Category Archives: addiction

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Adverse Childhood Experiences 7 : Revisiting Erikson

Welcome back, to Adverse Childhood Experiences, and I have been thinking about Erikson’s Eight Stages of Psychosocial Development.

These were mentioned in medical school and in residency. I was in medical school from 1989 to 1993 and in Family Practice Residency from 1993 to 1996. Family Practice is at least half psychiatry, if you have time. We are losing the time with patients in order to achieve “production”. I complained about the 20 minutes I was allotted per patient and was told that I should spend 8 minutes with the patient and 12 minutes doing paperwork and labs and calling specialists. This is why I now have my own practice. A new patient under 65 gets 45 minutes and over 65 gets an hour and my “short” visits are 25 minutes. I am a happy doctor. And on the Boards last year I scored highest in psychiatry….

So, back to Erikson. The first stage, at birth to one year is Basic Trust vs Mistrust. “From warm, responsive care infants gain trust or confidence that the world is good.”

I was taught that people would have to “redo” the stage if they “failed”. Let’s look at that a little more closely.

Take an infant in a meth house. No, really, there are babies and small toddlers that have addict parents, alcohol, opiates, methamphetamines. We do not like to think about this.

A social worker told me that the toddlers from a meth house were really difficult to deal with. They do not trust adults. The first thing they do in foster care is hide food.

Hide food? Well, adults on meth are not hungry, sometimes for 24 hours or more, and they are high. So they may not feed the child.

Now, should this child trust the adult? No. No, no, no. This child is adaptable and would like to survive. So even under three they will learn to hide food. In more than one place. This is upsetting to foster care parents, but perfectly understandable from the perspective of the child.

So has the child “failed” the first stage? Well, I would say absolutely not. The child looked at the situation, decided not to starve and learned not to trust adults and hid food. Very sensible. Adaptive.

Is the child “damaged”? That is a very interesting question. After 25 years of family practice medicine I would say that no, the child is not damaged. However, the child has started out with a “crisis” brain. The brain is plastic, all our life, and so this child did what was needed to survive.

Is the child “sick”? Again, I would argue no, though our society often treats the child as sick. We think everyone should be “nice” and “warm” and “why isn’t he/she friendly?” Well, if you started in an addiction household or a crazy household or a war zone, it would not be a good adaptation to be warm and fuzzy to everyone.

How do we treat the adult? In a warm fuzzy nice world the child would have a foster parent who adored them, was patient with them, healed them and they would be a nice adult. I have a friend who said that foster care was so bad that he chose to live in an abandoned car his senior year rather than stay in foster care. He couldn’t play football because he had to get back to the car and under the layer of newspapers before it got too cold. I am sure that most foster parents are total wonders and angels. But some aren’t.

I have a person who says that he lived on the streets from age 8. He did get picked up and put into foster care. He kept running away. “The miliary loved me because I could go from zero to 60 in 60 seconds.” That is, he has crisis wiring. He is great in a crisis. The military is a sort of a safe place, because it has rules and a hierarchy and stands in for the failed parenting. Expect that then you get blown up by an AED in Afganistan and hello, that makes the crisis wiring worse.

How DO we treat the adult? We treat them horribly. We say why can’t this person be nice. We diagnose them we drug them we shun them we isolate them we as a society discriminate against them deny them and we are a horror.

I get so angry when I see the Facebook posts where people say “surround yourself with only nice people”. Ok, how dare you judge someone? You don’t know that person’s history. You don’t know what they grew up with. How dare they say that everyone should be NICE.

I am a Veteran’s Choice provider. I have 6 new veterans in the last 3 months. I suspect I will get more. They are not “NICE”. They come in suspicious, hurt, wary, cadgy. And I don’t care, because I am not “NICE” either. We get along just fine.

When I run into someone who isn’t “NICE”, I think, oh, what has happened to this person? What happened to them when they were little? What happened to them as an adult? How have they been hurt?

Pema Chodron writes about sending love: to your loved ones, to a friend, to an acquaintance, to a stranger, to a difficult person and to an “enemy”.

Send love. And do something about it. Help at your local school, help families on the edge, help single parents, sponsor a child to a sport if their parents can’t afford it, pay for musical instrument lessons, do Big Brother/Big Sister, become a “grandparent” to a child at risk, be a good foster parent, donate to addiction care….

