Our POTS, EDS, Chronic Pain Memory, and Self
The Memory of Past Pain Increases Chronic Pain
The abstract of the above study puts it perfectly,
"A clinical implication of the results is that processing biases that extend beyond this healthy and adaptive process to enmesh the self-schema with pain and illness schemas could maintain and exacerbate distress and illness behavior in patients with chronic pain."
In other words, thinking about and identifying with pain and illness increases pain and this is an automatic and adaptive process. However, it becomes maladaptive when it increases pain intensity and pain chronically.
This occurs on three levels: the conscious level in autobiographical memory, and unconsciously and automatically at the neuronal level, and the gene level.
1. Talking and Thinking about Your Past Pain As Your Identity Might Increase Anxiety and Pain Sensitivity
The autobiographical memory of pain is biased to focus on and experience more pain. We may be constantly creating a narrative of the self whereby we are victims of pain and constantly revitalizing pain circuits due to excessive fear of pain, avoidance and fear of pain triggers, and talking about our pain and anxiety.
We may be able to consciously decrease chronic pain by not identifying the self with pain and illness. Is this possible? What do you think?
Ask these questions and observe the answers to see how much primary pain you have and how much autobiographical memory of pain creates secondary anxiety and pain sensitivity which may be amenable to conscious control.
1. How much pain do we experience most of the time?
When I asked this question of myself, I discovered at my worst, I have about 20 pain incidents per day, 1-3 per hour, and no significant pain per minute or second. That's a lot compared to most people, but why do I have to compare and thus created secondary pain and anxiety? Can one live in the moment and not constantly retrieve the memory of pain or create a narrative of the self victimized by pain?
2. Would our pain be so bad if it didn't disrupt our view of ourselves as the competitive worker, the supermom, the people we 'should' be?
I asked myself this question, for example, when I stand and experience dizziness and chest pain, couldn't I solve that just by sitting down? Surely, I can at home but on a 15 minute lunch break at work, certainly not, and this fact puts me at a great disadvantage as a worker and because of that creates secondary distress and pain sensitivity, but do I have to 'be' the worker? The supermom or dad? Do I have to be a 'self' at all, with all the recurrent memories of episodes of pain, depression, elation, successes, and failures? What do you think? Can we observe the answers for ourselves and find this out?
3. What if all humans had POTS and EDS?
In my mind, if everyone had it, it would hardly be a problem at all since it puts me at no disadvantage and the pain is usually bearable (unbearable pain is of a different character and will be discussed later). What if we did not compare ourselves to others and hence felt no disadvantage? Would not our pain and anxiety be much less troubling.
The writer is not asserting any answer for these questions but rather asking for your input and urging you to observe the process in your life and tell me what you observe. Your answer will not likely be the same as mine and hence I cannot tell you what you will observe.
The writer is certainly NOT suggesting that chronic pain is your fault and would disappear if you just forgot about it. Chronic pain exists at a much lower level, at the level of genes and neurons of which we have no conscious control over by changing out thoughts, and turning against your own thoughts is simply doing violence to yourself. That is exactly the type of violence we want to avoid.
A Preliminary Proposed Approach and Invitation to Discuss (in the comments section)
One of the proposed solutions is to speak of 'our pain', pain in general, or only of pain you are experiencing right now, and only speak of past pain in a general solution-focused way, or as it affects humans in general and some possible solutions, but this will be more fully examined in the subsequent discussion.
2. The Neuron's Memory of Pain
Research has shown that any pain that lasts more than a few minutes leaves a trace in the mind that can be reactivated by much more benign stimuli such that a simple touch can feel excruciating.
There is nothing we have done to bring this on ourselves. There is no one and no thing to blame. It is an automatic, adaptive process. It is part of us, part of what we experience: it is no more an enemy than our joys and pleasures.
What does this suggest about how we might approach this process mentally or even pharmacologically as will be discussed later? Is it helpful that we should turn against a part of ourselves or rather embrace and observe experience to see what it is telling us?
3. Chronic Pain and Anxiety Can Be in the Genes
The above study reveals that a gene that creates superior memory also creates a susceptibility to PTSD. It is possible that this susceptibility to increased fear and pain is inseparable from a superior memory that some people are endowed with by their genetic make-up.
So what does this suggest about an approach to chronic pain and anxiety? If it's in your gene's how do you approach it? We can you do about it? Is there anything you can do about it? Certainly at the present time you cannot change your genetics (gene expression can and does change by various processes), and if you could, would you give up a superior memory to decrease chronic pain and anxiety or take a different approach?
