Could you tell me about your background and how you became interested in chronic pain and psychophysiologic disorders?

It started 40 years ago this month, as I recall. I was doing well in my early medical career and training. I had received an award for excellence in medical school. I was passing my board examinations with flying colors and I became board certified in both gastroenterology and internal medicine.

I was in my first year of training to become a gastroenterologist and I encountered a patient for which all of that training was completely useless. I had no idea how to diagnose or treat this patient. She was 37 years old and for the past two years, she had been averaging one bowel movement a month. She was taking four different laxatives at double the dose and they weren’t working.

She was referred to us from a university. I was in Torrance, California at the time at UCLA Medical Center and she was referred to us from another university for some specialized testing. We were confident that the testing was going to show an abnormality because there was nothing else that could possibly be wrong with her.

The specialized testing came back completely normal. We had no explanation and there were no more tests that could be run. I was going to do her exit interview and tell her there was nothing more we could do. I didn’t want the conversation to be one sentence and done. I decided to ask her about her stress. Everybody else had asked her about her stress and she didn’t have any. She was happily married with two kids. She enjoyed her part time job at a bank. So that was the end of that.

But I still didn’t want this to be a short conversation. So I asked her about her stress before her illness began. I thought maybe something bad had happened back then. She started telling me that she had been sexually abused as a child. That was a big surprise to me because I had never heard anything like that from a patient before and I had no training in this area. I was in my eighth year of training and no one had ever mentioned to me that this was something I should look for or how to respond if I heard it from a patient. I fell back on the basics and asked her to tell me exactly what happened and how often and so forth.

It turned out that her father had sexual intercourse with her an average of once a week from age 4 to age 12. She suffered an absolutely horrendous level of abuse. I have grandchildren that age today and if something like that happened even once, it would be horrifying. At the same time, she was speaking of this in the same tone of voice you would use to read a grocery list. There didn’t seem to be any emotional content there. If you didn’t know better and I certainly didn’t know better, you would assume that she had fully processed this trauma and moved on. Yet at the same time, she had this incredibly bad physical condition that she was suffering from and no one had an explanation. Could there possibly be a relationship to this past abuse? I had no idea. No one had touched her against her will for 25 years. It seemed impossible that there would be a connection.

But I knew there was a psychiatrist at UCLA who was certified in both psychiatry and medicine and had an interest in these types of illnesses. That gave me something to do for her. I got her an appointment with Harriet Kaplan, the psychiatrist, never thinking for a moment that anything would come of it.

A few months later I ran into Harriet on the elevator. Just to make conversation, I asked “Whatever happened to that patient I sent you”? Harriet said, “Well, I’m not seeing her anymore. She’s cured. She doesn’t need to take laxatives anymore. Bowel movements are normal after eight or ten weeks of weekly counseling sessions”. That absolutely rocked my world because I’m eight years into my training and no one ever said that you could cure a serious physical condition just by talking to someone. I had no idea that such a thing was possible.

I thought I wanted to be a complete GI doctor. I wanted to be able to handle whatever came in through my door in my practice. I got Harriet to give me a basic framework for how she thought about these things. But I was kind of in denial. I thought this type of situation had to be rare. How could I have gone through eight years of training and never been taught this? The only explanation I could think of was that this is rare.

I found that it wasn’t rare when I went into private practice in Portland, Oregon and I started using the framework that Harriet had given me. Anytime I couldn’t find a biomedical explanation for a patient’s symptoms, serious psychosocial issues were present. They linked to the patient’s very real symptoms. There wasn’t someone like Harriet in Portland, Oregon so I didn’t have anyone to refer these patients to. Some patients would come back to me after cognitive behavioral therapy saying that it didn’t work. I began trying to help them and I wasn’t very good at first. But even as a beginner, I was getting better outcomes for those patients than they were getting from the rest of the healthcare system. It was very rewarding to see that.

My first book came out 15 years ago and that’s how it all got started. It was very rewarding to work with people who had been ill for years get successful outcomes with this approach.

Wow, that’s amazing. Eight years of training and no one had provided you with this type of framework for treating patients. 

