A fascinating article about the mind-body connection.  This is from a recent Journal of the American Medical Association.  

Viewpoint

September 16, 2019

“It’s All in Your Head”—Medicine’s Silent Epidemic

Matthew J. Burke, MD, FRCPC^1,2

Author Affiliations Article Information

JAMA Neurol. Published online September 16, 2019. doi:10.1001/jamaneurol.2019.3043

It’s all in your head” is a phrase sometimes said by physicians to patients presenting with symptoms unexplained by medical disease. As a neurologist specializing in neuropsychiatry, nothing bothers me more than overhearing medical colleagues proclaim this one-liner at the bedside or snicker about these patients during rounds. Unbeknownst to them, I also hear my patients’ version of being on the other end of this phrase and find myself constantly trying to repair the damage that these words can cause. Whether physicians like to admit it or not, medically unexplained symptoms encompass a vast terrain of clinical practice. In neurology, these symptoms fall under functional neurological disorder, but every specialty has their own variants and favored terminologies (eg, chronic fatigue syndrome, fibromyalgia). The inadequate management of this segment of medicine represents a silent epidemic that is slowly eroding patient-physician relationships, perpetuating unnecessary disability, and straining health care resources.

The irony of “it’s all in your head” is that although this phrase is often used inappropriately and dismissively, it is technically correct. The problem does indeed lie within the head. More specifically, it lies within the brain and its complex networks that we are just beginning to understand. Over the past 10 years, neuroimaging research studies have consistently identified brain abnormalities in patients with medically unexplained symptoms—yes, biologically based changes in the activity and connections of brain regions, such as the amygdala, prefrontal cortex, temporal-parietal junction, and other structures.¹ These brain circuit abnormalities provide physiological explanations for once mysterious links between regions implicated in emotional processing and the generation of “physical” symptoms (eg, pain, fatigue, weakness). Jean-Martin Charcot, MD, a famous 19th century French neurologist and early pioneer of this field, reportedly insisted that a “functional lesion” would be found when microscopes were sufficiently powerful.² Well, our microscopes are getting better, and we are now starting to see evidence of the predicted functional or software disruptions in the brain. We still do not fully understand what causes these software problems; however, recent research suggests a multifactorial etiology, including genetic predisposition, environmental risk factors (eg, childhood adverse events), and psychological stressors.³

Despite the growing scientific literature, there has been minimal shift in physician attitudes toward these patients. Physicians seem quite comfortable with the idea of structural brain lesions causing psychological symptoms, such as a frontal lobe stroke causing depression or a temporal lobe tumor causing delusions. However, the reverse causality of psychological factors (borne of the same substrates—neurotransmitters, neurons, and synaptic connections) leading to neurological or systemic symptoms is often hastily dismissed and remains highly stigmatized. Thus, many physicians either simply ignore these kinds of symptoms or wrongfully assume that patients are malingering.

Based on such attitudes, a typical physician-patient interaction may proceed as follows: (1) the physician provides a rundown of normal investigations, (2) the patient is told they have no known medical diagnoses, (3) a brief awkward exchange occurs, and (4) little further explanation, guidance, resources, or facilitation of an appropriate referral process is given. Even if the infamous phrase is not explicitly stated, this sequence leaves the patient to infer for themselves that it must be all in their head. Unfortunately, they do not perceive this as, “I have a real dysfunction of networks in my brain,” but instead understandably conclude that, “they think I’m crazy” or “faking it.”⁴ Sometimes, patients may hear the distant utterance of, “Maybe you should see a psychiatrist,” as they exit the office door, but in this context, such advice is rarely productive.