We will discuss a philosophical approach, a pharmacological approach, and a practical approach, in the that order, as per my own biases. Keep an open-mind and do not accept any assertions of the writer but rather evaluate and come to your own conclusions and approaches.
The Roots of Psychological Disorder - Discussion of Psychological Pain and Anxiety with The Philosopher, J. Krishnamurti
No Self, No Pain? The Philosopher's Proposals
Transcript in the link below of a discussion of pain and anxiety with The Philosopher, J. Krishnamurti (Hold down ctrl and click on the link)
--J. Krishnamurti, First Discussion with David Bohm, John Hidley and Rupert Sheldrake in Ojai April 1982
1. Avoid ruminating on 'your' pain and associating the pain with the self.
"Isn't the self, the me, the ego ...isn't that divisive? Isn't that exclusive, isolating process: the self-centered activity which causes so much disorder in the world, isn't that the origin, the beginning of all disorder?"--The Philosopher
2. Experience pain fully, in the moment as it occurs, passively observing it and what it is telling you such that you don't move away from it and can observe what it is telling you.
Is it telling you to change your diet? It is simply an indication of the processes of your body? Is it unbearable and telling you to take action now?
Disassociating from the pain and ruminating on the disadvantages to your self and your life causes the mind to 'bookmark' the pain and return to it such that pain sensitivity is increased and pain triggers multiply unchecked. Anything you associate with pain or harm to the self can then become a pain trigger. This is part of the process that occurs in PTSD, Generalized Anxiety Disorder, and Major Depression but it is also natural and adaptive. Do you see this process occurring? Can you simply observe it without moving away from it?
3. Do not accept pain. There are three levels of pain, benign, intense, and unbearable and when you give pain your full attention, you are able to see the intensity and act accordingly. Pain is natural and when it occurs, it may be helpful to experience with your full attention so as not to associate it with other thoughts which strengthens the memory trace and connects it with various triggers in your mind and environment.
Pain in general, however, is undesirable at any intensity and when possible should be eradicated. It is an act of love to yourself and others to be in favor of the eradication of pain and fear, obviously. Do you believe it is possible?
The philosophical approach put generally is to eradicate the self, the method of experiencing life in a selfish way, overly concerned with self and it's past memories and future fears. This is meant in a very extreme way, not simply in the sense of how one person may be more selfish than another but actually eradicating the concept of self and identity altogether, as a Christian, an American, a doctor or lawyer but rather being an authentic person in the world and acting according to what reality requires, reality being the moment, rather than your past and imagined future which is not reality. Is this possible?
The only way to know is to observe your daily life with choiceless awareness which is freedom.
What if we are trapped in memory as an artifact of biology, in effect cursed to live in the past, devoid of the ability to learn and explore, sitting at our computers, making tiny adjustments to life, i.e. trips to the bathroom, the grocery store, the doctor, stuck in patterns based on the past? This activity of ruminating on the past, not living in the moment, stuck in patterns of action where we barely diverge from routine, continually act in a mechanical way so as to maintain an identity as 'a counselor', 'a Christian', etc, such that our actions are severely limited. That kind of activity is strongly associated with depression, while exploratory activity is strongly associated with positive affect.
Given the possibility that this kind of activity is strongly ingrained in our neurons and genetics, some other approaches should be considered that can change brain activity and gene expression from an external source. Hence we will look at experimental pharmacology in light of the connection between pain and memory.
Experimental Psychopharmacology - The Manic Switch
Proclaimer : It is the writer's opinion that it is very possible that only external means such as drug treatment, changes in diet and exercise, or in extreme cases, electroshock or deep brain stimulation can produce profound changes in one's baseline level of mood or nervous system wellness. As such, drug treatments and other external means should be considered with at least equal or possibly greater gravity than philosophical or cognitive treatments. It is very possible that a mind and body which is chronically in fear and pain cannot be changed by any type of thinking or philosophy but only by external treatments.
Disclaimer: All of the treatments described are experimental and have side effects. None should be attempted without a doctor's monitoring. Links are provided to clinical trials for anyone interested.
The Claim: Evolution and genes have produced a manic switch in hierarchical creatures that can quickly switch one from anxiety and depression to hypomania and elevated mood
For more discussion of the evolutionary angle, see the collection entitled
Subordination and Defeat
An Evolutionary Approach to Mood Disorders and Their Therapy
by Leon Sloman and Paul Gilbert (editors)
Review by Keith S. Harris, Ph.D. on 1 Jul 2001.
