Hidden Within Us: A Radical New Understanding of the Mind-Body Connection

Introduction

I am a physician, not a psychologist.

I believe this book could not be written by a psychologist because it requires a physician’s experience—as well as noticing an unrecognized phenomenon that became impossible for me to ignore.

It is widely known that the day-to-day stress adults experience can cause physical symptoms including tension headaches, insomnia, fatigue, diarrhea, and more. This stress can also lead to undesirable health habits: overeating, weight gain, substance abuse, and others.

Many also believe that day-to-day stress and emotional distress are a direct cause of chronic medical conditions like hypertension, ulcers, inflammatory bowel disease, and others, and that mind-body interventions are useful in treating or preventing them. However, an enormous amount of mind-body research performed over decades has largely failed to confirm this belief.

My clinical experience agrees with those negative findings. Yet traditional mind-body beliefs persist. In accord with those beliefs, the psychosocial history physicians are taught to obtain from patients continues to focus on their current day-to-day stress and emotional distress.

So, is there a mind-body connection? The answer is a definite yes. Yet what I’ve observed has led me to a very different understanding of this connection; one that is rarely, if ever, considered or mentioned. It is a perspective with important implications concerning our understanding and treatment of many widespread medical conditions whose cause remains inadequately understood. I wrote this book to convey that understanding and its implications.

I will present this rarely considered yet unavoidable understanding as it unfolded to me. I learned that, to a large extent, the mind-body connection does not reside in the emotions we feel and that distress us. I came to realize that an absence of emotional distress does not preclude a mind-body origin. I was surprised to observe the unsuspected involvement of much more powerful emotions that, ironically, we don’t feel, and would insist that we don’t feel.

Evidence suggests that this connection pertains to a long list of conditions (among them, hypertension, chronic fatigue syndrome, fibromyalgia, other chronic pain syndromes, colitis, autoimmune diseases, migraine, unexplained anxiety, and possibly many others) that are not well explained by medical science. I do not believe that this mind-body origin is operative in all patients with these conditions. The proportion of patients in whom a given condition is attributable to this mind-body understanding differs from condition to condition. Even so, I believe it is an unrecognized cause or contributor in many patients and offers important, yet rarely explored treatment implications.

Patients see physicians for medical problems. Physicians are trained to obtain information about a current illness, review the past medical and surgical history, and inquire about current stress and emotional distress. However, an important component that is often missing is inquiry about past psychosocial history, and particularly childhood.

A classic example of the invisibility of past psychosocial history is apparent in the standard family history we are trained to obtain at every patient’s initial visit. We ask the age of the patient’s parents. If a parent is deceased, we ask their age at the time of death. Death at an early age is often an important clue to genetic risk, a clue that is highly relevant to the patient’s care.

However, we are never trained to ask, and no medical textbook suggests that we ask, a crucial corollary question that seems obvious: How old were you when your parent died at that young age? To a child, the death of a parent is a far greater emotional stressor/trauma than is the day-to-day stress during adulthood that is our focus. But because this event occurred decades earlier, it does not draw the physician’s attention.

I found that obtaining the psychosocial history often uncovered a past history of trauma or a period of severe, prolonged stress. And listening to my patients’ stories, I was often surprised at how many of them, no matter how rough their story, were doing fine, had experienced no psychological repercussions, and had never felt the need to consult a psychologist. I began to ask patients how they had managed to make it through those rough times. This book is about their answers, and the important implications of those answers.

Listening to patients has convinced me that we are much better endowed to handle severe stress and trauma than we realize. Even though we experience severe emotional distress, we have the capacity to be unaware of truly overwhelming emotion. This capacity is a crucial, yet widely overlooked component of our emotional resilience.

I am in awe of how well-equipped so many of us are, whether we realize it or not, to get through the worst of times. Just as we are born with bodies genetically built to help us survive physically, I’m convinced, based on my patients’ stories, that we are also endowed with the means to survive emotionally. It is literally in our DNA.

Evolution had to have built this capacity into us. Given what so many encounter in a lifetime, I don’t believe humanity could otherwise have survived. It is astounding that we don’t realize we have this capacity or that it is operative.

That said, my experience with patients has also taught me that powerful emotions that we don’t feel, aren’t aware of, and don’t suspect that we harbor within us are also at the heart of the mind-body connection. They contribute to the development of many medical conditions whose cause remains inadequately understood and whose treatment remains a challenge for many. In this manner, our emotional resilience is surprisingly—and perhaps counterintuitively—intertwined with the development, even decades later, of medical illness.

In the coming chapters I will explain how I came to realize the role that our capacity to not feel plays in both our emotional resilience and in the mind-body connection. I will also describe the relevance of this understanding in the treatment of medical conditions whose origin has remained elusive—conditions where a mind-body connection has been suspected but remains unproven, and others where it hasn’t even been considered.

I will present cases that will make this understanding clear and unavoidable as well as published evidence that supports this revolutionary understanding. I hope this book will open the door to this new understanding, and with it, to new pathways to treatment, healing, and, importantly, self-healing.

I specialize in the treatment of hypertension (high blood pressure), a medical condition that has been the subject of more mind-body research than perhaps any other. The widespread belief has been that stress and emotional distress can cause hypertension and that stress reduction can alleviate it. Yes, stress and emotional distress can transiently increase anyone’s blood pressure. However, decades of mind-body research have failed to confirm that they cause sustained hypertension or that stress reduction and relaxation techniques can lead to sustained blood pressure lowering.