The photo is from 2007, when my children and I visited their father in Colorado. A stranger in the parking lot took it at our request…..

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Songs to raise girls: Dark as a Dungeon

We sang Dark as a Dungeon as a family song and at singing parties from when my sister and I were very little. We learned many of the songs before we knew what the words meant. At some age I considered this a cautionary song and was glad that my father was not mining coal. I also decided that I didn’t want to mine coal.

It was written by Merle Travis, whose father was a miner in an Appalachian shaft mine: https://www.youtube.com/watch?v=-FPmSLzsbdM&list=RD-FPmSLzsbdM#t=1. Johnny Cash sang it: and Willie Nelson: https://www.youtube.com/watch?v=nKGCKwACj1I and Willie Nelson https://www.youtube.com/watch?v=s66nbyzqq8o. It became a protest song, to fight for safer conditions. We learned this and Drill ye Terriers, Drill and Sixteen Tons, so we were raised on protest songs.

The song words have morphed a little, since we sang from memory. Here is our version:

Come all ye young fellows so young and so fine
And seek not your fortune in the dark, dreary mines
It will form as a habit and seep in your soul
‘Til the stream of your blood runs as black as the coal

Where it’s dark as a dungeon and damp as the dew
Where the danger is double and the pleasures are few
Where the rain never falls and the sun never shines
It’s dark as a dungeon way down in the mines

I wrote an essay in college about a song that I learned from my mother. I researched versions of Green Grow the Rushes Oh. I had always wondered about some of the verses, because it’s a counting song, from one to 12. Twelve for the twelve apostles and eleven for the eleven that went up to heaven. In an atheist household it takes a while to figure out the meaning of apostle. But other verses are mysterious to this day: nine for the nine Bright Shiners and eight for the April Rainers. In oral traditions if you forget a verse you make up a new one.

There’s many a man that I have seen in my day
Who lived just to labor his whole life away
Like a fiend with his dope and a drunkard his wine
A man will have lust for the lure of the mine

The comparison ofΒ  mining to addiction impressed me: “it will creep in your soul, til the stream of your blood runs as dark as the coal”. “Like a fiend with his dope” — opiate addicts were called fiends. And people were called drunkards. So this song also made me cautious about both drugs and alcohol.

We didn’t learn the third verse:

The midnight, the morning, or the middle of the day
It’s the same to the miner who labors away
Where the demons of the death often come by surprise
One fall of the slate and you are buried alive

The last verse interested me. I liked the idea of bones turning to coal over time. My parents were atheists and did not go to church, but there were lots of songs that talked about God or heaven or the devil: including sacred music. We went to big chorus rehearsals when my parents couldn’t find a sitter and we were expected to behave politely during concerts: The Messiah. And we got to go to operettas. I saw Ruddigore in Ithaca at Cornell when I was 5 and the ancestral ghosts stepping out of their portraits and singing was terrible and wonderful.

I hope when I’m gone and the ages shall roll
My body will blacken and turn into coal
Then I’ll look out the door of my heavenly home
And I’ll pity the miners A-diggin’ my bones

The photo is my father’s family and he is in the back, first trumpet. This is the Bayers Family Orchestra. My great grandfather is conducting, my grandmother on violin and my grandfather on saxophone. They became a band when my grandparents moved away, because my grandmother was the only string player.

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Causes of Death in the United States in 2012

When I first started doing annual physicals I sat down and looked at the top causes of death and then organized the counseling part of the physical around them: starting with heart disease and working down the list. I think of the annual physical as my opportunity to “MOM” patients and say “STOP DRINKING LIKE A FISH OR YOU GONNA DIE EARLY,” though perhaps with a little more diplomacy. Sometimes without much diplomacy at all.

The top ten causes of death in the United States in 2012 were heart disease, cancer, chronic lower respiratory diseases, stroke, unintentional injuries, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide.

http://www.cdc.gov/nchs/data/databriefs/db168.htm#which_population

This is 2,543,279 deaths in 2012.

Let’s take the causes one by one.