It goes without saying that in the current human condition with our advanced cognition, anxiety and depression is not desirable at all, and one would be better served in a state of hypomania and elevated mood in any circumstances whatsoever. Hypomania also greatly decreases pain sensitivity and increases resilience to stress and better immunity.
The switch into hypomania is characterized internally by neuroplasticity, i.e. the brain begins to change and grow, the individual begins to explore and try new things whereas anxiety and depression are characterized by a stagnant mind ruminating on past fears. It is also characterized by rises in serotonin which has been documented in many creatures that switch from a subordinate to a dominant status.
This switch generally occurs in a person with a baseline of depressed mood due to a series of social gains or 'wins' when circumstances suddenly become very advantageous such as a lottery win and this mood elevation generally lasts fewer than 6 months before the person comes back to baseline depression, however some treatments have shown and ability to produce a hypomania and improved mood in hours that lasts several days with one treatment. We will discuss 6 of these which have been studied recently.
Scopalamine is a potent anti-cholinergic and used experimentally has been shown to produce a rapid switch from anxiety and depression into hypomania and elevated mood.
I hypothesize that like other medications in this group, the manic switch is caused by a stable blocking of acetylcholine in areas associated with anxious and troubling past memories and triggers. This memory blockade forces one to live in the present and explore current experience with confidence and curiosity. Scopalamine also reduces anxiety and pain sensitivity. Used at the right levels or with supportive medications, memory measures can be normal for non-traumatic memories.
Drawbacks of scopalamine include the possibility of overdose and a withdrawal syndrome.
Below is a link to a clinical trial of scopalamine for depression currently recruiting in Maryland, USA.
Several studies document rapid antidepressant response to ketamine. Ketamine is an NDMA (N-Methyl-D-aspartate) glutamate receptor antagonist which blocks glutamate and aspartate from activating the receptor. Glutamate is the main excitatory neurotransmitter involved in pain and memory in the brain, and glutamate receptors can be activated by glutamate such as contained in the food additive MSG (monosodium glutamate) and aspartate as contained in the sweetner aspartame both of which theoretically may increase pain and anxiety sensitivity.
Blockade of the receptor thus decreases nerve sensitivity overall and causes temporary mild depersonalization acutely, freeing the nervous system from pain and anxiety sensations, cutting one off from current and past pain and anxiety causing exploratory behavior resulting in neuroplasticity and increased mood, in other words, activating the manic switch from baseline mood to hypomania.
Below is a link to a clinical trial of ketamine for depression at Columbia University, currently recruiting.
3. Dextromethorphan (OTC Robitussin Gels)
Dextromethorphan is an over-the-counter cough suppressant opioid derivative which acts as an NDMA antagonist at sufficient doses, and with actions on "NMDA, μ opiate, sigma-1, calcium channel, serotonin transporter, and muscarinic sites", similar to ketamine. Dextromethorphan abuse is called 'robotripping' and causes dissossicative depersonalization, mild euphoria, psychosis and hallucinations at high doses, altered time experience, insensitivity to pain and anxiety, and blocks the effects of other psychoactive substances.
I have written on how to use dextromethorphan for chronic pain with your doctor's monitoring here:
Dosage and possible cross tolerance with opiates can be an issue with dextromethorphan. After one has achieved a 'robotrip', slightly below that dose may provide relief for treatment resistant chronic pain and depression. However, no one can tell you to robotrip as it is not safe and generally not legal but it is possible for your doctor to carefully raise your dose from an OTC dose which is 90 mg and monitor you so that you achieve an effective dose without the symptoms sought by abusers.
I have written about dextromethorphan because the safety and side effect profile is better than that of opiates such as methadone and oxycodone, however, the safety profile of experimental doses is less than or equal to that of treatments such as gabapentin and traditional antidepressants so experimenting should be done carefully with your doctor's monitoring and is best for those who want to get off of opiates or for whom gabapentin and tricyclic antidepressants are ineffective.
Dextromethorphan has very little physical addiction or withdrawal syndrome.
A 90mg dose of O-T-C dextromethorphan in Robitussin gels may be effective as an add on treatment for pain, depression, and anxiety when one is taking opiates or benzodiazepines to block symptoms of withdrawal including shaking, sweating, pins and needle sensations, and nausea. Get your doctor's advice to avoid adverse reactions, including serotonin syndrome which could be very serious. Magnesium with glycine as as cofactor is the body's natural NDMA antagonist and can also be used to block tolerance and withdrawal from prescribed opiates and sedatives and is much safer and readily available.