Ironically, in a book about the mind-body connection, I begin by stating that in the overwhelming majority of patients with relatively ordinary hypertension, the hypertension is not caused by stress and emotional distress and is not a mind-body disorder.

I have found a surprising and unexpected mind-body connection in patients with atypical forms of hypertension, including severe hypertension, unexplained episodic hypertension, or hypertension in relatively young patients. Their stories will make this understanding unavoidable, regardless of whether or not you are one of the over 100 million Americans who have hypertension.

More important, I will present observations and published evidence that suggest that this understanding is relevant to other widespread medical conditions that to this day remain inadequately understood and treated.

To protect patients’ anonymity, I have changed personal details, but the essence of their stories is preserved. It is their stories that moved me, and, in fact, compelled me to write this book.

PART 1

Noticing a New and Different Mind-Body Connection

Chapter 1

The Failure of Traditional Mind-Body Beliefs

The traditional understanding of the mind-body relationship that has dominated popular and research attention is that the stress and emotional distress that we experience are the cause of many medical illnesses. However, decades of psychosomatic research have failed to confirm this understanding. Yes, stress can indirectly contribute to illness through its effects on health habits such as overeating, smoking, substance abuse, and others. But, no, research has failed to confirm the belief that stress and emotional distress directly cause medical illness.

Two conditions that were almost universally considered to be quintessential mind-body disorders are hypertension and peptic ulcer disease. They have been the subject of psychosomatic research for decades. In this chapter I will summarize the results of that research, which make it clear, that the traditional, widely accepted mind-body understanding of these two conditions, and likely that of many other chronic medical conditions, is incorrect.

Hypertension and Stress:

Shattering the Long-standing Mind-Body Myth

Over 100 million Americans have hypertension. It is responsible for more visits to the doctor than any other medical condition. It is well-suited to teach us about the mind-body connection because measurement of blood pressure provides a physiologic telltale of the effect of emotions.

In this context, Susan’s story was quite surprising.

Susan, 56, came to me because of borderline hypertension, with systolic blood pressure readings ranging from the 120s to the 140s mmHg. The normal range, still debated, is generally considered to be less than 130, and ideally under 120. I was not ready to start Susan on medication, because if I did, she would likely remain on medication the rest of her life. I decided to defer the decision with periodic monitoring of her blood pressure both in my office and at home.

Two years later, at a routine revisit, still without medication, Susan was clearly very upset. She said her son, 32, had been diagnosed with cancer, which was likely to be fatal. He died a year later. During that year, Susan experienced severe emotional distress. She cried during every office visit. Yet despite having borderline hypertension, her blood pressure didn’t budge one millimeter, in my office or at home.

Decades of studies have consistently demonstrated that nearly everyone’s blood pressure increases in response to acute laboratory stressors such as mental arithmetic, simulated public speaking, and many others. The blood pressure rises, then quickly falls back to its baseline level.

The magnitude of the emotional distress Susan endured dwarfed by far the emotional distress experienced in those studies. Yet during months of severe stress and anguish, her blood pressure hadn’t budged.

I’ve followed the blood pressure of many patients during periods of severe stress. Though everyone tends to blame hypertension on stress, experience has taught me that stress rarely leads to sustained blood pressure elevation. Blood pressure can transiently rise, but the elevation usually is not persistent.

This consistent observation is in accord with the failure of decades of psychosomatic research to confirm a relationship between hypertension and measured levels of emotional distress, such as anger, anxiety, and depression.¹-⁴ It is also in accord with the inconclusive results of studies that have sought to prove that emotional distress contributes directly to the development of many other medical conditions.

Decades of research have also revealed that stress reduction techniques do not have persisting blood pressure lowering effects.¹ Biofeedback, progressive muscle relaxation, and stress management training have been found to be ineffective.⁵-⁶ And the results of many studies that claimed effectiveness were questionable. Many were compromised by a lack of utilization of 24-hour blood pressure monitoring; most studies predated that technology.

Over decades, thousands of studies were designed, conducted, and analyzed, not by skeptics but almost entirely by research psychologists who believed strongly that stress and emotional distress could eventually cause a persisting increase in blood pressure and that their interventions could help bring the blood pressure under control. Innumerable studies examined the widely suspected role of emotions such as anger and anxiety. Questionnaires were devised to measure perceived anger and anxiety and then assess its correlation with blood pressure and the development of hypertension.

Despite the widespread expectation of a relationship, none was found, as discussed in numerous reviews. Researchers modified the questionnaires repeatedly; the results did not change. The quality of the studies varied considerably, and, frankly, one can find studies whose results support any and every point of view. But in the aggregate, a significant relationship was not found.

Many studies have examined the role of stress—day-to-day stress, job stress, financial stress, relationship stress, and so on. Yet here as well, the expected relationship was not found.

If stress causes hypertension, one would expect job stress to be a prominent cause, given the amount of time we spend at work and the amount of aggravation we experience. In my review of the topic, most studies failed to find a significant relationship between blood pressure and job stress.⁷ Also evident was the limited quality and the cherry-picking of subgroup results in most of the studies that did report a relationship.

The most methodologically sound study in my review measured job stress and 24-hour blood pressure, then reassessed the 24-hour blood pressure five years later.⁸ It reported no relationship—not a single millimeter, between job stress and change in blood pressure from its baseline level.

If stress and anxiety don’t cause hypertension, why do so many people