Heart disease: This is number one. 599,711 deaths. 23.6% of total deaths all ages both sexes in the US in 2012. So that is where I start when I do the counseling part of a physical.

Let’s review heart disease risk factors:
hypertension
high cholesterol
family history
diabetes
kidney failure
lack of exercise
tobacco
alcohol
smoking other things…
illegal drugs
stress
obeisity
As you might guess, this part of the discussion can use up a lot of the visit….

Cancer: All the cancer deaths together are 22.9% of the 2012 total.
We can screen for a few cancers: lung cancer is now the number one killer for both sexes. A chest xray is useless for screening. There is a certain population of current or former heavy smokers where a screening CT is useful. No, I do not recommend a “screening full body CT”, that is crap. Yes, lung cancers do get picked up randomly when we do a chest film for some other reason.
We can screen for breast cancer, colon cancers, look for skin cancers, the prostate cancer screen is a counseling nightmare and I don’t recommend a PSA but will do one if the person wants and other cancers pretty much we have to watch for symptoms….stop smoking, ok? That’s what causes 70% of the lung cancer and breast cancer used to be number one in women but smoking made lung cancer beat it out….
If you want details about any screening test, go to the US Preventative Task Force site:
http://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care

Chronic lower respiratory diseases at 5.6%: ok, smoking again. Emphysema and chronic obstructive pulmonary disease, AKA COPD. Asthma too. This article is fascinating, that third generation children of smokers in a polluted part of California are worse and have inherited genetic modifications than third generation children of non-smokers who live in a less polluted part of California. Lovely. I grew up in a two pack a day camel household and no wonder my lungs are tricky.

Stroke, also called CVA, cerebrovascular accident, at 5.1% and then there are TIAs, transient ischemic accidents, the stroke warning symptom.

What are the risk factors for stroke?
Oh, smoking of course
hypertension
high cholesterol
stress
lack of exercise
obeisity
blocked carotid arteries
blood clots
atrial fibrillation

Unintentional injuries at 5.3%, also known as accidents.

Deaths from prescription medicines taken correctly outstripped deaths by MVAs, motor vehicle accidents and guns in 2007. The CDC declared an epidemic of overdose deaths, but it’s just starting to creep into newspapers and public consciousness.

Here: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

The unintentional injury counseling list includes:
wear your seatbelt
don’t drive inebriated
don’t get in the car with inebriated drivers
check your smoke alarms
in the elderly, decrease fall risk. don’t stack stuff on the stairs.
wear a helmet if you bicycle motorcycle ATV rollarblade ski or invent some new way of getting on the Darwin list. Base jump, for example.
don’t take a lot of controlled prescription medicines or combine them with each other or combine them with alcohol: opiates with benzodiazepines with alcohol with ambien or sonata with barbituates and hello, the drug dealer is not your friend and tells lies: they are cutting the methamphetamines here with tricyclic antidepressants and barbituates and my long term cocaine addict patient was getting methamphetamines with benzodiazepines when he was paying for cocaine. Really.

Alzheimer’s at 3%

This is moving up the list. Fast. Everyone dies of something. Alzheimer’s patients live an average of seven years from diagnosis….And the recent article about Human Growth Hormone transmitting not only prions but Alzheimer’s is really interesting, implies an infectious cause.

Here: http://www.nature.com/news/autopsies-reveal-signs-of-alzheimer-s-in-growth-hormone-patients-1.18331

That was HGH from cadavers. I still would not take HGH made in a lab for “anti-aging” either. Nope, nope, nope.

We don’t know how to prevent Alzheimer’s but that is not the only cause of dementia and we’re still naming different kinds. Very frequently a brain CT or MRI says “decreased white matter” or “small vessel disease”, so there is a contribution from all of the heart and stroke risk factors that can do bad things to the brain with the top ones being: tobacco, alcohol, hypertension, high cholesterol, stress, lack of exercise, diabetes, illegal drugs, and so forth. Keep your brain active and busy.

