're managing it extremely well. And but when I would ask the questions that I, you know, I just uh reviewed for you that Dr. Kaplan had taught me, and all of a sudden I'm finding that people are coping with enormous burdens that you know nobody else uh really knew about. It was wasn't unusual for me to be the first or second person uh ever to hear a story of childhood adversity from a patient, uh, for example. Uh and I I was shocked. I mean, 253 patients I would send them uh to mental health professionals when I uncovered this, thinking that they were gonna achieve the same quality outcomes that Dr. Kaplan had achieved. But uh it turns out that what dominates uh psychotherapy in the United States today is cognitive behavioral therapy. And that turns out not to be enough. Um and it's been compared with pain relief psychotherapy and uh randomized controlled trials now, and it doesn't work nearly as well. The the veteran study that I mentioned earlier, very tough group uh to alleviate chronic pain in, you know, average age, 73. Uh, and they put them through cognitive behavioral therapy as the control group, and only 5% of them achieved a relatively modest uh goal of 30% pain relief. But when they treated them with pain relief psychology, 42% achieved the goal, so eight times as much. Um, and that was just shocking to everybody because you know, normally in pain psychology studies, you get a very modest benefit, uh, you know, very small, what we call statistically an effect size. Um, and to get you know, eight times. Higher success rate was unheard of. And it's because the pain relief psychology focuses on all of these issues. It shifts the attention to the brain where the symptoms are being generated, and from the brain to what stresses are involved in changing the nerve circuits. It it focuses on the long-term impacts of childhood adversity. And when you do that, you get great results.

SPEAKER_01 22:28

I wanted to ask, I know you just we mentioned adverse childhood experience, and that term comes up a lot in public health. And I just but I just want to drive this home for folks. Can you just tell us what is an adverse childhood experience? Is there a screening tool that people use? Um yeah.

SPEAKER_02 22:46

There is. Yeah. I mean, it was um uh came about from the very first paper by uh Faliti and Anda. Uh and I know Vince Falitti. Uh we've we I spent a week with him back in the 90s. Um and his paper was published in the American Journal of Preventive Medicine in 1998. You can look it up, uh, and it was just shocking to everybody who saw it because he he looked at uh used a screening tool of 10 different areas of childhood adversity, which you know, things like um being abused, losing a parent, having somebody with mental health or substance abuse issues in the household. He he would give you a an ACE score of one uh for every one of the 10 um that you suffered from. And he found that one person in six in the adult population had at least four of these ACEs, and that those people compared with the population who had none. And it was 47% of his population that had no ACEs. So actually a minority that made it through their childhoods with none of these things. But the comparison between four people with four or more ACEs and those with none, um, the long-term health impacts were just off the charts. Uh, you know, depression, suicide, alcoholism, domestic violence, uh, obesity, um, substance use, um, uh early death, um, and even uh biomedical conditions like heart disease, cancer, diabetes, autoimmune disease were just off the charts. Uh, I think the the um the one that was the highest was uh the rate of intravenous drug abuse, which was um 11 times higher uh in the four plus ACES group compared to the no ACES group. So um the huge um impacts, uh you know, the some of the biggest impacts ever published. Um the problem with the standard 10-item ACE questionnaire are two. Uh one is it's too long to use as a screening tool in most primary care environments. And the second is that it's too short because it misses a lot of things. Uh, you know, when I give my presentations, I have a slide on which has got you know 10 more ACEs that are not covered by the standard ACE questionnaire. So what I did was I boiled the whole thing down to one question, uh, which is uh, how would you feel if you learned that a child you care about was growing up exactly as you did? And I give my in my written questionnaires, I give people four choices for how to answer that question. Uh number one, they'd be happy if they learned that a kid was growing up or their own kid was growing up just the way they did. They'd be neutral about it, they'd be sad or angry about it, or they'd be very sad or very angry. And I correlated that just to validate it with the full 10-item ACE questionnaire. And the correlation was really strong. I mean, the for statistics buffs, uh, the correlation coefficient was 0.66, which is really strong. The the um more sad or angry you would be about learning that a kid was growing up the way you did, the higher your ace score. With the the very sad or very angry group had an ACE score of over seven, which was astounding to me. Um, and it turns out that single question uh you know, it covers not just the 10 items in the ace questionnaire, but the whole range of different forms of adversity that people can go through. And so I like that question. It's short and it's also comprehensive.