Many of these patients can be so offended by this encounter that they quickly seek multiple second opinions and subsequent rounds of pricey and unnecessary investigations. Depending on the jurisdiction and medical record system, the original physician may be completely unaware of these additional rounds of care. Mounting negative and invalidating clinical interactions can become a source of distress and cause medical trauma. At this point, patients often either fall through the cracks or stumble on a fringe medical specialist or alternative medicine practitioner who may offer the “physical” diagnosis they’ve been yearning for. This could include a growing list of unsubstantiated metabolic deficiencies, infectious disorders, or autoimmune hypersensitivities. Anecdotally, the most common current example seems to be the diagnosis of chronic Lyme disease by unvalidated assays.⁵ Let me be clear that many of these practitioners are well intentioned and can offer holistic approaches that medicine could learn a lot from. However, there appears to be a subset that take advantage of these patients’ desire for a “physical” diagnosis and exploit their vulnerabilities.

For the patient, receiving such a concrete, “organic” diagnosis often quells mounting anxiety, which in itself could be partially therapeutic. However, now wedded to their given diagnosis with no knowledge of their actual software problem, patients do not see a need to address underlying factors that may be contributing to their disorder nor do they receive the multidisciplinary care that they may so badly need. The saddest part of this epidemic is that if addressed early, these symptoms may be reversible; however, with delays to proper diagnosis and management, prognosis worsens considerably.⁶

So how can we prevent or interrupt this concerning trend? Often, the first step to addressing a problem in medicine is providing data to prove that the problem exists. This is where the challenge begins and what makes this a silent epidemic. The magnitude of this crisis is difficult to demonstrate because these patients largely elude the billing codes used for case ascertainment in large population-based studies. This is because of a combination of gaps in current billing and diagnostic codes (country specific) and because of the fact that codes are not being used appropriately by many physicians. The latter may happen for multiple reasons, including lack of comfort with these diagnoses and concerns of medicolegal ramifications.

Despite a few isolated efforts to estimate prevalence⁷ and health care costs,⁸ the evidence base needed to sway research granting organizations, government policy makers, and health care and insurance systems has been largely elusive. I am optimistic that it is only a matter of time until the scope of this crisis is fully appreciated. I see firsthand the high patient volumes and health care resource utilization that currently escape record keeping. I raise these concerns to my colleagues, who wholeheartedly agree, but the conversation ends there and the silence continues. I am hopeful that new research technologies, such as natural language processing, could identify these patients in medical records despite the lack of adequate billing code data and that improved records systems will better track these patients through different health care pathways.

To address the epidemic itself, we desperately need more clinicians and researchers dedicated to interrogating the complex interfaces of mind, brain, and health. Currently, there are small pockets in different specialties, but these are not nearly commensurate with the volume and impact of these disorders. Second, and arguably more importantly, we need to fundamentally change the culture within the medical community to eliminate the negative connotations associated with these disorders. This change requires buy-in from hospital and health care leadership and a supportive infrastructure. These patients have complex conditions and require additional upfront consultation time, resources, and collaborative care. To prevent the cycles described previously, physicians need to be incentivized to take the time necessary to optimize the initial patient encounter. This includes delivering and explaining the diagnosis in a transparent and supportive context,⁹ providing patient-friendly resources (eg, https://www.neurosymptoms.org/), and referring appropriately for interdisciplinary management (eg, physical therapy, occupational therapy, psychotherapy). New educational and training initiatives across medical and allied health professions will be critical for enabling a successful transition.

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Article Information

Corresponding Author: Matthew J. Burke, MD, FRCPC, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, KS-274, Boston, MA 02215 (mburke11@bidmc.harvard.edu).

Published Online: September 16, 2019. doi:10.1001/jamaneurol.2019.3043

Conflict of Interest Disclosures: Dr Burke is supported by funding from the Sidney R. Baer Jr Foundation.

Disclaimer: The content of this article is the opinion of the author and does not necessarily represent the official views of Harvard University or the University of Toronto (and their affiliated academic health care centers) nor the Sidney R. Baer Jr Foundation.

Additional Contributions: I thank Saadia Sediqzadah, MD, SM (Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada), for her helpful comments and review of the manuscript. Dr Sediqzadah did not receive compensation for her contributions.

Thanks so much for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  

Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon comments on the results of a long running sunscreen use study from Austrailia. 

