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I believe that even conventional western medicine is realizing that the notion of a spectrum can apply to many conditions, not just a few, such as Autism Spectrum Disorder. Chronic lung disease, liver disease, dyslipidemias, and most most notably the spectrum of T2D, are all great examples of this. Maybe the future will be one where we can all be placed on a spectrum for many conditions, and use that information/proneness to recognize our own vulnerabilities to a host of mind and body conditions, and hence manage our lives better. RR Grinker wrote a very insightful book about that (Nobody’s Normal: How Culture Created the Stigma of Mental Illness), specific to psychiatry, his field, but with far reaching implications and suggestions for applications outside the realm of mental illness.
I too think that these introductions are a great idea. Not surprising to find a common theme of a chronic pain history among course participants. That includes me. I have worked in full service family practice (and latterly as a hospitalist) for about 35 years, working on Vancouver Island in BC, Canada. Leading up to 2009, I developed unexplained profound hearing loss and MSK pain (not at once!), the latter variably diagnosed as gout, pseudogout, PMR and psoriatic arthritis. While working and since I retired about 10 years ago, I have exhausted conventional treatment. Since discovering John Sarno, Howard Schubiner and the Curable group (I attended the 12 week boot camp), I am making gains in my recovery and will continue taking the steps to cure this. I would be curious about working part time with MBS patients later. I have found the journey humbling, fascinating and compelling. This has taught me about a huge deficiency/ blind spot but also an amazing opportunity in modern medical practice.
Good discussion. I have found that the structural plus MBS explanation for BPPV fits best. Like others who have posted, I have seen this problem typically in the context of a host of other complaints (back to the circumstantial assessment, ROS, pain chart, etc, where other MBS diagnoses are frequently present). With a history of repeat BPPV occurrences, the predictive coding error/rumination-fixation and buy in to the structural (and perceived as dangerous) explanation have typically gotten entrenched. Better long term results seem to occur (anecdotally) with a 1st time BPPV presentation and successful Epley procedure, where there is later opportunity to address the other complaints, especially where one’s credibility is established after resolving the problem early on, regardless of its cause. Ruminative sorts who comb the internet and fuel their fears,
are particularly vulnerable in these cases ie in search of (often another) diagnosis.Hi Team,
An interesting conversation, where PATIENT BUY IN (and not simply the search for a prescriber) continues to be the lynchpin, in this, a patient group that is often very cynical, critical, angry, desperate and even litigious. The novel (especially after years and decades of sx persistence, disappointment, unnecessary meds, tests, procedures, surgeries, and diminished hope) and essential ingredients we might offer are time, patience, and this new approach… to the management of a significant proportion of GP patient complaints…that our teachers have developed and refined. This new treatment model sadly does not fit into the piece work payment schedule in current use in Canada. My strategy has been to take on a manageable number of such patients, allow more time than usual, and stick to that agenda. By logging time with the patient at the outset, and in fact establishing credibility through a different type of exchange than has been previously experienced (eg hand on the doorknob), trust grows, and an action plan can emerge, with a careful and complete history, rock solid (minimum essential) diagnostics, careful recording and a plan forward that moves slowly and sensitively. In other words, we co-invent a plan that can turn off the Danger Signal. I appreciate Alicia’s candour re going too fast with a new patient and seeing them walk away. Yep, been there. A wise psychiatrist once told me, “if you are working harder than the patient, its time to back off and re-evaluate”. I have (painfully) learned more to be a guide than Mr Fix It, where the rate limiting step is determined by the patient, not by me. I am excited about learning new treatment strategies here, to engage a challenging and despairing patient group. Often on the meds list is a mix of psychotropics (SSRIs, SNRIs, TCAs, BDZs, atypical antipsychotics, etc) and narcotics, such that the role of each of these in the pill salad is confusing (and certainly numbing) at best, requiring a very slow and shrewd meds reduction plan. Yes, patients (with coexisting anxiety and dependent traits) become very invested in the notion that this pill salad is what is keeping them going, and any disruption in that list will cause them to topple. If Trust in our Program can be carefully cultivated and maintained, then careful meds reduction can occur, but I think the care giver-patient relationship must be sound before one starts. If the picture is further complicated by age related cognitive impairment, then we must modify our patient expectations and support/share that reality with the caregivers. The pharmacologists (depending on the meds and doses and pt comorbid conditions) typically guide us in weaning off the narcs first. I have no doubt that a pattern of positive interactions between doc and patient can boost the placebo effect of meds like SSRIs (longer term) and BDZ (short term) as we await the onset of effect of SSRS’s, while continuing to pitch the idea that the patient understanding, housecleaning and rebuilding is the more powerful and enduring stuff for the longer term. Where I live, the community supports for patients like this are woefully lacking. The belief-fear-chronic pain loop joins the mood disorders/anxiety and addictions loops where often all 3 coexist in these patients. There can be no doubt that providing a solid grounding in psychoeducation, ruling out structural/tissue damage, ruling in MBS, based on circumstantial and confirmatory testing/clinical assessment offers more than these patients have ever known in understanding and reversing conditioned response behaviours. Attitude is everything (Gordon) goes so well with seeing sx relapses/flares as opportunities, to harness the power of the prefrontal cortex to calm the and limbic system. But only when the danger signal has become contained and the slope of the line becomes positive.Hi Alicia,
Nothing like the humility and the learning that comes in helping you see (by keeping decent records and honest appraisals of how things are going with each pt) what works and what isn’t working! Having a checklist of options, but more importantly the skill and confidence to use each effectively, to organize and guide the choices of “what approach for what patient”, will be huge asset to us. The Western reductionist medical model can be paraphrased as, “when you have just a hammer, everything (and everyone!) looks like a nail!” The art in this business is in the capacity to individualize and customize our approach to each patient ie put the hammer away when the nail is not going in.
MurrayIt has been my experience that the single most powerful and indeed essential element in these interactions (and patient outcomes) is the “buy in” part, Howard. The engagement of the patient, where belief must enduringly trump skepticism and doubt, is the deal maker/breaker. After often years of disappointment and disillusionment, this can be a very tough sell! I think that the way you, in Unlearn Your Pain (and Alan Gordon, in “The Way Out”) emphasize how belief (ie Trust The Program), is the key, and you have both expressed that eloquently. Expectation of improvement or resolution leverages the placebo effect and sets the stage for neural circuit re-wiring. Expectation of improvement will also vanquish the nocebo effect. Because neural circuit disorder patients are often great skeptics, the pace of THEIR buy-in or acceptance of MBS (often by default, after nothing else would help) is often the rate limiting step in catalyzing and achieving lasting change.
It is not surprising to me ie intuitively obvious that provocative testing outcomes are proportional to patient buy in. Please send along a reference to that article you mentioned above.
I think it is very appropriate to offer up the list of hybrid diagnoses, beyond those that fit exclusively into the Mind or Body camps. Put another way, what chronic (and many acute) illness does not carry with it both mind and body components?
I wanted to add that the screening forms (Body Map, Lifetime Stressors, Lifetime ROS, Personality Traits) from our first week’s class seem to be very potent ways to gently introduce some new thinking to a “negotiable” patient and provide a ton of clues (red flags) to an astute practitioner.I look forward to learning more about how to proceed in the treatment realm. Very exciting! Best regards, Murray