Dis-Ease v. Disease

It is quite common to confuse dis-ease with disease, the former describing a state of malaise, discomfort anxiety, the proverbial sick to my stomach status or complaint. It utilizes the word sick yet it is not a true disease state by medical standards. Often these complaints are real and the subject, frustrated from not being taken seriously, seeks validation by working the symptoms into the closest disease state they can think of. It is common knowledge that some diseases and medical conditions lend themselves better than others to these psychosomatic signs and symptoms, i.e. ulcer disease, back pain, auto-immune, some cardiovascular manifestations, etc.

Chronic Pain is one of those very broad continuum dis-ease/disease conditions that is very common in western societies where billions of dollars are spent to treat it...usually badly and/or too much. The condition is barely acknowledged in the Eastern majority of humanity. That should help prove my point.

Back pain is one of the leading causes of chronic pain, in part of course because it often leads to monetary compensation and that is an incentive to keep treating (I refer the reader to my previous blogs). I have always told my patients that chronic pain is like a Greek Medusa  with multiple heads: you have to kill them all, if not individual heads will keep growing back. The heads can be described as follows: 1) source transmitting the pain signal, e.g. disc; 2) spinal cord wind-up and transmission: 3) cortical interpretation, amplification or inhibition; 4) emotional overtones (anxiety, depression, bipolar); 5) environmental and societal factors, i.e. spouse, children, finances; 6) extrinsic factors - secondary gains (WC, PIP, SSDI, legal case, etc.) to name the main ones. Factors 1 and 2, possibly 3, rarely 4 can be considered disease but the others are dis-ease. 

These "heads" often interact with each other. For example, I had a woman patient whose back pain increased (1) every time she had a fight with her son (5) until she decided to have him put in jail and her pain improved. Another patient's neck pain was well controlled with mild narcotics (1). Suddenly it got a lot worse and after insistent questioning she admitted that her father just died (4) and that made her "pain" unbearable. More narcotics in this case would replace getting liquored up at the neighborhood bar to forget. Sometimes the interaction is more sordid and manipulative but no less tragic: exaggerating pain complaints (1) to sell the drugs and derive some income (5). Of course more complex interactions happen all the time and chronic pain patients usually warrant expensive polypharmacy regimens to treat factors 1 thru 4 at least. The other factors are societal and behavioral, very real yet beyond the doctor's reach.

My good friend Dr Rinoo Shah, in a November 2012 SPINE editorial, points out very scholarly how spine pain classification is nothing but guesswork, varying with time and between providers. This certainly should prompt us all to be as little invasive and as much patient and conservative as possible regarding this very mercurial yet very costly condition. The simple reason is we never really know what head of the Medusa we must treat or we are actually treating...and since we have to try to kill them all, this can never be achieved with the scalpel alone. In a nutshell, Dr Shah describes it as a moving target, try treating that in the O!

Dr John Sarno, a now famous NYU professor and author, successfully treated a large number of people, including celebrities by advocating a Mindbody Prescription (1998), in essence Detreating Pain, via seminars and books, no drugs or heroic procedures. Several times, when a patient's pain stopped making any sense, I gave them his book or sent them to him and that did it. This also proves the point I made above that we are treating pain in this country badly and too much.

The best remedy is prevention, is to focus on treating the dis-ease to avoid it morphing into a disease and sprouting into a Medusa. WELLNESS is a great tool that is being utilized more and more although not early enough in most cases, simply because INSURANCE DOES NOT PAY FOR IT. I believe health insurance should stay out of that business and should be limited to catastrophic occurrences but that was the topic of another blog. Wellness has exercise as a corollary and personal responsibility as an engine. Having a third party pay for it defeats the whole purpose.

I remember a statement that applies here, from a psychiatrist friend of mine:

"Half the treatment is paying for it!"