No. And that’s still the case today. Just this year, I started being allowed to teach the medical students here in Portland for the first time. They’re finally getting from me the same basic framework that Harriet had given me all those years ago.

Can you describe this basic framework that Harriet had taught you?

I think of it in two parts. First is the diagnostic process that I call a stress evaluation and then there’s the treatment process, which I can probably call pain relief psychotherapy. There are several different treatment types, but they overlap a lot. They are aiming to alleviate patient’s symptoms, not merely helping people cope with them. They attempt to shift a person’s perspective and focus from the part of their body that is experiencing the symptom to their brain, where the symptom is actually being generated. The goal is for them to start thinking about what could be going on that would be impacting the brain in a way that would produce these symptoms. And that helps people to start thinking about sources of stress that are covered in the diagnostic stress evaluation.

Okay and I read that you’re the President of the Psychophysiologic Disorders Association (PPDA). Can you tell me about the PPDA and what its purpose is?

We grew out of a conference that was held in 2009. We started working together and formally started the PPDA in March of 2011. I’ve been the president since that time and our mission is to educate healthcare professionals and the public about how to diagnose and treat psychophysiologic disorders. These are disorders that are not linked to biomedical problems. There’s no organ disease that explains the symptoms. It’s all brain generated symptoms linked to one or more types of stress which can be uncovered and successfully treated.

Now we have randomized controlled trials from several locations around the United States that showed extraordinary benefits from this approach. Benefits that are far better than what has been achieved in the past with cognitive behavioral therapy or acceptance and commitment therapy.

We have put on numerous conferences, both live, in-person, and online. We have written a textbook with sixteen contributing authors. We have a second textbook coming out later this month or early November 2022. We have a webinar online for professionals with all the medical jargon removed so that patients can also benefit from taking it. The textbook is also jargon free. This is for medical professionals and people who like reading about science. We have a scientific bibliography that shows the scientific publications that support the recommendations that we make for diagnosis and treatment. That’s over 200 references long. Each one has a paragraph describing the key findings. We have lots of videos that illustrate different aspects of this condition. There is a list of resources that we provide that are outside of us; other resources that we believe are scientific and evidence based.

We are trying to be a hub or clearinghouse for everything that is backed by science that can help people struggling with this condition which is 40% of people going to primary care. But very few healthcare providers have had any training in how to diagnose and treat this. So people need to look for the kinds of independent resources that we recommend.

Do you think that the majority of people who have chronic pain are experiencing a psychophysiological problem rather than a structural problem?

Yes, absolutely. If you go to a physician because you’re experiencing a new symptom, you have a 40% chance that it’s a psychophysiological disorder (PPD). And then if the physician does the diagnostic evaluation looking for structural damage or organ disease, and they don’t find anything, you have to remember that symptoms happen for a reason. And if there is no structural or biomedical cause, then the possibility of you having a PPD greatly increases. So yes, definitely a majority. Some conditions are even higher than 40% when you are first being evaluated. Probably 75-80% of people with low back pain have a mind-body cause.

Based on what you’ve told me and what I’ve read about your research, you seem to believe that these types of conditions are directly related to stress. How exactly are we defining stress? What kind of stress are we talking about?

There are several different types of stress and we look for all of them. Some people have more than one. And the proof is in the pudding if you identify a significant stressor and you treat that and then find that the person’s physical symptoms improve. Then you have strong circumstantial evidence that you’re on the right track and that the stress and symptoms are connected. And the final proof is that you eliminate the person’s symptoms.

One of the first types of stress that I look for is your basic everyday life stress with what’s going on in your life at the moment. One of my patients, the only time that he would experience symptoms was when he was driving to work. Specifically when he was driving to work and not when he was driving home from work. On the weekends when he is not working, he can drive anywhere and feel completely fine. That was pretty strong evidence for what was going on.