Diabetes at 2.9%
Ok, it can make you more likely to have a heart attack. Also the biggest cause of blindness in US adults and the biggest cause of lower limb, yes, foot or leg amputation and the biggest cause of kidney failure in adults. Also if your legs are numb from uncontrolled diabetes, you don’t feel injuries and are less able to heal infections. And if blood sugar is high, there are lots of bacteria and especially staph and strep that LIKE high sugar.

influenza and pneumonia at 2.1%

Get Your Flu Shot. Really. And if you are 65 or older or you have tricky lungs or you have a tricky heart, get the pneumovax shot. The pneumovax protects against pneumococcal pneumonia ONLY, not all the colds or influenza or hemophilus influenza. And get your Tdap, because that stands for Tetnus, Diptheria, acellular Pertussis. Pertussis is whooping cough. It’s back. We’ve had three outbreaks in our county in five years. It kills babies under six months. They don’t whoop, they just stop breathing, apnea. Other people whoop, but even with antibiotics, they can cough for MONTHS. The flu shot usually gives 80% protection by two weeks after the shot. Only 80%, people say? Well, are you perfect?

Kidney disease at 1.8%

Causes: kidneys get worse as we age, for one thing.
diabetes
supplements and drugs: kidney failure is on the rise! Everything that we absorb and metabolize is metabolized by either the liver or the kidneys. Liver function can be perfect at age 100: that is, if it has not been trashed by alcohol, hepatitis B or C, drugs, supplements, mushrooms, whatever. Kidney function usually drops by age 80 and I am there calculating the function before I choose an antibiotic because you have to use lower doses in the over 80 crowd and the early kidney failure crowd. If you take ANY PILLS you should have a yearly test of your kidneys and liver function.
infection can hurt kidneys
inherited disorders

Suicide at 1.6%
40,600 deaths in the United States in 2013

Risk Factors http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

Family history of suicide
Family history of child maltreatment
Previous suicide attempt(s)
History of mental disorders, particularly clinical depression
History of alcohol and substance abuse
Feelings of hopelessness
Impulsive or aggressive tendencies
Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
Local epidemics of suicide
Isolation, a feeling of being cut off from other people
Barriers to accessing mental health treatment
Loss (relational, social, work, or financial)
Physical illness
Easy access to lethal methods
Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

And for those who want in depth information, 15 leading causes of death by state:
http://www.cdc.gov/nchs/nvss/mortality/lcwk9.htm

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Chronic pain update 2015

As a rural family practice physician, I am in an area with very few specialists. Our county has a 25 bed hospital and we have a urologist, three general surgeons, three orthopedists (except when we were down to none at one point), two part time hematologist oncologists and that’s it. We have a cardiologist who comes one day a week. We have a physicians assistant who worked with an excellent dermatologist for years: hooray! Local derm! Our neurologist retired and then died. We had two psychiatrists but one left. We had one working one half day a week.

I trained in treating opiate addiction with buprenorphine in 2010 and attended telemedicine with the University of Washington nearly weekly for a year and a half. Then life intervened. I attended last week again, but not the addiction medicine group. That is gone. Now there are two telemedicine pain groups.

And what have I learned since my Chronic pain update 2011?

Chronic opiates suck, and especially for “disorders of central pain processing” which includes fibromyalgia, reflex sympathetic dystrophy, TMJ, chronic fatigue, and all of the other pain disorders where the brain pain centers get sensitized. We don’t know what triggers the sensitization, though a high Adverse Childhood Experience score puts a person more at risk. Cumulative trauma? Tired mitochondria? Incorrect gut microbiome? All of them, I suspect.

Jon Kabot Zinn, PhD has been studying mindfulness meditation for over 30 years. He has books, CDs, classes. Opiates at best drop pain levels an average of 30%. His classes drop pain levels an average of 50%. I’ve read two of his books, Full Catastrophe Living and ….. and I used the CD that came with the former to help me sleep after my father and sister died. Worked. Though I used the program where he says, “This is to help you fall more awake, not fall asleep.” Being contrary, it put me to sleep 100% of the time.

Body work is being studied. Massage, physical therapy, accupuncture, touch therapy and so forth. It turns out that when you have new physical input, the brain says, “Hey, turn down the pain fibers, I have to pay attention to the feathers touching my left arm.” So, if you have a body part with screwed up pain fibers, touch it. Touch it a lot, gently, with cold, with hot, with feathers, a washcloth, a spoon, something knobby, plastic. Better yet, have someone else touch it with things with your eyes closed and guess what the things are: your brain may tell the pain centers “Shut up, I’m thinking.” Well, sensing. A study checking hormone blood levels every ten minutes during a massage showed the stress hormone cortisol dropping in half and pain medicating hormones dropping in half. So, massage works. Touch works. Hugs work. Go for it.