SPEAKER_01 26:30

And I'm glad you brought up the time it takes because you know, in today's world, there's this you hear a lot of practicing doctors talk about like they don't have a lot of time to spend with uh patients, or you know, their bonuses are based on how many patients they see. Um, so I think it's really good to have such a question that you can ask if you have a shorten amount of time, you know, and then hopefully you're able to spend more time uh with a patient down the road.

SPEAKER_02 26:56

Yeah, we I should mention we have a uh a somewhat longer version, uh, 12 items uh on our website, uh nchronicpain.org, that people can take to see if they might be suffering from this themselves. Um and it's set up in a way that um the more questions out of the 12 to which you answer yes, uh the more likely it is that you are suffering from a psychophysiologic disorder.

SPEAKER_01 27:22

So it's not just in people's heads. Sometimes you hear the oh, it's just in your head, right?

SPEAKER_02 27:27

No, absolutely not. This is a uh physiologic process. It is in your brain, not in your head.

unknown 27:34

Okay.

SPEAKER_02 27:35

And that's a huge distinction.

SPEAKER_01 27:36

Okay, so can you talk a little more about this? How does an ACE and maybe an adverse childhood event or how many ever someone may have, how does it change the nerve pathways? What do we know about that?

SPEAKER_02 27:47

Yeah, the physiologic process, I don't think we've worked out in uh you know every single detail, but the uh it's very clear that the circuits are different. We've got, oh gosh, six or eight studies of different forms of psychophysiologic disorders, whether it's fibromyalgia or irritable bowel or somatization, um, that show that the brain circuits are different on fMRI. So we also know that uh people who have experienced uh ACEs have a much higher rate of a whole range of different uh psychophysiologic disorders, whether it's fibromyalgia or pelvic pain or premenstrual syndrome or migraines, uh irritable bowel, um, the list goes on. Um so there's very strong correlation between the ACEs and these uh psychophysiologic conditions, and also between the ACEs and the changes in nerve circuits in the brain. So it it appears to be that if you are under threat as a kid, you know, a lot of my patients grew up in environments that resembled uh living in a minefield, for example, then um you are having your flight or flight nerve system uh turned on uh for much longer stretches of time than is healthy. And uh it is likely that that's the process that leads to the changes in nerve circuits. The good news is that with pain relief psychology, uh there can be physical changes in the brain back toward a healthy pattern. We haven't got a ton of studies on that yet, but the boulder back pain study showed that not only does pain relief psychology alleviate pain, and they got they had patients with chronic back pain for an average of 10 years and got two-thirds of them uh completely pain-free with just one month of treatment. Um and the corollary to that was that their brains physically changed. They they did fMRI scans on them before and after the pain relief psychology, and the brains changed. Um, you know, it was um really great to see that. So um we have the uh the correlation on that end as well. Not only do people with these chronic pain syndromes have changed uh changes in their brain circuits, but they can also be changed back with uh the appropriate form of treatment.

SPEAKER_01 30:17

My next question's gonna be around recovery and what you do when you know you think someone has this and and the road to recovery that you send them on. But I did want to go back when you mentioned the patient who only had pain when they were driving to work and you said that person had a history of work stress. I was curious, is there often that specificity where you know there's a a specific adverse event that may manifest a specific way in in a person and you know it it's somehow linked?

