Archive for February 19, 2019

Medicine’s Next Frontier?

I just finished reading a collection of essays by a forester from Hümmel, Germany, outside of Cologne, titled The Hidden Life of Trees.  That could be a good title for a parody, but Peter Wohlleben is an earnest forester with an urgent message. He’s the first to make me believe that trees are social creatures.  And he taught me that much of the interesting life of trees takes place underground.  No wonder it’s hard to believe that trees in forests develop a symbiotic relationship with an elaborate web of fungi through which their roots communicate with the roots of other trees and share nutrients—dubbed the “wood wide web.”  It’s enough to make me think I should throw away my chain saw.

Isn’t it impressive how much time we can spend around trees without understanding one of the most basic aspects of tree life—that they are social creatures that have evolved elaborate ways of depending on each other? We know this about people and animals.  Why should it be different for trees?

This book resonates with another book I’ve been thinking about, the one I’m trying to write.  My working title, The Healer’s Blind Spot, tells you that it too is about the hidden life, in this case the life beneath the turf of our awareness where stress gnaws like a beetle infestation at the roots of our health.  The humble forester spent his career tending to one forest in central Europe, and I’m one clinician who has tended to my group of patients in the Midwest of America.  I too think I have an urgent message for the world about the hidden life.

The National Institutes of Health once declared the 1990’s would be “The Decade of the Brain.”  Before then the brain was beyond the frontier, something few of the best clinicians claimed to understand. Of course it took more than a decade, but now we can see the brain in action and we know the brain, at least the basics of how it works.  The brain was the last major organ to be mapped in detail at multiple levels of understanding, a bit like exploring our last major continent.  In my lifetime before the brain, modern medicine declared the frontier was the heart and then cancer.  In my parent’s generation the frontier was infections, antibiotics, and vaccines.  Imagine life and modern medicine without an understanding of the hidden life of microbes, the heart, cancer, and now the brain.  It’s hard to appreciate what we don’t know until we can see it.

Now that the major organs have been explored, what’s the next frontier for modern medicine?  After mapping the surface of the world, we can only go out or in.  “Out” for medicine could mean exploring out from the individual person to the social and environmental dimensions of health, a bit like exploring our place in the universe of people and environments.  How does group behavior affect individual health through families, teams, institutions, neighborhoods, and prisons?

“In” could mean exploring more deeply the genetics and epigenetics of health and illness, but we’ve already crossed into that frontier.  We’ve mapped the human genome and are starting to understand how it works.  Clones for humans are threatening and a few tantalizing clinical benefits of epigenetics are just beginning to reach the common press.

Another inward frontier that is currently harder to see than genes is the nether world of the stress response system.  This system is the ancient orchestration of our major organ systems that evolved to allow us to respond to challenges in ways that are so quick and automatic that we don’t have to think or be aware of them.  The blink of an eye, the jump in heartbeat, the flinch, the crouch, the sudden sweat—that quick, that automatic.

I saw this frontier with a new clarity a few weeks ago at a conference for psychiatrists in Orlando while attending a talk by Curt LaFrance, MD, about “functional neurologic disorders.”  The term “functional disorders” refers to a group of illnesses or syndromes that cause substantial suffering and disability but don’t fit our current measures and notions of pathology. Every specialty has at least one functional disorder, and they’re usually regarded as the orphans in the specialty’s family of illnesses.  About 5-10% of visits to these specialties are for these functional disorders, so it’s hard for specialists to ignore them, if they’re inclined to.

In neurology it’s psychogenic non-epileptic seizures and functional tremors.  In cardiology it’s atypical chest pain.  In rheumatology it’s fibromyalgia. In gastroenterology it’s irritable bowel syndrome.  In psychiatry it’s somatic symptom disorder.  Most specialists and primary care clinicians regard these disorders as orphans because they don’t fit our trained ways of thinking; they don’t reveal themselves through standard diagnostic measures; and they don’t respond to the traditional and most remunerative treatments so cherished by each specialty.

One of the themes of my book is that most doctors have a blind spot for the role that stress plays in our most common chronic illnesses such as diabetes, heart disease, and obesity.  When LaFrance flashed a slide with a table of the specialties and their functional disorders, I recognized that table as one I’ve seen many times.  But this time I saw it through the lens of this book I’m working on and asked myself what these functional disorders share in common.

The first answer that came to me was treatments.  In spite of these disorders being treated in very different specialties in a variety of ways over the years, they’re all now most effectively treated with various combinations of a) cognitive behavioral therapy, b) graded exercise or physical therapy, c) antidepressant or antianxiety medications, and d) meditation or relaxation techniques.  These are not the usual tools for neurologists, cardiologists, rheumatologists, or gastroenterologists.

The second answer that came to me from the realization that functional disorders respond to a common set of treatments was that these functional disorders share a common mechanism, a chronic dysregulation of the stress response system called autonomic imbalance.  This simply means that for too long their autonomic nervous systems have been overactivated or hyperaroused, with too little time resting or relaxing between activations.  The sympathetic nervous system is too active while the parasympathetic nervous system, which promotes rest and digestion and tissue repair, has not been protective enough.  Like an infestation of the tree’s roots and the fungal web that feeds them, autonomic imbalance destabilizes us at our roots. This condition of autonomic imbalance can be traced to many of our corrosive habits of modern life: ruminations and worry, cheating on sleep, physical inactivity, artificial stimulants, noxious diets, excessive work hours, clinging to unsafe relationships, and social isolation.  If we strain our stress response systems long enough and relentlessly enough, they falter into these disabling syndromes which we euphemistically call “functional disorders,” or diseases that are easier to diagnose, like diabetes, depression, and heart disease.

But most clinicians, even good ones, are not in the habit of thinking about the stress response system.  The stress response is invisible to us in part because we don’t have standard measures for stress in the clinic.  We don’t see the stress response system because most of the stress response occurs deep in the subconscious mind and deep in the organs we can’t see or often feel until we’re in big trouble.  We see and feel the trouble when it’s too late, after the diagnosis of a heart attack or the prescription of insulin for diabetes.

Our current understanding of our bodies and our health is like our current understanding of our global climate.  To explore the deeper oceans of our subconscious mind and our stress response system, we will need new ways of studying them and analyzing what we find.  Detailed monitoring of multiple organ system responses to multiple daily challenges across many people, often called “ecological momentary assessment,” will provide the kind of big data needed to make sense of the mysteries behind how toxic stress makes us ill.  Climate science is a big data challenge.  So is stress science.  Only in the last decade has it become possible to apply these new big data analytic approaches to understand the complexity of the stress response system in your lifespan or mine.

Imagine what that frontier can reveal to us about the hidden costs and benefits to our health of childhood trauma and prayer, unsafe neighborhoods and a belly-laugher joke, an abusive spouse and an easy hug, rush hour road rage and a note of forgiveness or thanks.  Some day these frontier mysteries could become our familiar underworld.  Imagine how it would change medical care if we could see both the crown and the roots.