90% of this women’s skin aging is due to the sun. I hope her grandson uses sunscreen.

It’s that time of year when I must nag about tanning.  In rainy Seattle it is so tempting to soak up the sun once summer arrives (that is usually about July 5th).  But please, think before you rip off your clothes, don your thong and grab your beach towel.

A good study published by the Annals of Internal Medicine and reported in the Wall Street Journal  has shown that regular use of sunscreen reduces skin aging by 24%.  It had already been shown many times that sun protection prevents most types of skin cancer but now what seemed to be obvious has also got some scientific cred.   Now my nagging has some scientific backing!

I’m certain we are hardwired to love the feel of photons bombarding our skin but way back when we were being hardwired and learning to walk upright, we would die from an abscessed tooth or a ruptured appendix or (if we were lucky) a quick take down by a leopard long before we developed skin cancer or even a bad case of the wrinkles.

Fortunately, sun protection has finally caught up with our longer life spans.  We have really good sun screens and sun block, protective and comfortable clothing and don’t forget about umbrellas, cabanas and the most lovely shade of all, trees.   And lets hear it for staying indoors when the sun is at it’s strongest.  How about a nice glass of ice tea with some fresh mint leaves and a good book.  May I recommend The Storms of Denali by Nicholas O’Connell, or A Visit from the Goon Squad by Jennifer Egan, or I Remember Nothing by the late and great Norah Ephron?

And just to remind you, I nag because I care.  Thanks for reading.  Dr. Lisa Lynn Sowder

I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Anti-vaxers have been on my mind lately.  I recently had a nasty comment directed at my @breastimplantsanity Instagram telling me I should be ashamed of myself for promoting these “toxic bags of death”.  Those who follow @breastimplantsanity closely know that I am not a huge breast implant fan and much prefer other options for breast enhancement but I digress.  This particular detractor’s Instagram was militantly anti-vaccination   I just about choked on my Diet Coke.  So, breast implants are to be feared but not smallpox, polio, diphtheria, mumps, rubella, measles, chickenpox, meningitis, shingles, genital warts, cervical cancer, tetanus, pneumococcal pneumonia, etc?  Give me a break.

I am being generous here when I say anti-vaxers are misguided and so very coddled and sheltered from the reality of communicable diseases of childhood in and adulthood.  They don’t know what they don’t know but they don’t know even know that. 

Take a look at this photo.  This is from a book called Sleeping Beauty which consists of medical photos taken during photography’s earliest era and curated by Stanley B. Burns, M.D.  The book was published in 1990 and unfortunately is out of print.  This photo, “Mother With Her Dead Daughter”, was taken in the early 1900’s.  This may strike the modern reader as really sicko but most working class families of that era could not afford to have a photographs taken but would often splurge for a photo of a dead loved one.  Take a closer look at the photo.  Does the daughter look dead or even ill?  Doesn’t she just look like she is sleeping in her mother’s lap?  The real give away is this poor mother’s face.  It’s just haunting with its steely resolve. The daughter looks so normal because she died so fast.  Childhood mortality in this era ranged from 30 to 50 percent (!) with most children dying quickly from a wide variety of infectious diseases.  Those diseases so common then now make the news and are almost always associated with pockets of low vaccination rates.

It wasn’t so long ago that the whole world was a low, no really, a zero vaccination rate pocket.  Back in 1990, I was touring The Breakers, the mansion owned by transportation magnate Commodore Cornelius Vanderbilt (1794 –  1877) in Newport, Rhode Island.  Our little touring group was ushered into the mansion’s library to await our tour guide.  There were many family plaques hanging on the library walls and I was really moved to see how many family members, members of this rich and elite clan who could afford the best medical care of the time, died in early childhood.  But this was before the modern era of vaccination.