SPEAKER_02 30:51

I don't know if I'm making sense, but yes, um, you know, you have both you know chronic stress from the past in the form of ACEs that can manifest in the body in any of a range of ways, but um, I also look for connections um chronologically between when and where a particular stress is happening and when and where the patient is having uh symptoms. And it it doesn't come up as often as the ACEs. The ACEs is probably the single largest uh factor in people with psychophysiologic disorders, but absolutely do find uh particular significant events in people's lives that are triggering this. Uh trauma is a good example. Uh patient who had uh her parents uh and husband were in a severe car accident. She was not in the car herself, but it was obviously such a traumatic event in her life that uh it triggered symptoms for her. Uh the parents were killed, and the husband spent six weeks in intensive care before making a full recovery. And her physical symptoms began very soon after that, and she was still having them five years later. And nobody, it was nowhere in her chart that her uh family had been through this uh serious trauma. Um, another patient of mine had um three years of episodes of abdominal pain, nausea, and vomiting. And when I asked her where the pain was, she formed her hand into the shape that a little kid does to uh make a pistol out of their hand. And she pointed this pistol barrel at the right lower quadrant of her abdomen to show me where the pain was. And when I got to the part of my diagnostic process where I asked about trauma, it turned out that her brother had been murdered with a gunshot wound to the right lower quadrant of his abdomen. So there's a direct connection. Um and to finish that story, uh, he had been shot a decade before she became ill. Um, but uh the triggering event for her was that she had encountered her brother's killer in a store, um, literally days before her first episode. Uh and it turned out the story was that he had been arrested and convicted and uh served um nine years in prison, and then he was paroled, and he was back in the community, and nobody had warned her that he was out there. So that when she encountered him in the store, it came as a complete shock. And that was the trigger uh for her illness. So very specific uh event in that case.

SPEAKER_01 33:30

Wow. That really makes you think about the the connection you know the mind has to the body.

SPEAKER_02 33:35

Um and and she had never mentioned this, you know. It was nowhere in her chart uh because it, you know, the shooting had taken place ten years before she became ill, so she wasn't making the connection herself.

SPEAKER_01 33:49

There's a lot of chronic conditions out there. Uh folks are looking for help. You a patient like this comes into your office, or you you know, you know someone who you think might benefit from uh the treatment approach. What what does that look like? What sort of path to recovery would you send someone on?

SPEAKER_02 34:08

Well, the the most straightforward are if if we can identify the stress that is happening in the patient's life uh right now, like the man driving to work, just helping him be aware of the connection, uh bringing that into conscious awareness so he can at least be aware that this is what's responsible. And um, frequently patients can begin to cope with that uh on their own. I obviously couldn't change his workplace, but once he understood the connection, he could start to change it for himself. Um, and the if they're having depression, anxiety, or post-traumatic stress, there are well-established treatments for those that work very well. The challenging group are the people with the long-term impact of ACEs. And you can't change the ACEs because it's happened in the past, obviously. So, what we work on is to change the long-term impacts, of which there are three general classes. The first are personality traits that are stressful for people. Um, the second are uh triggers that are going on in the present day, um, and they're triggering because they're linked to the aces of the past. And the third and the most challenging are repressed emotions. People have anger, fear, mostly anger, but also sometimes fear, shame, grief, guilt, that are repressed, that are not uh open to conscious awareness. Um, and all three of those can be addressed. The the common personality traits that are stressful are um low self-esteem, uh extreme self-criticism, lack of assertiveness, um perfectionism, uh, excessive devotion to the needs of others to the point where it's detrimental to yourself. There's a whole long list of them that uh grow directly out of a child's coping with their uh childhood adversity. Um, and they can be uh successfully addressed if people are become aware of you know what they learned about themselves as children that isn't true. Um, if they can begin to change some of those beliefs about themselves that were um put into them as fundamental assumptions by their unhealthy childhood environment, uh, we can make changes, which reduces their stress level and uh improves the uh quality of their uh personal relationships. The the triggers, uh the simplest one there, the most common, are an ace perpetrator who's still in your life at the moment, uh, you know, typically a parent who mistreated you, and they're they're still in your life, and they're still typically uh uh not doing well by you, let's put it that way. And can we empower you to set some boundaries with that person so that their negativity isn't so impactful? Um, and usually we can. And then the repressed emotions. Um the uh summarize my approach there uh uh is a thought experiment that I do with people where I have them imagine themselves a butterfly on the wall of their childhood home. And they're just you know on the wall there watching what's going on, and they're watching their own child or a child they care about, trying to cope with that environment for a week, say. And they can't do anything about it, they can't intervene, they just have to watch their kid or another child that they care about try to deal with everything that the patient had to deal with when they were growing up. And that is difficult and frequently painful, but it really helps people to connect with the reality of their experience. None of us has a parallel life uh to compare ourselves with. So when my patients look back at their childhood experience, they tend not to appreciate just how tough it was. But when they imagine their own kid trying to cope with the same experiences, um, they frequently are shocked by the emotions that start bubbling up. And that really helps them to um become cognitively aware of emotions that might have been buried for years or sometimes even decades. One of my patients had been physically ill for 79 years over something that happened when she was age eight. Um, and it was only when we helped her connect with that that she began to experience improvement physically. So once people have connected with these, um, then I have them write about it. Um, you know, I they write an unmailed letter to an ace perpetrator, for example, or journal about how it makes them feel to uh think about a kid growing up the way they did. And when you put those emotions that have previously been repressed into words, either spoken words or typed onto a computer or handwritten on a piece of paper, the more those emotions come out in words, the less they have to express themselves via the body.

