If you have IBS, depression, fatigue, chronic pain, or fibromyalgia and you’re only following the conventional medical approach, you’re probably not going to get better. There IS a path to healing from IBS, fatigue and chronic pain. But you need to address the underlying biological issues that create the symptoms. Learn about why these conditions develop. And learn the “can’t miss” things that you need to heal in order to get a good outcome. Robert is 40 and is stuck and can’t move forward in life. He’s a super intelligent and motivated person, but he has severe fatigue, abdominal pain, anxiety, and recently can’t sleep well. He needs to be near a bathroom all morning because his bowel is so irritable that he needs to run to the toilet on a moment’s notice. He has had workup of his debilitating digestive symptoms and the specialists said it was Irritable Bowel Syndrome. Nobody has explained his debilitation fatigue. And nobody has helped his need to run to the bathroom immediately and frequently. Turns out he has abnormalities in his daily pattern of cortisol secretion. He’s a talented, hard working ethical person and he’s deeply frustrated that he can’t do what is meaningful for him. Conventional medicine has nothing to offer him.
Robert is not alone. Thousands of people have similar clinical situations. The conventional approach is to think about each of the symptoms as separate problems. There is no integrative understanding of what underlies the whole picture. And rarely any practical solutions.
There is Hope
But his situation is not hopeless. Many people get better with the right understanding and treatment.
If you understand the underlying issues in complex chronic pain and illness, you are more likely to find what works to help you feel better, and help in healing IBS, fatigue, and chronic pain.
Video Questions
The video discusses the following questions, among other things:
How does the functional medicine approach think about complex pain and illness, and offer improvement where conventional medicine has failed?
What does it mean that he has “an abnormal pattern cortisol secretion”?
Is this “adrenal fatigue”?
What is the connection between stress, adrenal dysfunction, IBS, fatigue, and pain?
How can someone heal from fatigue, IBS, anxiety, and other related chronic illness?
This is a complex topic. These initial two videos give an overview and some of the scientific underpinnings of the functional approach to complex illness.
Subsequent videos will answer the questions of:
What can a person do about the problem?
What are the most commonly overlooked issues that keep people from healing? Even though they’re doing an integrative approach.
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Did You Know:
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Dr Shiller is available for telemedicine consultation worldwide regarding chronic pain, fibromyalgia, autoimmune disease, fatigue, and stress-related illness. Contact the office or schedule a consultation at www.drshiller.com
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Hey, everybody, Dr. Shiller, and today I want to talk about why people get stuck with chronic pain and chronic illness? And what you can do about it, and we are going to start in particular talking about irritable bowel syndrome, fatigue, chronic abdominal pain, which often goes along with anxiety and insomnia, and there is potentially more to it. There are various constellations of symptoms that people get that are really disabling and conventional medicine does not really have good answers frequently for those issues. In my eyes, part of the problem according to the way I trained in conventional medicine is that we tend to think about each of those symptoms as a separate problem. We tend to not see that they are connected to each other based on underlying physiologic imbalances that are common to a lot of those symptoms, and so abdominal pain, fatigue, brain fog, chronic fatigue, neuropathy, headaches, even things like dementia, confusion, cognitive changes. There are underlying physiologic principles and imbalance that are connected with each other. You are one unit; all your systems are connected to each other. So, we are going to explore that so you can understand it. This is stuff that is not made up, it is stuff that is based on scientific evidence coming out in the past 20 or 30 years. It can take decades for that to get into common mainstream medical practice. What I see over and over again is someone who comes to me and they have had the best medical treatment, and thank God they have not had a disease that is progressive that is going to kill them, but they have ongoing symptoms. The docs either gave them meds that did not help them or gave them too many side-effects or you know what they just were not listening and understanding the whole picture. On the other side, I have seen a lot of people who have gone the more natural medicine approach, and they have gone one aspect out of that or two aspects, but they have not really holistically understood the depth of the underlying physical dysfunction. So I want you to understand that so you can understand what might be going on in your case. so that you can know what you might need to do and what you might be missing, and the whole point is that you should feel better. So, that is where we are going. I want to do this in the context of a case. I want to talk about a guy who came to see me, and his name is Robert, he is in his 40s. Basically, what is going on is he is exhausted and he cannot get moving in the morning, he cannot function. He has got chronic pain in his belly. He has got so much, like diarrhea every day, especially in the morning that he cannot really leave his