Another patient of mine had been experiencing low back pain for 25 years, every single day, except for two weeks out of the year. He was going on vacation during those two weeks and he had no symptoms. I didn’t want to jump to conclusions too rapidly. I thought that maybe he was lying comfortably on a warm beach, taking good care of his back. So I asked him what he did on vacation and it turns out that he was fly fishing in British Columbia. So you have to imagine what kind of moves you’re making when fly fishing. You’re twisting back and forth with the fishing rod, you’re reaching down into the bait bucket, and you’re reaching down to net the fish. And then he tells me that when he’s done for the day, he’s helping the lodge owner clear brush from the lodge. And all this time, he has absolutely no symptoms in his back. The symptoms come back as he returns to his regular day job. So that was very clearly not structural back pain.

Another form of everyday stress that we see is people who are constantly taking care of everybody else in their world and they fall short when it comes to putting themselves on the list of people that need to be taken care of. So they’re living their life as if they are on a treadmill they can never get off of and are constantly focused on the needs of everyone else, and they never get around to doing anything fun or relaxing for themselves. And that can catch up with you after a while.

The biggest single category and the biggest shock of my medical education was finding out that stress you experienced as a child could make you ill as an adult. And the common denominator here is treatment of the child that knocks their self-esteem down on a long term basis. I have a written screen questionnaire with 37 questions. The last question is “How would you feel if you learned that a child you care about was growing up exactly as you did? Would that make you feel sad or angry?”

A lot of my patients who look back at their own childhoods like to say, “You know, it wasn’t that bad” or “I made it through it” or “Other people have been through worse”. But when you ask people to imagine your own child going through the same experiences that they went through, it’s a completely different question. And you will see people’s facial expressions change dramatically when they start to think about that. They suddenly realize that things were a lot tougher than they have allowed themselves to believe. We get into a discussion about what they had suffered and we find that there are long term consequences. Not just the symptoms they’re now experiencing, but personality traits like being excessively self-critical, low self-esteem, being a perfectionist, or being a people pleaser. These personality traits crop up again and again in people with chronic symptoms that have no biomedical explanation. And they’re very stressful. And they come as a direct result of the person’s survival when they were a child.

Another major consequence of adverse childhood experiences (ACEs) is unrecognized negative emotions like fear, anger, shame, grief, and guilt. It’s like boiling magma on the inside of a dormant volcano. With my patients, I don’t see these emotions on the outside, but on the inside, they have these boiling emotions that can take some time and experience to access. If they’re not expressing themselves outwardly, they can express themselves in the form of physical symptoms.

The last long term consequence of ACEs are the presence of triggers, things, situations, or people in a person’s present day life that are linked to the past and that are triggering for them. The most obvious would be someone who had mistreated you when you were a child who’s still in your life today. That’s going to be triggering and it’s going to cause a lot of stress for you.

The other parts of the stress evaluation are mental health conditions that may not be recognized such as depression, anxiety, and PTSD. It’s very common for all three of those to manifest physically rather than with a mental health symptom. Many people who are manifesting these physical problems will say that they don’t feel depressed, anxious, or symptoms relating to emotional trauma. Yet their bodies are telling us that there is an impact there. You have to know how to ask in more detail about symptoms of depression, anxiety, or PTSD that can clarify if those diagnoses are present.

This leads to my next question, how exactly is stress presenting as physical symptoms? What’s the science behind that?

Well, the brain is actually anatomically different in people with this condition. There are MRI studies of the brain on people with fibromyalgia, somatization disorder, irritable bowel syndrome, etc. Researchers experimentally inflict pain on the person and they check the brain out with an MRI to see what parts are lighting up. The parts of the brain that are active and lighting up in people with fibromyalgia, for example, are different than the parts of the brain that light up in people who don’t have fibromyalgia. There are real anatomic differences in how signals from the body are being processed by the brain.

There are constant signals going from the body to the brain. Just as our brain gets signals from our eyes, ears, tongue, and nose, it receives signals from the interior of the body. But it can misinterpret and amplify those signals. All pain is generated from the brain. Pain is a construct created in our brains based on signals that are coming from the body and sometimes the brain. All these symptoms are 100% real, but they’re not coming from the part of the body where we are feeling them.

What are specific treatment strategies that you are finding most effective when treating someone with psychophysiologic disorders?