I am old enough to sport a smallpox vaccination scar on my upper arm and to remember lining up in a local grade school gym to receive one of the first oral polio vaccines.  These two scourges of humanity are all but wiped out thanks to world wide immunization.   And I am old enough to remember being sicker than a dog with red measles and I still see my faint chickenpox scars when I puck my eyebrows.  And I had a college dorm buddy, only one year older than me, with legs crippled by polio.  He missed the vaccine by a year.  These are real diseases that the young whipper snapper anti-vaxers have been spared because their neighbors do vaccinate themselves and their children thereby providing herd immunity.

So little miss smarty pants anti-vaxer Instagram diva, I could wish the pox on you, but I won’t.  I wouldn’t wish the pox on anyone, not even an anti-vaxer.

Boy, I feel better having written this and thanks for reading.  Dr. Lisa Lynn Sowder

I’d be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Alison giving the elbow to one of our hard working nurses.

Yesterday we had a wonderful massage therapist come into the office to give our staff 30 minute massages in celebration of Nurses Week.  Oh yeah, I sneaked in and had one too and it was great.  While having my back, neck and shoulders, arms and hands kneaded, pulled, rubbed and elbowed, I had a very nice chat with Alison the therapist.  She is a weight lifter and I had a lot of questions about the mechanics of power lifting, what she thought of body builders, strength training for the over 60 crowd (me, for example), dwarf throwing contests and a bunch of other stuff.  I was so impressed with her knowledge and explanations of how strength isn’t just from muscle bulk but also from neurons in the neuromuscular junction acting in a coordinated fashion, from muscle memory for some actions, from bone strength and angle and from mechanical advantage.  This lady’s b.s. meter was set at zero, just where I like it.

It was particularly nice to have this encounter because a few days earlier there was an article in the Seattle Times about craniosacral therapy which had my b.s. meter red-lining.  Nicole Tsong, who is a yoga instructor, has a nice weekly column about exercise, nutrition and other self care and I usually enjoy reading it.  But this past Sunday, yikes did she go off the rails.  Nicole’s treatment, basically a massage, sounded pretty standard and pleasant but then the therapist started talking nonsense.

Cut and pasted from the article:  Craniosacral therapists observe your cerebrospinal fluid, which moves in roughly eight-, 20- and 100-second cycles, Christman said. My flow was good from my tailbone up until she got to my left shoulder, she said, where the flow contracted. She could work on my connective tissue to help the fluid move, or manipulate the fluid to move back into my shoulder, she said.

Yes, this is a head rub and it feels great but she’s not manipulating your skull and she is not observing your cerebrospinal fluid. Just sayin’.

Christman had asked me before the session about head injuries, and I told her about a concussion I had in college. After working on my spine and pelvis, she moved to my head and started gentle pressure around my skull to manipulate the tissue and bones. I was already relaxed, and when she started to work on my head, I succumbed and closed my eyes, nearly nodding off.

Since this is my blog, I’m just gonna get this off my chest.   Cerebrospinal fluid (CSF from now on) sort of circulates and sloshes around in the ventricles of the brain, between the brain and the skull and in the center of the spinal cord but ………………… 8, 20 and 100 second cycles?  Why not 34 seconds or 82?    Hmmm.  It has been awhile since I took neruoanatomy but that sounds like b.s. to me.  Oh, and the therapist observes the CSF?  I don’t think so.  CSF can be observed when doing a diagnostic spinal tap or doing a spinal anesthetic or during brain or spine surgery or in cases of a skull fracture when CSF can be observed dripping out of ears and nostrils.  Methinks Ms. Christman was not really observing CSF in a therapy session.  But why would she say she was?  Oh, and then CSF in the shoulder?  Nope.  Not there.  There is synovial fluid in the shoulder joint but not CSF.  If you have CSF in your shoulder you should report of the emergency room … stat.

Now lets deconstruct that head rub that Nicole got.  God, I love a good head rub, don’t you?  But I know that a head rub does not manipulate the skull.  The skull does have joints (called sutures) but they fuse in early childhood.  The only way to move a skull around is with power tools and preferably in the OR with a neurosurgeon.