SPEAKER_01 39:15

And how long does this process take on average? I mean, I'm sure there's variations.

SPEAKER_02 39:20

There are huge variations. Um, the story I love to tell, and this was the my first book called They Can't Find Anything Wrong. I chose this to be the first story in that book, was a woman who uh basically tried to kick me out of the room when I went to see her. She had been admitted with nausea, vomiting, and extreme dizziness. And I went to see her and she said, you know, doctor, don't waste your time with me. Um, I've already had every conceivable diagnostic test, and they never find anything wrong. So, you know, you'd be better off spending your time with your other patients. And, you know, she had good reason to say that because uh she had been hospitalized at a major university on the West Coast 60 times in 15 years. She had seen a dozen specialists and a psychiatrist, and they had no idea why she was having these attacks, uh, which she was having between six and 10 times a year. Um, but you know, I I said, I've kind of made lost causes a specialty of mine. So why don't you, you know, if you could give me half an hour to tell me your story once more and maybe you know, we'll find something. Uh and you know, she just kind of rolls her eyes and her husband looks down at his shoes. And yeah, 45 minutes later, we had found the stress that was causing her illness, uh, which was a trigger. It was, you know, that her mom was an ace perpetrator and her mom was still in her life. And that it was as simple as that. Just bringing that into conscious awareness. She was cured on the spot. She went home from the hospital the next day. She called me a year later to say she'd gone the entire year without a single episode. Uh, so, you know, 45 minutes and she was cured. I wish I could claim that to do that for everybody. Um, at the other extreme, I've had patients who uh needed years of psychotherapy to achieve um uh complete relief of symptoms. Um often those are patients who, when they come to me, they're already getting large doses of opioid opioids to uh treat their pain, and you know, they've gone pretty far down that road, and it's it takes a while to kind of bring them back to uh successful outcome. Um, but it's it's remarkable how uh quickly some patients will turn around. Uh one man who had pain for 55 years, um I saw him in the days of uh paper charts before we had the electronic record, and volume three of his paper chart was three inches thick, you know, just full of uh normal diagnostic tests and unsuccessful treatments. And uh he was basically well in 30 days. He was a had survived a severe physical abuse as a boy.

SPEAKER_01 42:04

That's incredible. Uh for lots of reasons, just because I think it's just not on folks' radar, you know, when they get thinking about pain, they're trying to find, you know, some very specific cause and not this, it's not thought about readily.

