National University Podcast Series

WPC Ep. 9: Chronic Pain and Functional Neurological (Previously Known as Conversion) Disorder: A Psychological Perspective

• Dr. Andrew Martin • Season 1 • Episode 9

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WPC Intern Jennifer Brown interviews Dr. Andrew Martin on the psychological perspective of chronic pain and functional neurological disorder.  

SPEAKER_00:

Welcome to the Whole Person Center podcast. Our mission is to improve the human condition by providing resources, research and training opportunities, and direct health services while supporting the development of highly competent professionals.

SPEAKER_01:

Hi everybody, my name is Jennifer Brown. I am an intern at National University, and I'm currently interning at the Whole Person Center. And today it is my great privilege to collaborate with a pain psychologist, and his name is Dr. Andrew Martin. Dr. Martin, can you please tell us a little bit about yourself?

SPEAKER_02:

Sure. And uh thank you, Jennifer and Dr. Bickler, and thank you for all your listeners today for tuning in. It's great to get to talk about this topic, and I'm looking forward to it. So I've been in practice for a little over 20 years. Uh in the beginning, I practiced general psychology, so just treating depression and anxiety, doing some psychological testing. Then a few years ago, I started working in more medical settings where I got exposed to chronic pain and other physical problems that cause a lot of emotional distress. And it was around that time that the psychological treatment of chronic pain began to really take off. And as your listeners can probably imagine, that has a lot to do with the opioid crisis, people looking for non-medicine solutions to chronic pain. And so now I work on the interventional pain management team at the Orthopedic and Spine Center of Newport News, Virginia.

SPEAKER_01:

So what made you decide to work on pain psychology and chronic pain?

SPEAKER_02:

It was late in my career with the Navy. I worked at a traumatic brain injury clinic. And there we had a lot of chronic pain and a lot of neurological symptoms. And so it was important for us to collaborate with other medical providers. And I started to see how valuable it is for psychology to be on a team, even if the team's really treating a medical issue like chronic pain, we have a lot to contribute. And working together, patient outcomes are almost always better. And then from there, when I got out of the Navy, I looked around for other places where I could use those new skills, and that's how I landed working in chronic pain.

SPEAKER_01:

Thank you for answering that. And also for people that don't know me very well, I was also in the Navy. I was a hospital corpsman, and I also worked in a traumatic brain injury clinic. So I do know a little bit of what it's like to work with patients who also have PTSD as well as chronic pain. And also the clinic that I worked with was working with people who were amputees, so they would actually help create the uh the things that people would use to help walk again, to help use you know, their general movements, and it was really uh very impactful. And it was just at the Naval Medical Center in San Diego, so it's really amazing what the Navy is offering to people now. Can you briefly explain how physical and psychological triggers can exacerbate pain?

SPEAKER_02:

Sure. So it has to do with the fight or flight response. That's something a lot of your listeners have probably heard of before. Um, and anything that's stressful can set off the fight or flight response. That then can worsen pain and other physical and emotional problems. So our ancestors developed this automatic physical response to danger called fight or flight. And what happens is blood flow and oxygen increase to the large muscle groups, our hearts beat faster, our breathing gets faster, and we get ready to fight or run away from a threat. And it all happens without us even having to think about it. So the problem with a fight or flight response is the part of the brain that triggers it doesn't know the difference between a tiger chasing us through the jungle back then and some of today's chronic emotional and physical stressors, like pain. It reacts the same way. So that means that even if we don't need to be in fight or flight, our body is in fight or flight. As you can imagine, that can really wear on us over time and make emotional and physical problems even worse. And the fight or flight response includes changes to the brain too. It forces us to focus only on the threat. And in the case of pain, you may have heard people say, when the pain is bad, I can't focus on anything else. Well, that's by design. The brain wants us to keep all of our attention on the threat to give us the best chance of survival. Unfortunately, with pain, that means our brain opens up to as many pain signals as possible, greatly increasing our felt pain. And then we see that relationship between stress and pain in other ways too. For instance, sometimes I'll treat somebody, say, for a sexual assault, for PTSD, post-traumatic stress disorder, and then a few weeks later they come in and say, Hey, my chronic back pain is gone. Well, their pain is still there because there's something wrong with their back. But the volume has been turned down because their system isn't in fight or flight mode all the time, staring down that pain. Um, they've relaxed their nervous system so much that now they don't feel it as much. And we see that in a lot of interesting studies, and I'd like to mention a few of them. A lot of people have probably heard of placebo studies. Placebo is a fake medication, right? So you give we give the research participants a sugar pill and we tell them this is powerful pain medication. And then they report their pain goes down, even though it's just a sugar pill. And the opposite can happen too. We can give people a powerful pain medication, tell them it's just a sugar pill, and they'll say, Yep, my pain didn't change at all. Clearly, that says that somehow the brain is involved with how much pain we feel. Now, this isn't anybody's fault. This is something that just happens unconsciously. In World War II, an army doctor was so blown away by something he observed that he wrote a paper about it. He treated villagers and U.S. soldiers in the town that got hurt really bad. And he noticed something really strange. The soldiers, the US soldiers, they didn't ask for much pain medication, didn't report much pain. The European villagers, lots of pain medication they were asking for, lots of pain. So, you know, what do you think is the difference there? Well, if you're like me, your first thought was, well, the soldiers are tougher, and you know, they signed up for this. But these were really bad injuries. These were beyond tough guy and training type of injuries. The difference was that the soldiers' injuries meant that they were going home from the war. The villagers' injuries meant that they were now maimed, living in a war zone. That changed the activity that was going on in their thoughts and emotion centers, which then changed how much pain they were experiencing. One was still very much in fight or flight mode, the other was starting to relax from that. A great another example is coping skills training. I can teach people how to use coping skills for chronic pain, they never use any of them, and they still report their pain going down. I'll say that one more time. I can teach people lots of coping skills for dealing with chronic pain, they never use any of them, and they still report that their pain goes down. That's probably because just the idea that something might be able to help them is relaxing their nervous system until they're feeling less pain when they're like that. Um, and this all that happens because just the belief that some relief is available or on its way calms us down and stops us from staring at the threat or the pain.