Below is a link to a clinical trial of Dextromethorphan/quinidine for neuropathic pain in Multiple Sclerosis in the US, currently recruiting:
Each of these treatments are experimental but currently available in some form. Dextromethorphan is available over the counter in Robitussin Gels and in prescription as Nudexta. Scopalamine is available as transdermal patches. Ketamine is currently used only experimentally for depression and routinely as anesthesia in pediatric contexts. Anyone wanting to try them for pain or depression can join one of the trials listed or contact your doctor and create a safe, well-researched plan to explore these treatments in a way that reduces the risk of side effects as each of these treatments can have severe side effects used in the wrong way.
4. Deep brain stimulation and other electro-magnetic therapy
There is no doubt that deep brain stimulation may relieve depression and other neurological suffering. The draw back is the obvious side effects that come along with skull perforation and electrode implants inside the brain. It is indicated for very extreme depression and severe brain dysfunction but can in the future be improved such that it is available for anyone wanting a mood boost.
Below is a clinical trial of deep brain stimulation for treatment resistant OCD.
A much safer therapy called transcranial direct current stimulation is now available that uses electrodes placed on the head to direct a low current to parts of the brain which are malfunctioning.
Below is a link to a clinical study of transcranial direct current stimuation to relieve knee pain in osteoarthritis, in Massachusetts.
It is my opinion that safer therapies will progress to the point of being available to all to boost mood and performance. I suspect that small electrodes directed in through the nasal passages to sites of stimulation experienced by drug abusers who snort active substances will prove to be a safer and more effective route to deliver a current to the pleasure centers of the brain via smell nerve receptors that send pleasure signals via a direct route to the brain.
5. Magnesium treatment
Magnesium from 125-800mgs has been shown to relieve depression in some clinical settings, especially in magnesium deficiency. Magnesium is the body's natural NDMA antagonist and glutamate blocker and like ketamine and dextromethorphan block the NDMA receptor when combined with glycine. Magnesium taurinate and magnesium glycinate have been shown to be particularly effective, as have intraveneous magnesium infusion. Other forms of magnesium may be harder to absorb or may not reliably make it into the blood stream; however, many persons have been able to achieve a natural relaxation effect with magnesium sulfate in epsom salts which are readily available. Magnesium is more effective for chronic pain when combined with an antidepressant such as Elavil.
Magnesium is also used to attenuate sedative withdrawal.
Those with chronic pain and anxiety who use opiates, benzodiazepines, gabapentin, venlafaxine or other substances that can produce withdrawal may be greatly helped by supplementing with magnesium to prevent partial withdrawal evident by shaking, sweating, nausea, nervousness, and pins and needle sensations on the skin which is evidence of excitotoxicity which can cause secondary nerve damage. This is discussed here:
Below is a link to a clinical trial of magnesium sulfate in treatment resistant depression, currently recruiting in Florida, USA:
"If we could only reach that dial inside and turn it up"
The purpose of learning about these therapies is not that the reader should immediately seek out these substances in particular but rather contemplate the mechanism, how neuroplasticity and exploratory behavior is induced by mechanisms which block the process of ruminating on past experience. The mechanism is very deep in our minds and has even been studied in small animals such as mice, so it's not about our conscious habits but is rather a very deep rooted process which we can use our accumulated knowledge to improve and produce feelings of love and happiness for ourselves and others.
Why hasn't man already done this? It has been possible to nearly eradicate fear and pain for many decades now but the pharmacological industry is driven by the capital produced by treatments that only work enough that one has to continually pay money to get substances which are addictive and work incompletely. It is a process we are all stuck in and a part of; there is no evil person to blame, we are all cogs in the machine when we purchase our meds.
What can be done to improve this situation? What do you think?
In subsequent posts, we will discuss the environmental and social strategies for flicking the manic switch, which includes being successful in the social games that we are a part of. It is the writer's bias that this is an inferior approach, equal to winning the rat race however it could be, possibly, one of the most sufficient approaches since we are social animals and though highly intelligent, may yet be caught in and only respond to positive social cues and worldly success. What are your thoughts on this?
DF Seldon, MS, NBCC
Psychotherapist, in treatment for POTS and hEDS