Anyone who has taken coursework on teaching patients about pain, has undoubtedly heard about the “Lion in the Room” or similar story. We talk at length about the effects of a state of prolonged sympathetic response for those of our patients living in chronic pain. They are constantly in “fight or flight” mode, living with altered levels of adrenaline and cortisol at all times. We teach people that living in prolonged stress is like walking around with a lion perpetually following them, drooling and licking his chops, a constant threat. An ongoing stress-response alters multiple body systems, from immunity to appetite to romantic interest.
Prompted by some discussions with colleagues, I’ve been doing a fair amount of information gathering on stress lately: stress and cardio-vascular disease, stress and metabolism, and of course, stress and pain. Why Zebras Don’t Get Ulcers is an absolute go-to book on stress, stress-related diseases and coping. It was written by Robert Sapolsky, a professor of biology and neurology at Stanford University, and a research associate with the Institute of Primate Research, National Museum of Kenya. He makes complex physiology quite accessible, and is engaging and snarky to boot! Interestingly, Sapolsky discusses an element of the stress response I hadn’t thought much about, suggesting gender differences in the physiology and psychology of stress:
“Recent work by UCLA psychologist, Shelley Taylor suggests that the ‘physiology of the stress response can be quite different in females, built around the fact that in most species, females are typically less aggressive than males, and that having dependent young often precludes the option of flight…Rather than the female stress response being about fight or flight, it’s about “tend and befriend”—Taking care of her young and seeking social affiliation…. The fact that oxytocin is secreted during stress in females supports the idea that responding to stress may not just consist of preparing for a mad dash across the savanna, but may also involve feeling a pull toward sociality.”
Oxytocin: More Than Warm Fuzzies
This concept is very intriguing, especially for those of us treating people in pain, who seek to establish a strong therapeutic alliance with our patients. As we “tend and befriend” patients, we may be influencing their neuro-hormones in ways we had never imagined. Consider the comments made by Kelly McGonigal in her 2013 Ted Talk “Making Stress Your Friend.” McGonigal notes:
“Stress makes you social… Oxytocin, often referred to as the cuddle hormone because it is released when you hug someone, is so much more than that. It is a neuro-hormone. It fine-tunes the brain’s social instincts and primes you to do things that strengthen primary relationships. It makes you crave physical contact with friends and family, enhances your empathy, and makes you more willing to help and support people you care about…”
Furthermore, oxytocin is a stress hormone. It is secreted by the pituitary gland as part of the stress response and, according to McGonagil, is as much a part of the stress response as adrenaline. It motivates you to seek support. McGonagil states:
“Your biologic response is nudging you to tell someone how you feel instead of bottling it up. Your stress response wants to make sure you notice when someone else in your life is struggling. When life is difficult, your stress response wants you to be surrounded by people who care about you.”
The benefits of oxytocin secretion are numerous: it protects your cardiovascular system from the effects of stress. It’s a natural anti-inflammatory, and helps blood vessels stay relaxed during stress. It helps heart cells regenerate and heal from any stress-induced damage, in effect strengthening the heart. And, all of the benefits of oxytocin are enhanced by social contact and social support. According to McGonagil:
“Your stress response has a built in mechanism for stress resilience, and that mechanism is human connection.”
It is Better to Give Than to Receive
If we think about our amazing brains and the role of mirror neurons, could it be possible that some of the “non-specific effects” of therapy actually occur because our “tending and befriending” stimulates our patients’ oxytocin? And to take it one step further, have you ever thought that your empathy, compassion and care actually has a protective effect on you? As Sapolsky wraps up Zebras, he notes:
“Often, one of the strongest stress-reducing qualities of social support is the act of giving social support, to be needed…In a world of stressful lack of control, an amazing source of control we all have is the ability to make the world a better place, one act at a time.”
McGonagil noted a similar effect of providing care for others. She described a study, in which 1,000 adults age 34-93 were included. Participants were asked how much stress they had experienced in the last year. They were also asked how much time they spent helping others. Researchers then watched public records for 5 years to see who died. For every major stress event that was reported (major family crisis, illness, financial issues, etc.), the risk of death increased by 30%. But, among people who spent time caring for others, even if they reported stressful events themselves, they demonstrated absolutely no increase in risk of death, essentially having the same (lower) risk as the non-stressed individuals. Caring created resilience. In my favorite quote from McGonagil’s talk:
“What we see time and time again, is that chasing meaning is better for your health than trying to avoid discomfort.”