SPEAKER_01:

That's really interesting because I've actually taken a couple of positive psychology classes, and it's kind of based off of the idea that uh something positive and something meaningful and valuable can happen in someone's life, and that can really impact uh our well-being in a different way. You know, it's not focused on illness and psychological distress or anything, it's really focused on the positive things, and that that's really encouraging knowing that just some somebody mentioning something to you can actually improve our well-being, even though we may not even be open to the idea of it actually helping. All right. Our next question is based off of your perspective, explain what F and D is, which is also functional neurological disorder and its relationship to pain.

SPEAKER_02:

So uh this is from the Diagnostic and Statistical Manual for Mental Health and Psychiatric Disorders. So their definition is functional neurological disorder involves one or more symptoms of changed voluntary movement or sensory function, where a physician has shown that those symptoms are incompatible with the neurological disease that would normally go along with that symptom. So typical symptoms include things like unexplained muscle weakness, paralysis, uh, abnormal movements like tremors. Uh, it can be swallowing and speech problems, mysterious attacks or seizures, uh, loss of feeling, or sensory problems like visual, smelling, or even hearing problems. So hearing that, some people might think, okay, so the person's making this stuff up. But that's not the case. That's a totally different issue and it's very rare. With functional neurological disorder, it's believed that people are not intentionally producing those symptoms. Because those symptoms are really inconvenient. The symptoms themselves are a great source of distress for people with a lot of functional impairment. What's going on is the person's unconscious mind might be creating the symptoms, but that's not within their control, so it's not their fault. The symptoms aren't their fault. Just because a doctor can't explain it doesn't mean that it's your fault. So we don't know how common functional neurological disease is because it takes a lot of steps to make the diagnosis. You've got to have mental health people involved, you've got primary care, multiple specialists, so it's not very easy to research. We do know that transient functional neurological disorder symptoms are pretty common, but the sustained symptoms are more rare. What we of what we do know, it happens in about two to five people per 100,000. Now in a neurology clinic, uh, functional neurological disorder is a little more common, but still pretty rare. They say that about 5% of the patients who come in to see them wind up having functional neurological disorder. So, how does it work? Is the is the next question. What's going on? Why is the unconscious doing this? Uh well, it helps to start with what does it look like when everything's working well for us emotionally? So, to function well emotionally, we need to be able to do a lot of different things, all many of them automatically. We need to know when we're under stress. We need to know what we're feeling, we need to help ourselves, and when we can't help ourselves, ask others for help and maybe be able to accept their help. Uh, we need to be able to avoid things that are stressful to us. A lot can go wrong in that process, especially if somebody goes through a lot of emotional or even physical trauma, especially in childhood. So if any of those processes are compromised, it's thought that with functional neurological disorder, the unconscious mind is trying to fill in the gaps to accomplish those steps using the body. Maybe something going wrong with the body is a call for help, or maybe that thing going wrong is helping the person avoid a feared situation that they don't know how to avoid otherwise. Something else that supports this theory is people's reaction to psychotherapy. When folks with functional neurological disorder undergo psychotherapy and resolve some of their emotional conflicts, those symptoms often reduce significantly. Not always completely, but usually a lot of them go away. And people with functional neurological disorder will often tell you that their symptoms are worse when they're emotionally stressed. And later on in our conversation, I'll share a way that they can track that relationship.