SPEAKER_02 42:22

Yeah, it's it's kind of embarrassing to me as a physician that you know my colleagues um throughout the US and around the world uh are not considering this possibility. Um, you know, just at least thinking that if it's if they don't find a biomedical explanation for a patient's symptoms, they should at least be thinking about, well, could the brain be doing this? You know, we all know about uh phantom limb pain. We all learn about that uh in medical school. And um, somebody has an amputation and yet they still feel pain and the location of the missing limb, uh, that's clearly not coming from the limb that is now no longer there. It's generated by the brain. And people with entirely intact bodies can um experience this as well if their uh stress level is high enough or endures for long enough.

SPEAKER_01 43:17

The mind-body connection.

SPEAKER_02 43:18

Yeah, I mean, as one of my colleagues says, you know, anybody who has a neck, you know, has has got a connection between their brain and their body. Yeah. Um and it, you know, again, I had to go through this learning process. I I went through seven years of training without having any clue about this. I was skeptical. Um, and you know, when I started being able to successfully alleviate symptoms uh myself just by talking to people, um, you know, one more extreme example that I I'd love to share is a 17-year-old girl. I was asked to see her on hospital day 70 for unexplained abdominal. Pain. She had already been seen by six other gastroenterologists. She was getting 250 milligrams of morphine a day by PCA pump, which, if your listeners are not familiar with morphine doses, of you know, this was a I don't know, a hundred, 110-pound young lady. Five milligrams of morphine would probably have been enough to alleviate pain from a fractured leg. And she was getting 10 milligrams an hour. And, you know, it was all a question of uncovering the stress in her life, uh, addressing that successfully. Um, she was out of the hospital in a week, and she was off of all the opioids in 30 days.

SPEAKER_01 44:42

Wow, that's uh incredible.

SPEAKER_02 44:46

Geez, I'm I'm I'm I put her actually, I'm creating a new course. So we have a really good course right now for it. It gets, you know, starts with very basic introductory material and goes pretty advanced. Um, that's on the nchronicpain.org website. But I'm putting an even more advanced course out uh in January, and that young lady is uh features prominently, let's put it that way.

SPEAKER_01 45:13

So your website nchchronicpain.org.

SPEAKER_02 45:16

Yep, that's the easiest to remember. Yeah.

SPEAKER_01 45:19

Okay.

SPEAKER_02 45:20

There's there's others, just not yeah, you can go to ppdassociation.org. Ppd is our abbreviation for psychophysiologic disorders, uh, but uh it's easier to remember nchchronicpain.org.

SPEAKER_01 45:34

And you know, it's just interesting because when you think about lots of folks, what they say. Sometimes, you know, if you go on Instagram, you can follow a lot of people who are chronicling, sharing their journey with chronic issues. And as I think of those accounts, I think about something like this, or somebody who may feel the words you use a lost cause, and they feel without hope, you know, and that just feeling hopeless itself is um can be damaging for a person in many different ways.

SPEAKER_02 46:02

Yeah, the uh the woman that I mentioned who'd been hospitalized at a university 60 times, I mean, she was in just utter despair. I mean, she felt like she was gonna have to live with this condition that was just randomly striking her um six to ten times a year. And she just assumed it was gonna be that way the rest of her life and you know, just uh can only imagine um how hopeless uh she felt. And a lot of people feel that way. And a lot of people feel like um their illness couldn't possibly be due to stress because um it's so real. Uh and you know, I understand that. I had the same thought when I first encountered that very first patient. This is a severe symptom. That patient was um averaging one bowel movement per month uh despite taking four different laxatives at double the usual doses. I mean, that that was a very real serious condition. And the 17-year-old girl with the morphine around the clock, you're never going to convince her that her symptoms were not real. Uh and they they were real, um, but they can be generated um by the brain, uh, which is capable of incredible levels of severity um in certain cases.