apartment for a while. He has got gas and bloating. He feels anxious a lot. Lately, he is not sleeping so well at night, and sometimes he just cannot kind of get motivated, because he feels so overwhelmed about all the different stuff going on. So, things are kind of like over the top for him, and the physical issues started about 20 years ago, and he had a very stressful time during his higher education and stuff was going on that was maybe even on the level of like emotional abuse with some of his teachers, what they were doing to him. It turns out that he also had some emotional and physical trauma when he was a child. There was probably some abuse. There was his own subjective sense of being neglected by his parents, and over the years, he tried various psychotherapeutic things. He has always felt kind of not at ease with himself. He has tried various psychotherapeutic approaches but never really stuck with anything, and lately he has had a lot more difficulties. He got divorced several years ago. He has had other challenges. It is hard to move forward professionally. He does not emote. He feels like things are kind of bottled up a lot inside, and he wants to move forward. He has got clear goals. He is actually a great guy, but he is having a hard time doing what he knows he needs to do, and so I did an evaluation. We did a little bit of testing and here is what it showed.–Next Slide–We did it what we call a 24-hour cortisol secretion, which means like four times over 24 hours. We look at a saliva test and we see how much cortisol is in his saliva, which has been shown to reflect what is in the blood, and what is cortisol? It is one of our stress hormones, and cortisol is regulated by a feedback loop.–Next Slide–So, you may have seen other videos that I have made where I talk about like this, the stress system of the body, and then we have an acute stress response which is part neurologic and part from epinephrine/norepinephrine, which are also called adrenaline and noradrenaline, and cortisol is a hormone that is also secreted in response to stress, and it helps modulate certain aspects of your physiology when you are under stress, but it also kind of has a kind of tempering effect on your acute stress response. It is more like your chronic stress response, and cortisol is subject to all kinds of feedback. You know, in this cartoon here, this diagram, here is your adrenal glands, that is where cortisol comes from and so do epinephrine and norepinephrine, and that controls your hypothalamus, which is in the core of your brain. There is a normal daily rhythm of that secretion, but stress or inflammatory signals, things called cytokines stimulate the pituitary to stimulate the adrenals and that is what puts out the cortisol, and there is a feedback system to the pituitary, a feedback system to that hypothalamus, and it tends to modulate and balance things. Now that feedback loop gets out of balance in people who have chronic stress, and it is shown to get dysregulated, and that is one of the things that is going on in chronic fatigue syndrome in lots of people with fibromyalgia and frequently other chronic illnesses. So, let us unpack this a little bit so you can really understand it.–Next Slide–I want to go back to Robert’s actual testing, right? So, this is a graph over 24 hours, like early in the morning, at night, and then at noon in the afternoon, and this green band is kind of like that is normal cortisol secretion, and check out where he is at, he is below normal, especially in the morning relative to the green where he is kind of closer to that in the afternoon and evening, but in the morning, he is pretty down low, and there is also something called DHEA, and that is kind of a precursor to sex hormones and it is often also modulated or downregulated in people who have a chronic cortisol response, and so that morning low cortisol is something that could be expected to really cause him to be a really fatigued and not be able to move himself in the morning, because cortisol is what parts of what gives you your bump, and so we are seeing some real physiologic data that this guy is really suffering from a dysregulation of his hormonal system, and a lot of people with fatigue are experiencing that.–Next Slide–So, let us go a little further. Let us take a step back and think differently about chronic disease. When I was in medical school, they did not teach me systems biology, they taught me a fairly kind of cookbook method of thinking about very, a really simplified way of understanding things within each organ system. If there is high blood pressure, you do this; if there is pneumonia and inflammation, you do this. If a person has got this kind of hormonal problem, you give this drug, and systems biology is looking a little bit more complex wise, a little more complexity, and I actually got trained to think about this way when I was an engineering student at MIT. We modelled complex systems and understood how all these different variables interacted with each other, and I was a little disappointed when I went to medical school, like really you guys are thinking so simplistically out stuff, but it actually works in acute illness, and if you have an acute illness, you want to go to the emergency room, you want the antibiotics, you want the person who is going to stop the bleeding or you know if your blood pressure is 50/ 20 and you are passing out or dying, you need that kind of acute care, which is fairly straightforward and simple. The place where that model tends to fall down is with chronic illness. It is getting better, but it is a slow process. So, let us just talk for a second about what is systems biology? First of all, we understand that all the systems are one system. So, your cardiovascular, digestive system, your hormonal system, your immune system, are profoundly interconnected with each other. There is complexity in relationship among all of the parts. All of the reductionistdetail that the specialists are thinking about, whether it is an endocrinologist or rheumatologist or a cardiologist, who knows so much detail about their particular organ system. Well, we try to take that and put it in the context of your overall integrated biology, and we try to look at patterns that give rise to problems over time as opposed to just looking at one snapshot with a bunch of blood tests or you know a scan or something like that. We want to look at, well, what was it like when you were born? What happened during the course of your life, and how did this process that you are in unfold?