(Disclaimer: McGonagil did not report the source of the above study in her lecture, so I can’t vouch for the academic quality of it).
A Safety Net
Human connection creates a “safety net,” and often, that is what patients are seeking in the midst of their pain experience. In a fantastic interview on the evolution of the opioid crisis we now face, Anna Lembke, a Stanford psychiatrist focused on addiction care, made the following observation:
“The other under-recognized piece of this is what I call the medicalization of poverty. Opioids have become a proxy for a social safety net. So we have doctors routinely confronted with patients who not only have multiple medical problems — from diabetes to hypertension to asthma to cardiac disease — but also very significant psychological, social, and economic problems. Many of them are undereducated. Many of them are underemployed. Many of them are homeless. Many of them are struggling with multigenerational trauma.
Because we lack a social safety net to take care of these people, we are now medicalizing their problems, and telling doctors that they have to take care of their problems. Doctors are feeling incredibly overwhelmed in this space with this growing population of individuals with very complex biological and psychosocial problems. In the face of that, they’re prescribing opioids — because opioids work quickly, patients are grateful, and it seems to be something they can do in the face of overwhelming problems.”
To be sure, in my experience, a large percentage of my patients suffering from complex, chronic pain carry with them much heartache, social isolation and loneliness. Their safety nets have too many holes and fail to catch them as they fall. We can become a lifeline for them, but we have to be wary of that as well…
Getting the Rug Pulled Out
Let’s examine an undesirable scenario in light of the “cuddle-hormone” as we treat patients with complex, chronic pain. We encounter our patient, do a thorough, highly skilled evaluation, and establish an appropriate plan of care based on what we have ascertained “makes her tick.” We use PNE, exercise, a little manual therapy, and graded exposure. She is surprised by how much she actually likes coming to therapy, and after 3-4 visits, she is exercising regularly, bringing in her log book and relishing in our encouragement and accolades. All looks well, and we pat ourselves on the back for a job well done. We see our patient gradually building resilience before our eyes. We equip her with knowledge, an internal locus of control, and tools to help herself when the pain creeps in. We use compassion, empathy, humor, and trust to help her climb out of the pit. By visit 6, she is beginning to stand on her own two feet in terms of improved function and symptom control. We carefully tether her for a couple of weeks, see her for a follow-up visit, and she successfully “graduates” PT… We even show a good outcome on FOTO! Woo hoo!!!
Then what? What if her remaining safety net is lacking? What if the “cuddle hormone” had inadvertently become a “coddle hormone” of sorts, without which, our patient is doomed to fall flat on her face upon discharge? How well can we expect her to do in the absence of encouragement, comradery and accountability? Should she have been “discharged”? Did we discharge too early? When can we EVER discharge this type of patient without the risk of them coming right back to our clinics 2-3 months down the road? How many times has this cycle repeated itself in your practice?
So herein lies the call for creativity. What can we do to foster a strategic, pro-active discharge plan that honors the human need for connection, as well as the other needs we know are crucial to changing the lives of those suffering from chronic pain (exercise, knowledge, sleep and goals)?
Going the Extra Mile
I am reminded of a success story of my dear friend and colleague, Elizabeth. Elizabeth specialized in aquatic therapy, and saw the need for after-care in many of the patients she treated. She took the initiative to start an affordable after-care class for “graduates” of aquatic PT, meeting at a local pool twice a week for several weeks. Clients who had enjoyed the water and expressed a desire to continue were invited. A handful of patients took her up on the offer, and two women in particular showed great enthusiasm. Through the class, they became fast friends, and long after the class ended, they continued to work out together at the pool. More than 5 years later, I see them frequently in our community shopping at Kohls or going out for lunch together, and in fact, they jokingly refer to each other as being “joined at the hip.” They continue to go to the pool, and in fact, have one another listed as emergency contacts on health care forms (after their spouses). I can’t help but think these ladies needed more than physical therapy when they were referred to aquatic therapy, and they found what they needed thanks in large part to Elizabeth’s commitment to go the extra mile and nudge them from “goals met” to “goals sustained.” That is life change.
So, what ideas do you have to share for after care?
Ideas for oxytocin-enhancing activities?
How do we maximize this benefit without coddling?
Is it our role to intervene in the realm of our patients’ social connectedness?
If it weren’t for HIPPA, I’d love to be a match-maker or small-group coordinator for patients who could really help one another! E-harmony for patients… Maybe if we build it, they will come…???