Nicole almost dropped off to sleep and maybe would have been the best way to avoid listening to this balderdash which is fancy word for b.s.

Thanks for reading!  And I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

You gotta read this from today’s Slate.com.  This will involve some heavy mental lifting so put on your thinking cap and take the time to read the entire article.

MEDICAL EXAMINER
Cuba’s Sonic Attacks Show Us Just How Susceptible Our Brains Are to Mass Hysteria
The symptoms so many Americans experienced were probably not caused by a secret weapon. That doesn’t mean they’re not real.

By FRANK BURES
FEB 01, 20185:43 AM

A few weeks after the 2016 presidential election of Donald Trump, several people working for the U.S. Embassy in Cuba fell mysteriously ill. Some lost their hearing. Some had headaches and a pain in one ear. Others reported feeling dizzy or nauseous, having trouble focusing, or feeling fatigued. Later, some would have a hard time concentrating, remembering things, sleeping, and even walking.

These symptoms were “medically confirmed,” as the State Department’s medical director Charles Rosenfarb put it, and brain scans were said to show abnormalities in the victims’ white matter, which transfers information between brain regions. The illnesses were believed by the government to be “health attacks,” carried out by a foreign power, though as Todd Brown, assistant director at the Bureau of Diplomatic Security, told the Senate Foreign Relations Committee, “investigative attempts and expert analysis failed to identify the cause or perpetrator.”

Nonetheless, investigators concluded the illnesses, which ultimately affected 24 people, were likely the result of a “sonic device.” This conclusion seems to be primarily due to the fact that some diplomats reported hearing a high-pitched noise in their homes and hotel rooms.

Despite a lack evidence for such a weapon, or any known way it could affect white matter, the sonic weapon theory proved irresistible for both media outlets and for Cuba hawks like Sens. Marco Rubio and Bob Menendez, both of whom immediately transformed the sonic weapon into a handy political weapon.

In the months following the “attacks,” new diplomats arriving in the country were warned of this sonic danger. Embassy employees were played a recording of what was thought to be the sound so they knew what to listen for. Soon, people at the Canadian Embassy in Cuba began reporting symptoms similar to what the Americans had experienced, as did a few tourists there. A husband and wife at the U.S. Embassy in Uzbekistan became ill as well. Whatever it was, it seemed to be spreading.

There is increasing recognition that these epidemics of hysteria, which usually mirror prominent social concerns, present real individual and public health problems.
With no details, no motive, and no plausible explanation for what kind of weapon this might be, doubts began to surface. The FBI investigated and reportedly found there had been no such attack (though it suggested maybe it was a “viral” weapon). Sen. Jeff Flake also cast doubts on the sonic version of events. A handful of skeptical stories began to appear amid the more alarming ones, suggesting this might be what in the past was known as, “mass hysteria,” but which is now referred to as “mass psychogenic illness,” or a “collective stress response.” (These include things like the twitching girls in Le Roy, New York, in 2011; the 600 paralyzed girls in Mexico in 2007; and the Belgian Coca-Cola scare of 1999, which affected 100 students with more than 900 others reporting a related symptom, and costing the company somewhere between $103 million and $250 million.)

Epidemics of this sort are well-known in the scientific literature. Robert Bartholomew, a New Zealand–based medical sociologist and the co-author of Outbreak! The Encyclopedia of Extraordinary Social Behavior, Mass Hysteria in Schools: A Worldwide History Since 1566, and other books on the subject, has collected a database of some 3,500 cases. While the precise mechanisms are difficult to pinpoint, and the diagnosis is always controversial, there is increasing recognition that these epidemics of hysteria, which usually mirror prominent social concerns, present real individual and public health problems.

Yet many people still assume victims of such phenomena are simply faking or imagining their symptoms. In the Senate hearings on the attacks, Sen. Rubio asked Rosenfarb whether he thought this was, “a case of mass hysteria, that a bunch of people are just being hypochondriacs and making it up?”