–Next Slide–So, let us unpack that a little bit more, and let us look at this contrast, and you know conventional medicine really was formed by this miracle that happened when they developed antibiotics, where suddenly people who were dying of streptococcal pneumonia were living, because they discovered penicillin, and this one disease, one cause, one treatment model dominates a lot of medical thinking, and even until this day when we have got research showing how many different variables are involved, I find a lot of my colleagues really in this kind of like, well is it this or that, what is the cause? And a lot of patients come to me and say, “well what caused it? And the fact is well about five things caused it, and it happened over the course of 20 years. So, let us try to understand it that way, and it is hard to get your head out of that one disease, one cause, one treatment thing, and again each doctor has their own particular algorithm for fairly simplistically treating things. Patients usually pass it, do what you are told, and it is mainly about acute problems, and it is not great for chronic problems, and functional medicine is different, systems biology, and the main thing, the main point of this whole slide is that we look at antecedents, triggers, and mediators. I am going to unpack that in a second, because that is what helps us understand how that disease process develops overtime. We want to understand the process, address underlying issues and enable the patient, which might be you to be proactive and to do things that are lifestyle-oriented, actually can help you heal.–Next Slide–So, let us talk about antecedents. These are like foundational principles, like things that are early in life that set the stage for your whole life. We are going to get more into detail, do not worry. Triggers are transient events that come and go, but they shift your system in a significant way, and then mediators, these are things that are kind of persistent changes that keep you stuck in a disease pattern.–Next Slide–So, let us unpack this some more. Antecedents, triggers, and mediators. The thing I want you to know is this, really important, listen up. These things are interacting over time. It is a process. It is like something is flowing downstream that can start when you are a little kid, that can be triggered when you are 12 or 16 or 18 or 20, that can get worse overtime as it progresses and get re-triggered when you are 40, and then suddenly you are 49 and you are sick, and the conventional approach is, well what is wrong with you now? as opposed to well how did this all develop and let us look at how that unfolded overtime because that gives us clues about what we can treat. One way we like to talk about it is that conventional medicine tends to be downstream medicine. The person is already sick, what are we going to do about it? And in functional medicine, we try to go upstream, we try to find that process and get at its roots in an upstream sort of way.–Next Slide–So, antecedents like I said set the stage, what are we talking about? Stuff like genetics, early life experience, culture.–Next Slide–These things determine physiology and triggers shift the system. Examples of that are things like infection, trauma, surgery, an acute illness where someone is in the hospital for a while, life event, intense treatment with medications. These things modify metabolism, they change your beliefs and emotions and behaviour.–Next Slide–They can affect gene expression and function of the genes and the physiology of every system in your body, and those become mediators, and that is what keeps you sick. Metabolic biochemical changes, mental and emotional changes, social changes, behavioral changes, and let us unpack this a little bit, right.–Next Slide–This is going to be kind of a simplistic picture that I will go into more detail, but let us for instance just think about your brain, right, and your brain is the place where you perceive danger and your stress response happens through your brain, it is a perceptual thing. It can also happen through your body, because you can have a physiologic stress, but look, we will get into that later for a second. So, we are understanding now that the brain and the gut are incredibly connected. You know, there are journals of gut-brain axis connections. If you look in almost every specialty journal, whether it is rheumatology or cardiology or orthopaedics, nephrology, gastroenterology, and so on, all of them are talking about the gut-brain axis, and part of what happens is like this that, there is this two-way communication, and we will go deeper into this, but some of the predominant changes that happen in your gut are dysbiosis due to changes in the bacteria, the gut, inflammation, increased permeability. Anyhow, we are going to unpack this some more. Those changes tend to dysregulate the immune system, and that can