There are new medicines. I don’t like pills much. However, the tricyclic antidepressants, old and considered passe, are back. They especially help with the central pain processing disorders. I haven’t learned the current brain pathway theories. The selective serotonin uptake reinhibitors (prozac, paxil, celexa, etc) increase the amount of serotonin in the receptors: chronic pain folks and depressed folks have low serotonin there, so increasing it helps many. As an “old” doc, that is, over 50, I view new medicines with suspicion. They often get pulled off the market in 10 to 20 years. I can wait. I will use them cautiously.

We are less enthused about antiinflammatories. People bleed. The gut bleeds. Also, the body uses inflammation to heal an area. So, does an antiinflammatory help? Very questionable.

Diet can affect pain. When I had systemic strep, I would go into ketosis within a couple of hours of eating as the strep A in my muscles and lungs fed on the carbohydrates in my blood. This did not feel good. However, the instant I was ketotic, my burning strep infected muscles would stop hurting. Completely. I am using a trial diet in clinic for some of my chronic pain patients. I had a woman recently try it for two weeks. She came back and said that her osteoarthritis pain disappeared in her right hip entirely. She then noticed that the muscles ached around her left hip. She has been limping for a while. The muscles are pissed off. She ate a slice of bread after the two weeks and the right hip osteoarthritis pain was back the next day. “Hmmmm.” I said. She and I sat silent for a bit. It’s stunning if we can have major effects on chronic pain with switching from a carb based diet to a ketotic one.

I attended one of the chronic pain telemedicines last week and presented a patient. My question was not about opiates at all, but about ACE scores and PTSD in a veteran. The telemedicine specialists ignored my question. They told me to wean the opiate. He’s on a small dose and I said I would prefer to wean his ambien and his benzodiazepines first. They talked down to me. One told me that when I was “taking a medicine away” I could make the patient feel better by increasing another one. As I weaned the oxycodone, I should increase his gabapentin. I thought, yeah, like my patients don’t know the difference between oxycodone and gabapentin. No wonder patients are angry at allopaths. I didn’t express that. Instead, I said that he’d nearly died of urosepsis two weeks ago, so we were focused on that rather than his back pain at the third visit. All but one physician ignored everything I said: but the doctor from Madigan thanked me for taking on veterans and offered a telepsychiatry link. That may actually be helpful. Maybe.

And that is my chronic pain update for 2015. Blessings to all.

http://www.cdc.gov/violenceprevention/acestudy/

http://www.umassmed.edu/cfm/about-us/people/2-meet-our-faculty/kabat-zinn-profile/

I can’t think of a picture for this. I don’t think it should have a picture.

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Chronic pain and antidepressants

Continue reading →

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Phoenix Rising

P for Phoenix, for the Blogging from A to Z Challenge. This post is for Amanuensis Sobriquet-Reverie. Her poem today “Burn the witch” brings up present and past difficult memories. Here is the poem I wrote about it in 2003.

Phoenix Rising

Set a torch to me
Why don’t you?

It’s not the tearing sound of fabric
A small rip
And now a tear
That I feel

It’s the torch

I’ve been here before
A job where the idealistic came
As moths to the flame
Self-immolation
Because they had ideals

I watched and burned and rose

It’s the torch
The flames that rise
As the witch is burned
Tilts back her head
In ecstasy and knowledge
Eager to learn what she can
From these burning brands

In the burning we learn
In pain we learn
If we can remain open
Ashes fall to the ground
Buckets of water
Wash any remains to grey mud
Gone, punished
Relief for the frightened
An example has been set

No but what stirs at night
Moon or none
What rises from the mud
The ashes
Takes form
Takes flight
Laughing

Set a torch to me
Why don’t you?
And see what is created

a local bookstore
previously published on everything2.com

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Hurt and healing

H is for healing and hurt in the Blogging from A to Z. I mentioned dreaming of monsters in my Gift post, and this is the poem about that dream. It is hard work to heal.