SPEAKER_01:

What is it like working with people with F and D Sure.

SPEAKER_02:

So as a practitioner, it's important to offer a lot of reassurance that what they're experiencing is not their fault. Um, it's also important to help them understand they're not alone because this can be a very lonely diagnosis. You don't hear about it much, people don't talk about it much, um oftentimes it's very frustrating to interact with the medical system with that diagnosis. So a lot of empathy for those issues. And in fact, uh sometimes I'll recommend a support group because what better way to realize you're not alone than to sit in a room full of people who are experiencing what you're experiencing.

SPEAKER_01:

Do you think that people with chronic pain can have worsening functional symptoms with FND?

SPEAKER_02:

Oh, yes, absolutely. Because and the relationship goes both ways. Anything that's stressful, chronic pain is stressful. Functional neurological disorder symptoms are stressful. Anything that can stress out the nervous system can make another thing that we're experiencing worse.

SPEAKER_01:

So you mentioned that F and D tends to be very disabling. Is that correct?

SPEAKER_02:

Yes.

SPEAKER_01:

What similarities have you found between the disabling severity of people with chronic pain and those with FND?

SPEAKER_02:

Okay. So there's a couple that stand out. One is the effect that the symptoms have on those around us. My chronic patients often feel guilty about their condition, and we spend a lot of time working on how this is not our fault. And our relatives and friends are probably more understanding than we imagine. That's very similar with uh functional neurological disorder. Uh, another is the intense fear that a problem with the body causes. So our brains, again, don't really know the difference between physical problems and the threat of death. Back in the day, if our bodies weren't working, that had some serious consequences. Not so today, but the brain doesn't know that. So there's a lot of distress surrounding both chronic pain and functional neurological disorder. And last, I'd say the unpredictability of pain and neurological symptoms makes a lot of folks afraid to work, even if they really want to, or afraid that they won't be able to keep a job. And while that's of course true for some types of jobs amongst my employed patients, um, most of their employers are pretty understanding, and it's really nice to see that.

SPEAKER_01:

And people with FND often have worse or poorer quality of life because of this condition, right?

SPEAKER_02:

Mm-hmm, absolutely. And it affects so many areas of the life, emotionally, relationships, job functioning, leisure time. Yeah, it's really one of those things that touches almost every part of our lives.

SPEAKER_01:

Yeah, and unfortunately, the medical system really doesn't have a perfect cure for it. There is no specific medication that can be given to patients to stop their symptoms. So it's very difficult to really find remission because every patient is different and every patient's triggers are different. So, what do you think that needs to change within society to help modern uh physicians and practitioners really help people with both chronic pain and people with FD?

SPEAKER_02:

Well, I like the way that society is trending in my 20 years. Um, for instance, your generation is much more likely to seek behavioral health treatment and to kind of see it as just another medical issue, like a sprained ankle or a headache, where my generation that there's still a lot of stigma around seeking help. Um and I'm seeing this in the media. So uh a few years ago, Queen Latifah had a um a good public service announcement saying, hey, tell your doctors everything about what you're feeling, including your emotional health. Um the rapper Logic named one of his tracks after the National Suicide Prevention Lifeline, which is now changed to 988. Uh, and then the Indianapolis Colts had one recently telling us that, hey, it's okay to get help for emotional stress. Um, modern medicine, you you mentioned, I think is also trending in the right direction. So psychology is still a pretty young science, and we're still working our way into other areas in medicine. But I see that happening more and more. So you're seeing more integration of psychology, which I mentioned at the top of the hour, um, into medical practice, especially around certain diagnoses. We're seeing more and more clinical practice guidelines or best practices saying, hey, you need to include a psychological evaluation for this. You need to get psychology and mental health involved in the treatment of this, even if it's not a psychological disorder, even if it's just a medical one. So we're seeing much more integration with that for traumatic brain injury, chronic pain, uh, cancer, and other similar.