SPEAKER_01 47:20

I wonder too, if maybe it's threatening for some folks, maybe threatening uh the knowledge base that we're given uh because we're not taught so you know, it's not really taught, you know, the power of stress. I mean, it's getting there, it's moving in that direction. But maybe if you think, wow, I've tried everything, uh uh nothing's working, you know. But just this, it's kind of intimidating to think we don't know all these things that the mind can do, the brain can do.

SPEAKER_02 47:48

Um, you know, there's a stigma to it as well. I mean, people um don't want to feel like they have a mental health condition or that they are somehow too weak to handle their own stress. Uh, and many of them have been coping with significant levels of stress for their entire lives. So it feels uh the level of stress they're coping with feels perfectly normal and they are not perceiving that uh they have anything unusual in the way of the stress level that they're uh coping with. So, you know, my my point to people is that anybody can get this. Uh, you know, and most of my patients are uh my belief is mentally stronger than average because you know it's like they've been working out with with weights since they were kids. Uh, and their their coping capabilities are remarkable. Uh and so it's you know, it's only natural that they're gonna believe that you know, I I couldn't have stress um doing this to me because I don't have that much stress.

SPEAKER_01 48:51

Yeah, that's a great point. Yeah. And or like maybe, you know, they can just handle a lot, but um they can. Yeah, they don't know what it's like without the burden, yeah.

SPEAKER_02 49:01

And so yeah, once they put set the burden down, then they realize, you know, the heroic perseverance that they had to go through everything they had to go through. And you know, many times the the aces were subtle. I mean, they were one of my patients um right realized after we'd had quite a long conversation that he only got praise from his parents when he did something better than his brothers and sisters could do it. And his brothers and sisters were pretty accomplished people, and so it wasn't easy to outdo them. So it ended up he rarely got uh any idea from his family that uh he was a good, quality, capable person. And it he suffered as a result of that.

SPEAKER_01 49:49

Makes you really think about the approaches to healing. You know, if you're only considering the body and you're not really considering the mind-body connection, it's so different, those approaches.

SPEAKER_02 50:01

Yeah, and the way of thinking. I mean, uh, we're we're taught as physicians to think physiologically, to think about organs, to think about structures and damage and disease and all of these psychological ideas that you and I have been talking about are they a foreign concept. It's uh I make the analogy sometimes of you know, asking uh telling a group of plumbers they have to become electricians. And it's you know, there's gonna be resistance there.

SPEAKER_01 50:29

Yeah. Wait till we introduce the spiritual element. That's a whole other ballgame.

SPEAKER_02 50:33

Yeah, yeah, that's right. And that that has played out. I've got some of that in my uh advanced course that's coming out in January. There are two patients in there that where their religion played a prominent role uh in the stress they were suffering.

SPEAKER_01 50:50

I I'm fascinated by that. But yeah, I I always think about that view, whether it's mind body, mind, body, spirit, or just you know, body different perceptions, different approaches. Uh it has to make a difference. Has to make a difference.

SPEAKER_02 51:04

Yeah. And in in one of those cases, the religious element was was a positive one, but it was still um creating uh symptoms in his body.

SPEAKER_01 51:16

Yeah, yeah. Well, I I think that's true with religion. Religion depends on what humans do with it, right? Like whether it has a positive effect or a negative effect. Um yeah.

SPEAKER_02 51:26

No, some of my patients, you know, the only source of love and support in their early lives was a higher power. And it it literally saved them. Um, but other patients they grew up with a belief in a watchful and vengeful higher power. And that was a became a source of stress for them that contributed to their illness.

SPEAKER_01 51:53

I can definitely see that. Having gone to Catholic school, I think the religion teachers that were a little more gentle, I always tended to like want to hang out with them versus you know, the fire and brimstone ones. I was like, I can't sleep at night, lady. This isn't good.

SPEAKER_02 52:08

Yeah, absolutely. One of one of my patients um grew up in that environment. And unfortunately, uh in grade school, she was molested and you know, she absorbed the belief from that that as she put it, she was a walking sin.