Advice to Micheal

Neverland
Is such an ironic name
Can’t they hear?
Can’t they think?
The land where boys never grew up
The Lost Boys

And you
Are not molesting
Boys
You are
Searching
When I heard
About your childhood
I knew
They were wrong
They’ve missed the boat

You sang
Like an angel
And the world
Stole your childhood

Hotel rooms
With older brothers
Sex
Drugs
Alcohol
Money
Chaos
And you must have been
So frightened
Lost
Pressure to sing
As the star

Locked your core self away
To keep it safe

My childhood
Was scary too

I started my search
With a dream
Of a dark hole
From which came the sound
Of monsters
Howling

I was scared

I went to the hole
anyway
scared
of the howling

The hole was dark
And roots stuck out of the side
Like reaching fingers

I got a flashlight
And looked

It wasn’t as deep
As I thought
And the roots worked as
A ladder

I climbed down
Into the hole

I found three monsters
Howling

Baby monsters

I put them in my pack
And carried them up
Into the light

They howled

I bathed them
And diapered them
And fed them
And rocked them

They howled
They didn’t know what to do
When taken care of

I named them
Fear
Grief
Shame

At last they stopped howling
And sat
Warm
Wrapped in blankets
Ugly
Sullen
Lower lips thrust out

And I found a shrink
To talk about my dream
And to help heal the monsters
That I had rescued

We always have more
Work to do
But now I have a little girl
Inside me
Who came to greet me
When I had healed the monsters
Enough
She is beautiful

You won’t find
The Lost Boy
That you are looking for
Outside you
He is inside
He is innocent
And beautiful

You may have to face
The monsters
Of your childhood
To reach him
Yours was worse than mine
I’m sorry

You may have to face
How much people you loved
Hurt you
Even though they loved you
I’m sorry

Find help
And rescue
The Lost Boy
And joy

Good luck.

Poem written August 10, 2005. Previously published on everything2.com.

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Love in Ten Sentences

Janebasilblog nominated me for this challenge and I finally have done it. Now to tag ten MORE people…..

Details of the challenge: Write a 10 line poem with four words to each line, and each line must contain the word β€˜love’. Nominate 10 people to carry on the challenge.

love complicates my life
love and don’t like
behavior not deserving love
love pours forth anyhow
love feels deep hurt
love withdraws lick wounds
love heals ventures forth
less contact mean loves
behavior change brings love
complicated joy : love anyhow

I still need to nominate ten people to carry on and write the NEXT love in ten sentences. I will add that…

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Adverse Childhood Experiences 4: Psychophysiological Illness

I went to the 46th Annual OHSU Primary Care Review, held at the Sentinel Hotel in Portland, Oregon last week.

It was excellent. It was surreal since the Sentinel Hotel started as a 1923 Elks’ Club and the satyr cupid friezes kept distracting me with the marble penises and war chariots during the lecture updating us on urinary incontinence.

Three lectures that I went to talked about Adverse Childhood Experiences.

This is the first conference that I’ve been to that anyone has talked about that study since I heard about it, in about 2005. I have not been to a lot of big conferences over the last few years because I opened my own clinic and money was tight.

Anyhow, the study is creeping into consciousness.

In the mornings, we had the big lectures in a large hall. There were three break out sessions in the afternoon, held in the main meeting, billiard room, club room and library. We all joked about Colonel Mustard and candlesticks.

A gastroenterologist, Dr. David Clarke, gave a two hour session titled “Hidden Stresses and Unexplained Symptoms II”.

Objectives:
1. How to uncover the cause of an illness when diagnostic tests are normal.
2. How to find hidden psychosocial stresses that are responsible for physical symptoms.
3. The process used to achieve successful outcomes in stress-related illness.

He talked about childhood stress. That if someone had a really difficult childhood:
“Surviving a dysfunction home is a heroic act and produces individuals who are:
a. reliable and get things done
b. detail-oriented
c. Perfectionist
d. Hard-working
e. Compassionate”

So what is the down side? “Surviving a dysfunctional home also produces emotional consequences that may lead to :
a. Long-term relationships with partners who treat you poorly.
b. Addictions to nicotine, Alcohol, Drugs, Food, Sex, Gambling, Work, Shopping, Exercise.
c. Quick Temper or being violence prone
d. Anorexia and/or bulimia
e. Mental health problems such as nervous breakdown or suicide attempts
f. Sacrificing your own needs to help others
g. Self-mutilation
h. Learning not to express or feel your emotions.”