There are basically three different types of new pain relief psychotherapies. They all have their individual names, but they overlap a lot. The first step is to let people know that their symptoms, whether it’s chronic pain or something else, is not coming from the part of the body where they feel it. The physicians have checked those places out and they’re not finding anything that explains the person’s symptoms. Once I get people on the same page as me, we can do the stress evaluation and find out what their stressors are. Then we treat the stressors.

If there’s a domestic violence situation, we can try to deal with that. If a person has major workplace stress, we can help them connect the idea that that’s where their symptoms are coming from. Then they can focus on the issues at work and try to deal with them.

I try to address personality traits by helping them see where they came from. If someone’s self-esteem was beaten down, in any variety of ways, they emerge from their early years feeling like a second rate human being. I try to help people see that what they went through was the equivalent of being born on the far side of Mount Everest and having to climb up and over to get to be an adult and that they shouldn’t blame themselves for where they happened to be born or the situation they found themselves in. Instead, they should give themselves tremendous credit for having come through that situation and begin to think of themselves as heroic for their perseverance. When they can do that, it’s a huge change in their self-image. It’s a 180 degree flip in how they view themselves. That has great benefits for a lot of the other areas of their lives that are stressful. Many of the other unhealthy personality traits will fall away like dominos. Personality traits like extreme self-criticism, perfectionism, people pleasing, poor assertiveness, difficulty setting boundaries, and choosing less than ideal partners in relationships. All of these things begin to improve when you see where those problems came from in the first place.

Another big one is helping people connect with their buried, negative emotions, especially anger. One of my patients was an only child and her parents fought with each other verbally and emotionally continuously. She tried to be the peacemaker. She failed at that and felt that failure personally. When she was eight years old, her parents divorced but kept living in the same house together. They slept in separate bedrooms, but they continued to fight and live together. She told me repeatedly that it wasn’t that bad, that she had coped with it, and left it in the past. She didn’t think it could be responsible for the fact that she had eight or ten different physical symptoms for over 20 years until I asked her to imagine her beloved niece trying to cope in that household. She just stared at me and she was a very verbal person. She was talking continuously up until that point. At the end she said that if she had watched her niece go through what she went through, she would shoot herself. She realized for the first time, just how terrible it had been which then led to her giving herself a lot of credit for having made it through that. She began to think of herself as a heroically perseverant and enduring person. This changed her self-image dramatically. She dumped her narcissistic boyfriend the next day. She made a lot of changes and eventually had the self-respect to insist on mutually supportive people in her life. She has been happily married to a wonderful person for 10 years now.

Treating those emotions, bringing them to the surface, and helping people recognize them is hugely important. Next we have to identify the triggers. If you have an ACE perpetrator in your life or a situation in your life that reminds you of past traumas, you need to recognize how triggering those are. You need to be able to set some boundaries and make some changes so that you are lessening the impact.

The last part is treating stressors like anxiety, depression, and PTSD. These can be treated with traditional methods. There are some really effective treatment modalities, either psychotherapy or medications or both. There’s nothing magic about how those are treated. The magic part is figuring out that those diagnoses are present when they are presented to the healthcare system with primarily a physical symptom instead of a mental health symptom. People get better when we do this.

I’ll tell you one more story of a patient who completely convinced me that I was really onto something there. Early in my career, I was kind of a beginner. I was asked to see a patient who had been hospitalized for nausea, vomiting, and extreme dizziness. When I went into her room she said something that no other patient in my medical career had said to me. She said, “Thank you for coming, doctor, but don’t waste your time with me. You’d be better off seeing your other patients.” And I asked her why. She explained that she had been hospitalized at a major West Coast university 60 times over the past 15 years. She had every conceivable diagnostic test and she was having these attacks of dizziness and vomiting 6-10 times a year. Half of the attacks were bad enough to put her into the hospital. Nothing was showing up on her diagnostic tests, so they had a psychiatrist come and speak with her. As with most mental health professionals, he wasn’t trained in what to look for in someone who is physically ill as opposed to mentally ill. He said that she didn’t have a mental health diagnosis. He failed in finding what was wrong.