be making the immune system overactive or under-reactive, but the point is your immune system is meant to be imbalanced, and oxidative stress is actually a biochemical stress that is part of immune dysregulation quite frequently, and they have a cyclical relationship with each other, and going further, your mind-body connection is profoundly integrated with your immune system and your tendency towards oxidative stress. Oxidative stress is biochemical stress that you have implied entire body and mind experience as stress. So, stressful experiences can whack out your immune system. Immune dysregulation and oxidative stress can affect your brain function. I want to point out something else here, like okay, we all understand that stress and perceived danger can affect your brain, but what is with this arrow. The fact is and this has been shown over and over again that when a person is in a stressed mind state, they are not thinking clearly, they are not relating to life with clarity. There is a shift in brain function and brain connectivity in a stressed brain that actually leads us to perceived danger more frequently when it might not even be there. There is something called negativity bias, where we are all kind of biased to look out for danger, but someone whose stress axis is on overdrive has an overactive vigilant tendency to look out for danger, and you may have heard of things like PTSD, where someone has an overactive stress response, and you know something happened to them in the war or whatever it was, and they have some kind of simple stressor that most people would just say, “oh that is just the car making a noise, but this guy is jumping in for cover and diving for cover.” Let us unpack this a little bit more, right. I took the arrows connecting the brain and gut out just so it would not be confusing. This is a little diagram that just shows your pain pathways. Now, I am going to unpack this later, but the fact is your experience of pain, whether it is in your body, in your hands, in your gut, wherever it is, is a sensory phenomenon, where certain nerve endings are activated, but that signal cruises up through your spinal cord where it gets conditioned and altered and goes into the core of your brain where it gets altered, and then it goes up to the part of your brain when you say “ouh” and the point is you have got amplifiers, your system of pain transmission can be turned up and it can be turned down. Immune dysregulation has been shown to turn up your pain amplifiers. When people have systemic immune activation, they frequently have central brain inflammation, and that is part of what creates hypersensitivity of that pain transmission system, and that is what shows up in fibromyalgia, it shows up in a lot of chronic pain states where like peripheral neuropathy and osteoarthritis, and for sure, it shows up in irritable bowel syndrome, where people get really bad pain just from eating normal stuff. Part of it is the way their gut is reacting, part of it is that their pain pathways are amplified, the volume is turned up, and it does not mean they are faking it, it means their biology is turning up that pain processing system. One more step here, we want to just think about cellular function. This is like a goofy cartoon of a cell and you got these little organs in your cells called mitochondria, and mitochondria are part of what makes cellular energy, and cellular energy is what lets you have energy. You have got millions and millions of mitochondria, they are constantly active, they are power plants, they are everywhere, especially active in your brain, in your muscles, in your heart. If your mitochondria are not functioning, you are not functioning, and all of these changes that we are talking about, like immune dysregulation and oxidative stress, can stimulate dysregulation of your cellular function and your mitochondrial energy production, and when your mitochondria get sick, it activates your immune system and oxidative stress. Stress itself can trigger the mitochondria to shut down and turn off, especially when it is chronic ongoing stress. In the short-term, stress pumps you up. In the long-term, chronic stress knocks you down, and also mitochondrial dysfunction keeps your brain from working properly, because your brain is not producing energy. What is happening? Brain fog, fatigue, confusion, etc. The point is we have got vicious cycles, we have got cycles of interaction of these physiologic processes that can be triggered by all kinds of antecedents, triggers, and mediators. What else is here? Oh yeah, do not forget pain and mitochondrial and cellular function, because for sure, your nerves are cells, and if your nerves are not properly functioning, they are going to get sick and they are going to generate more pain. So, look, I want to unpack this some more. I am going to talk more detail about this with some more scientific pictures, and we are getting to about the 20-minute mark here, and so you might be like a lot of my patients where, okay the concentration and memory might be a little challenged because of the chronic illness and the things we are really talking about here. So, we are going to cut this video right now, and part 2 will go into more depth, about really understanding more of the science behind these kinds of changes and how this constellation of underlying physiologic imbalances or changes can give a rise to a lot of different symptoms and really disabling conditions. Keep a lookout for that and you can watch it right now or come back to it later when you have more energy. Thanks a lot for watching, make sure to subscribe, share with your friends, and see you in the next video.
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