Got that? Right. Not everyone, not all the time, but the adverse childhood experiences add up. These reliable individuals may eventually get enough positive feedback to decide that they deserve a relationship that is actually good. They may get angry about their childhood or past bad treatment. “They may have a really hard time expressing that anger because they spent years learning how to suppress emotion and the feelings may be directed at people for whom there is still some caring. When there is enough of this anger present it can cause physical symptoms that can be mild or severe or anywhere in between.”

Let me give two examples from my own practice. I can’t remember their names or the details, so I am making those up: no hipaa violation.

The first was an elderly woman who came in with her husband for stomach pain. We started with a careful history. We tested for helicobacter pylori. We tried ranitidine. We tried omeprazole. We studied her diet and did an ultrasound to rule out gallbladder disease.

At the third visit I was starting to talk about an upper endoscopy. This was more than 15 years ago, back when we did not start with a CT scan. Her husband said, “Doctor, is there anything else it could be?”

I was surprised. “Well, yes. Depression is on the diagnosis list. Sometimes depression can present as stomach pain. Could you be depressed?”

My elderly lady covered her face with her hands, started crying and said, “I try not to be!” while her husband nodded.

We cancelled the endoscopy. I said it really was not something to be ashamed of and we talked about therapy. She did not want talk therapy and we tried paxil. She came back in two weeks, and already she and her husband were brighter and relieved.

Second case: again, stomach pain, this time in a four year old. Mom brought her in.

I did a history and did a gentle exam. The exam was normal. Her stomach was not hurting now. She wouldn’t say anything.

We established that the stomach pain occurred on week days only, not on the weekend. In fact, usually at the after school daycare, not in school.

“Is there a time at the school daycare that she has stomach pain?” Mom was shaking her head when big sister piped up.

“It happens before recess.” Mom and I turned to stare at the six year old.

I said, “What happens at recess?”

“The big kids knock her down,” said big sister, pissed. “I try to stop them, but they are bigger than me. She’s scared. The teachers don’t see.”

“Oh. Thank you for telling us!” Little sister was crying and mom hugged her and big sister. Mom did not need instruction at that point. She called me a few days later. She talked to the daycare, they watched and the four year old was protected. Her stomach stopped hurting.

Dr. Clarke also described a case, where driving through a town would trigger four days of nausea and vomiting that required hospitalization. This had been going on for 15 years. He figured out why that particular town was a trigger: when the patient recognized the why, he was able to go for therapy.

People aren’t lying about these illness, they are not making them up. Doctors have called it somatization, but really it is the body holding the emotions until the person is safe enough to deal with them. Doctors need to learn how to recognize this and help with respect instead of stigmatization and dismissal.

I hope that more doctors learn soon…

Dr. Clarke’s list for further reading is below. I don’t have any of these yet, but they are on my wish list.

They can’t find anything wrong!, by David Clarke, MD. See also www.stressillness.com

Psychophysiologic Disorders Association: www.ppdassociation.org

Caring for Patients, Alan Barbour, MD

Unlearn Your Pain, Howard Schubiner, MD

Pathways to Pain Relief, Frances Anderson PhD and Eric Sherman PhD

Ted talk about ACE scores: http://www.acesconnection.com/blog/nadine-burke-harris-how-childhood-trauma-affects-health-across-a-lifetime-16-min

by

Angel Witness

Sometimes
Even as you make
The same mistake
Cross the threshold
Open the door
Lift the glass

You feel the presence
Of angels
Drawn by the seriousness
Of your decision

Present
Not to pull you away
From the cup
The drug
The wrong man
The dire pattern
You feel their intensity
The presence
As if outer space
Has clung to their wings
Or motes from heaven
Alien
The weight of their gaze
And their interest

Sometimes
Even as you make
The same mistake
It’s not the same
To sense an angel
Witness

previously published on an obscure writing site