This was a loaded question, with Rubio deploying the term mass hysteria as a means of dismissing this possibility altogether. But Rubio’s assumption—that a mass psychogenic illness is the same as faking or hypochondria—is wrong, as was his dismissal of the idea that this might explain the illnesses in Cuba. Indeed, mass psychogenic illness is likely the best explanation for these illnesses. According to Bartholomew, if you removed the word concussion from discussion of what happened there (but left the “white matter tract” changes in its place), you’d have a “textbook case” of mass psychogenic illness, in everything from its symptoms to its spread.

“There’s no evidence whatsoever that this was caused by a sonic device,” Bartholomew says. “It is physically impossible to have brain damage caused by an acoustical device. And most of those symptoms are not symptoms of sonic weaponry.” Anxiety and nausea, he notes, can be caused by both mass psychogenic illness and acoustic weapons, but the noise would have to be incapacitating and high volume. None of the other symptoms reported in Cuba are associated with an acoustic assault.

And what’s more: “This is a small, close-knit community in a foreign country that has a history of being hostile to the United States,” he says. “That is a classic setup for an outbreak of mass psychogenic illness.”

History is filled with cases of “sounds” making people ill. In Kokomo, Indiana, locals have been plagued since 1999 by a low frequency hum, which one resident said caused, “short-term memory loss, nausea, and hand tremors.” In Taos, New Mexico, a similar sound causes resident “sleep problems, earaches, irritability, and general discomfort,” by one account. Similar hums are reported in Bristol, England, and Windsor, Ontario. In 1989, a “Low Frequency Noise Sufferers Association” was formed in London. The people reporting illness from the noise produced by wind turbines have given the phenomenon its own name: wind turbine syndrome.

Unfortunately, it is also possible to lose your hearing without being attacked by a secret weapon. The Handbook of Clinical Neurology volume on Functional Neurological Disorders lists “nonorganic hearing loss” in its chapter on “Functional Auditory Disorders,” alongside conditions like musical hallucinations, misophonia (“hatred of sound”), “acoustic shock” from a sudden noise (symptoms include “pain in or close to the ear,” tinnitus, balance problems, hypervigilance, and sleep disturbance), and others. In Germany, there is a common condition called Hörsturz, which is a sudden loss of hearing related to stress. In 1973, at a nursing school in Papua New Guinea, there was an epidemic in which students were struck deaf, among other symptoms, with no apparent external cause.

“It’s very easy to manipulate people’s physical well-being through giving them expectations about sound,” says Keith Petrie, who researched the power of the mind in relation to wind turbine syndrome. When Petrie and colleagues exposed people to both infrasound and sham infrasound (silence), they found it wasn’t the sound itself, but their expectations—or what’s known as the nocebo effect—that produced adverse physiological reactions. Witnessing another person with symptoms can create an even stronger response, as can the perceived cause.

“When we gave them a plausible, biological explanation,” says Petrie, “it increased their symptoms the next time they were exposed to sound. When we gave them a nocebo explanation—and both explanations were equally credible—their symptoms decreased.”

On the surface, studies like this make it easy to agree with the Marco Rubio line of thinking that sufferers are just faking it. But the people who were told there was a medical reason for the hearing loss are not just imagining the resulting symptoms—they are physiologically real, “medically verifiable,” and cause deep distress, even if they resolve quickly, as most do.
“People suffering from mass psychogenic illness are not hypochondriacs and they’re not all making it up,” says Bartholomew. “It is a real condition with real symptoms. It could happen to anybody.”

There is real crossover between the condition’s mental origin and physical manifestation.
Research into the nocebo effect has been hampered by the ethics of subjecting people to it, but a picture of the mechanisms is emerging. And one important factor is “abnormally focused attention,” as neurologist Jon Stone puts it.

“As human beings, we’re more prone to these phenomena than we like to think,” says Stone, co-editor of Functional Neurological Disorders. “The rate of functional symptom experiences in the general population is very high. People have these symptoms a lot and just normalize them. We’re never very far from a functional disorder.”