SPEAKER_01 52:25

Yeah, that's that's horrible. That's when it gets really destructive for sure. This was so interesting. Thank you so much for sharing, and I love all the examples that you shared. I think that can really create an image for folks. If people are interested in learning more, uh perhaps physicians, practitioners, and perhaps folks themselves who might be listening to this and thinking, hey, maybe I can benefit from this sort of treatment. What can you tell folks? Where can they go?

SPEAKER_02 52:53

Yeah, and chronicpain.org. Uh, we have um very careful to put just scientific evidence-based uh materials on there. And if people are curious about, you know, could I have this myself? We've got this 12-item questionnaire on there that is designed so that the more of those questions to which you answer yes, the more likely it is that uh any physical symptoms you're suffering are due to this process. And there are abundant resources on there. There's books, um, there's uh reference to an app on there called Curable. Um, there are webinar-based courses. We've had uh two um international conferences that we've recorded. Uh, the one that we just finished uh recently, uh, you can still get continuing education credit for if you're a healthcare professional up until uh October of 2024. So, you know, and and it's always growing. We've got also uh international webinars every month that people can ask uh questions of experts in the field. And starting next year in 2024, we're gonna have uh uh webinars just for professionals uh to uh present cases that they have questions about.

SPEAKER_01 54:13

And you yourself, you've written a few books.

SPEAKER_02 54:16

Yes, and my first book was called They Can't Find Anything Wrong. It's uh written for patients, um, and it's got probably four dozen case histories in it that illustrate the spectrum of different kinds of stresses that can make people physically ill. We have a textbook for professionals called psychophysiologic disorders, but we deliberately wrote it without jargon so that the medical people could read the mental health material and vice versa. And one of the side benefits of that is that for readers who are interested in the science of all this, uh, it's very accessible to them. It's a little higher reading level than my first book, but uh certainly nothing um that uh a high school graduate couldn't handle.

SPEAKER_01 54:59

Well, thank you so much for your time today. I'm gonna go get a copy of your book. Thank you. The first one. Maybe the second one, but definitely the first one.

SPEAKER_02 55:08

Uh you would you would enjoy them both. Uh it um the um they're written about uh a dozen years apart, uh so there's been some growth in the science uh since then. But the stories are always good. The the first book is story-based, and uh those are kind of I read a lot of science too, but I do like the stories.

SPEAKER_01 55:28

I uh it's just it's fun to read, you know, and uh you can see people going through it and uh I don't know.

SPEAKER_02 55:35

Yeah, that there's a president of the American Psychosomatic Somatic Society that gives that book to his own personal patients. So um it's um it's got a lot of uh clinical value.

SPEAKER_01 55:47

Well, thanks so much, and uh happy Halloween to you.

SPEAKER_02 55:54

I I don't know if you're going trick-or-treating or not, or yeah, I've got twin six-year-old grandsons, so I think there's gonna be some of that.

SPEAKER_01 56:02

Yeah, yeah, there's gotta be, absolutely. Um, I plan on dressing up a little later and just walking around and having just just partaking in the spirit of it all.

SPEAKER_02 56:12

Sounds great. Thank you so much. Uh I really appreciate your interest in this and uh spreading the word uh to I'm sure a lot of your listeners uh will appreciate it.

SPEAKER_01 56:22

They will, definitely. All right, take care, Dr. Clark.

SPEAKER_02 56:26

Thank you.

SPEAKER_01 56:27

Bye-bye. All right, thank you to everyone for listening to this episode. I hope you stick around, subscribe, and please share this episode with someone who you think might benefit from it. All right, and now for the closing quote Learn to read symptoms, not only as problems to be overcome, but as messages to be heeded. And that is wisdom from Dr. Gabor Mate. And hopefully I did not murder his name. But it's always possible. Alright, everybody, I hope you tune in next time. And uh maybe I'll see you out there in social media land or in real life. It's always a possibility. Uh, and of course, if you see me out there with my dog or whoever, say hello. Alright, everybody. Goodbye. For now.