SPEAKER_01:

Yeah, I think that is true because in some of my studies I learned about how primary care and behavior health tended to uh they're trying to progress um clinics mainly to have them both in the same place so that people have access to primary care, but it's if they need to go to therapy or psychiatry, even it's right next door, and it's really easy to help um really have patients and the physicians talk to each other because they're so close, they can have uh you know weekly meetings together, they don't have to be in separate buildings, they don't have to be in separate cities, and I feel like this is really helpful for patients. And I noticed this also within the Navy, they it was still difficult to get mental health, but it's definitely uh there's less stigma attached to it. And I think that hopefully when things keep progressing, it will be we'll be at a time where we don't have to tell our supervisors that we have a mental health appointment. We can just say we have a medical appointment, and it will be okay. And also that if we go to seek mental health help, we are not automatically going to be discharged because that's a real fear is that if we go to mental health, then something's going to happen, they're going to discharge us, they're going to it's going to lead to something bad, but that's not necessarily the case.

SPEAKER_02:

Yeah, the integration of primary care and mental health is extremely valuable. And there are decades of research showing that uh mental health rates of problems go down, physical um rates of problems go down, um, satisfaction of patients increases, satisfaction of providers increases, the whole system saves money, our uh healthcare costs uh get lower across the board. So very valuable. Even in the age of you know, electronic and quick uh communication, like you said, having that uh uh behavioral health provider right next to the primary care providers, it helps with uh communication, and then that just helps patients. And it's one less step between referral where somebody might fall through the cracks. So then the next step I think would be for um our our payment system to start recognizing the value of that discussion, paying for that a little more or paying for it, period. Because right now the system doesn't necessarily reward discussion between doctors, and I think we see patient outcomes are much better when, like you said, the doctors do talk to each other.

SPEAKER_01:

Thank you, Sherry. For those of us who want to dig deeper into this conversation, where might we find additional information or resources?

SPEAKER_02:

Okay, so there's a few um websites that I like. I like the National Institutes of Health website, uh, the Mayo Clinic, WebMD, and the Cleveland Clinic. Now, when you look at those last two, you may want to look under conversion disorder rather than functional neurological disorder. That was the old uh the old title for the for F and D. And then for behavioral health providers who want to learn more about treating F and D, there isn't a clinical practice guideline out there yet that I know of. But there is a nice book chapter written by some physicians uh who work with neurological issues summarizing a lot of the research, and it's called The Psychological Treatment of Functional Movement Disorder. That's by Joel Mack and Kurt Lafrance Jr. Also in that chapter, and in a workbook by Ryder et al. titled Taking Control of Your Seizures is an interesting worksheet called the Abnormal Movements log. That's that tool I was telling you about earlier that helps people track the relationship between stress in their lives and their movement and sensory problems. That helps them zero in on which situations might be the most stressful and need the most attention when they're working in therapy.

SPEAKER_01:

Finally, what resources might you have for people who have F and D and how might people access these resources?

SPEAKER_02:

So generally, I would start with my primary care provider and ask them to help me find a clinical psychologist, which is a doctoral-level mental health provider. Specifically, a health psychologist is the most likely to have experience treating functional neurological disorder and other diagnoses with predominantly physical symptoms. If you can't find a health or a clinical psychologist, you might expand your search to include telehealth providers, uh, even from other states. There's a program called PsyPact that I participate in that allows psychologists to see patients in other states via telehealth. And very important for your listeners to know, telehealth services are just as effective as in-person treatment for mental health. They've studied it a lot, especially during COVID. And while not many people think it's gonna help be as helpful, it always is. So, and if you can't find a psychologist, any mental health counselor can help with stress management, which potentially can impact functional neurological disorder symptoms. Um, and one last thought it's it's common to have functional neurological disorder and actual neurological disorders that a physician will diagnose. So, in when we look to mental health to help us, it's important not to not to drop the ball on the our physical needs. So always maintain your work with your physician, even though you may be working with a counselor too. And remember, you're not alone. There's hope that we're learning more and more about how to help people with functional neurological disorder. And above all, no matter what you may hear, it is not your fault that this is happening to you.

SPEAKER_01:

Thank you so much, Dr. Martin. I also want to mention that I think people can find providers on psychology today. It's a really big resource for people who are trying to get psychologists or therapists or psychiatrists, and they can even look up uh what type of topics they want to talk about. And also the Whole Person Center also works with timely care to give students access to um 24-7 support and also scheduled visits with providers. So I want to thank everybody for listening in today, and I hope that we can do more podcasts in the future. Thank you.

SPEAKER_00:

Stay tuned for our next podcast. Until then, breathe intentionally, laugh wholeheartedly, connect within, and towards people who inspire you and who bring you joy.