The key clue in her case was that she would always get one of these attacks whenever she drove through a little town about 45 minutes from where she lived. She had a verbally and emotionally abusive mother who had been abusive towards her for 47 years. She was now 50 and the only time she passed through this town was a trigger for her when she was on her way to visit her mother. There was a direct connection. And a lot of her attacks happened in her home community after she talked with her mother on the phone. If she drives anywhere else, she doesn’t have these attacks. She realized that’s what’s been doing this to her for the last fifteen years. She was cured and never had another attack again. Many other patients need years and years of psychotherapy to get the same outcome. In her case, just bringing the issue into conscious awareness was enough to alleviate her symptoms.

Something I’ve encountered in the ER is that a lot of patients are offended by the idea of their pain having a psychological cause. They usually believe that they have a structural problem that can only be resolved by medication or surgery. How do you get past this barrier?

I tell them that the symptoms are perfectly real. They just happen to be generated by the brain. A good example that you can share with people is phantom limb pain, where somebody who’s limb has been amputated will feel pain in the part of the body that is no longer there. The only place that pain can be coming from is the brain. The brain can do that in people who have never had an amputation. The brain can cause pain and other symptoms. Literally, from head to toe, migraines, tinnitus, vertigo, temporomandibular joint problems, visual disturbances, pseudoseizures, swallowing problems, breathing problems, pain in any location, nausea, vomiting, diarrhea, constipation, etc. All of these are very real and can occur by being generated by the brain. I try to persuade people that this is not psychological and this is not in their head. There’s a hugely important distinction between in your head and in your mind. And if people can accept that, we can move forward. I like to bring these issues up at the beginning of the evaluation, when I may not know for sure about whether they have an ulcer or a gallstone causing their symptoms. I just tell them I want to be complete about this. I like to say, “We’re going to investigate you for gallstones as a cause of your pain. Or we’re going to investigate you for ulcers. But at the same time, we don’t want to neglect the possibility that your pain is brain generated because of stress”. I think of it and explain it to patients as a part of a complete evaluation.

What is your advice for someone who is newly diagnosed with chronic pain and has no idea where to start? And then what is your advice for someone who has had chronic pain for over twenty years and believes that they have tried everything?

Well, for someone who is new we want to do a diagnostic evaluation to make sure that there is not an organ disease or a structural abnormality that’s responsible. And then if there is not any of that found, then by far the most likely explanation is a mind-body condition, a psychophysiologic condition. And we need to do the diagnostic assessment. And it’s the same thing for someone who has had this for twenty years and who believes they have tried everything. Most of the time, they haven’t tried this.

We now have gold standard randomized controlled trials published in top journals all over the country. The Harvard Hospital, Beth Israel Deaconess, the Los Angeles VA, the Boulder Back Pain Study, a fibromyalgia study out of Ann Arbor, all doing vigorous research in different conditions, using these very similar pain relief psychotherapies and getting dramatically better results than the traditional forms of psychological treatment like mindfulness based stress reduction or cognitive behavioral therapy. And I mean massively better.

The Boulder Back Pain Study had two control groups and 150 patients with ten years of back pain. The two control groups dropped their pain from 4 out of 10 to 3.5 out of 10. The psychotherapy group dropped from 4 out of 10 to 1 out of 10. With 8 sessions of pain relief psychotherapy, it was absolutely extraordinary the separation they got. And then they followed the patients for a year. They had only received psychotherapy for a month and a year later their pain scores were still at a one, and two-thirds of them had pain scores of zero. This is after ten years of pain.

I encounter patients who have bipolar disorder, schizophrenia, and other psychological problems where it is difficult for them to understand and be compliant with treatment strategies. Do you have any recommendations for how to approach chronic pain with these patients?

The treatment so often depends on verbal communication and cognitive processing by the patient of the information that we’re trying to convey. So clearly a first step with patients with serious mental illness is to treat the mental illness as best you can and try to get them into their best possible mental state before going onto address some of these other techniques. If they’re not able to process information very well the treatment techniques are less likely to be successful.

Despite its success, it seems that the PPDA and mind-body medicine are not very well known in the treatment of chronic pain. How can these resources become more well known and accessible to people?

That is something that I think about everyday. And we are working on our marketing to get the word out to as many people as possible. We have conferences, we have a textbook, and we have advertising through social media. As a nonprofit, we get $10,000 a month from Google AdWords to try to help people who are searching for us. It’s a difficult process.

We are attempting what’s called a paradigm shift in the practice of healthcare. Physicians and other healthcare professionals are reluctant to change how they practice without abundant evidence. The abundant evidence exists now. But we have to let people know. We have 200 scientific references published in 200 different journals. There’s no physician that reads 200 journals. It isn’t humanly possible. We have to bring all the information that’s available together and crystallize it into a relatively brief message and then train both medical and mental health professionals to collaborate. No medical professional is going to want to take on the task of the psychological treatment of these patients and no mental health professional can take on the job of making sure that there’s no biomedical explanation for the patient’s symptoms. It takes both the medical and mental health professionals to collaborate with each other, where the medical professional does the assessment for structural damage and the organ disease and then hands off the care of the patient to a mental health professional. Both of them need this training. They both need to learn about psychophysiologic disorders so that this giant blind spot between the mental and medical can be closed. We want the medical professional and the mental professional to communicate with each other, overlap a bit, collaborate, and understand the underlying issues well enough to do a good handoff from one to another. When we get this done routinely, the results are just magic.

We trained a group of doctors in Albany, New York. We trained a psychologist using the online webinar information that’s on our site. She then cured one of their most difficult, challenging, and frustrating patients using that technique. She then took that patient around to see all of the family doctors that the patient had previously burned out. And the family doctors were shocked at how much better she was. Three of them wanted to learn how the psychologist had done this. They took three hours of training just to get the basics because that’s all medical doctors need. All of a sudden, 40% of patients who were tremendously frustrating for them in their practices suddenly became open to improvement, open to successful treatment with the psychologist as the backup for the difficult cases. One of those doctors took me aside at a conference and said “this has put the joy back into my practice”. Now there are 72 doctors practicing this way in Albany. All doing PPD work. Collaborating with mental health professionals who have learned these techniques has absolutely transformed the care of these patients from 19th century methods to 21st century methods. That’s the wave of the future.

To close this up, is there anything else that you would like to talk about?

I went this whole interview without mentioning my first book, which is called They Can’t Find Anything Wrong. It’s written for patients and there’s information about it on my personal site stressillness.com. I should mention that all of the money from that book goes to support the nonprofit PPDA. I also donate all of the money I earn through faculty salaries, consulting fees, patient care fees, book royalties, and speaking fees. Everything gets donated so I don’t have any financial conflict of interest with this. Our nonprofit supports research in this field. We supported the Boulder Back Pain Study. We weren’t involved in running it, but we supported finances for one arm of the study. And we’re supporting another study at the medical school in Denver that’s going to be launched next year. We’re very optimistic that that’s going to add to the growing mountain of evidence about the benefit of these techniques.

Takeaways:

• All pain is generated by the brain. That does not make the pain any less real.

• There are a lot of resources out there. Check out the PPDA site (https://ppdassociation.org/).

• The majority of people with chronic pain have a psychophysiologic disorder.

• Stress comes in several forms. Stress can lead to chronic pain.

• Childhood trauma can impact your physical and mental health as an adult.

• Treating chronic pain involves addressing current life stressors, adverse childhood events, personality traits, and understanding where the pain is coming from.

• People working in medicine currently believe that a biomedical approach is the best way to treat chronic pain. Research is revealing that this is not true. We’re still learning. We’re still researching. Changes in healthcare are happening.

Huge thank you to Dr. David Clarke for doing this interview with me. I absolutely loved speaking with him. He gave me so much hope that chronic pain can be cured. I look forward to reading his books and trying out his treatment strategies. Don’t forget to check out https://ppdassociation.org/ and http://www.stressillness.com/about.php to learn more from him.