What were once known as conversion disorders (meaning the conversion of a mental problem into a physical one) are now referred to as functional disorders. The old terms like psychosomatic or even psychogenic imply a purely mental origin, but the current parlance reflects the more complicated picture, that there is real crossover between the condition’s mental roots and physical manifestation. A “functional disorder means something has gone wrong with the network, the connections, the pathways, as opposed to the physical structure of the brain. And when these functions go wrong, normal sensations like tiredness, dizziness, or pain can grow much worse and become persistent.

One of the findings in Cuba that reporters seized on was the assertion that victims had suffered some kind of head trauma. As Rosenfarb put it, there were “clinical findings of some combination similar to what might be seen in patients following mild traumatic brain injury or concussion.” Here, he appears to be talking about abnormalities in the patients’ white matter, but a concussion isn’t the only thing that can have that effect. White matter changes with experience and learning, and becomes more robust in response to using a given pathway repeatedly. If those pathways are related to a disorder, it may appear in “diffusion tensor imaging” scans as anomalies.

“Diffusion tensor imaging,” says Stone, “is a technique that shows abnormalities in patients not only with minor brain injuries, but also with chronic pain, anxiety, depression, you name it. This is not a mark of brain injury. It’s a mark of brain dysfunction. It’s evidence that they’re ill.”

One problem in understanding the reality of a functional disorder is that most of us, when we are ill, look for a single cause, a simple chain of events that starts with an event, or a germ, and ends with our own misery. But functional disorders don’t work in this linear fashion. They are recursive and multifactorial, a feedback loop between our expectations, emotions, and physiology. According to Mark Hallett, a senior investigator at the National Institute of Neurological Disorders and Stroke, a picture of how they work is beginning to emerge, in a sense that, “when the so-called limbic system of the brain [the part of the brain that drives instinct, mood, and emotion] is overactive, it might induce the different symptoms that arise.”

Which is to say that if we fixate on our naturally occurring experiences and feelings, they can become amplified, particularly if the limbic system is overactivated by fear and anxiety. This creates a kind of loop between mind and body that it can be difficult to get out of, and which can make these conditions difficult to treat.

“It’s very powerful,” says Petrie. And often underestimated. “From the comments I read by the physician associated with the [embassy attacks], it was interesting how he dismissed this explanation” Petrie says. “He didn’t seem to understand how easily this can happen.”

Most people don’t. That includes just about everyone involved in the Cuban attacks. Mass psychogenic illnesses are not as intuitive to grasp as cold or a flu, but they are just as serious, and should be treated as such. In Cuba, they have not been. Instead, a fixation on secret weapons has obscured a real illness with real consequences, one which can not only be “medically verified,” but which regularly afflicts people across the world, and to which anyone with a functioning brain is vulnerable.

Thank you for reading!  Dr. Lisa Lynn Sowder

I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity

I participate in a few doctor only on line message boards and forums.  A topic that has been front and center the past few months has been the #METOO movement and some of the challenges women in medicine face.  I’d like to share a few of my own stories.  Fortunately none of them include Harvey Weinstein.

I finished medical school in 1983.  1/3 of my graduating class were women.  These days women comprise more than 50% of most medical school classes.  I did my general surgery residence at the University of Utah, not exactly a bastion of progressive ideas.  Surprisingly about 20% of the surgery residents were women.  I felt very little discrimination but maybe I was just to busy and exhausted to notice?  I did get a couple of evaluations that I thought were just hilarious and still do. They were both from the Latter Day Saints (Mormon) Hospital.  One described me as “defensive, argumentative and with a chip on my shoulder”.  The other described me as “a sharp little gal”.  My boyfriend at the time just about split a gut laughing when he saw these. He was also a general surgery resident and never got such amusing reviews.

I had a few interesting experiences with male patients.  When I was doing an Intensive Care Unit rotation as a wet behind the ears intern at the University Hospital, I helped with a middle aged Mormon Elder who was crashing badly from acute pancreatitis.  (If you have never heard of this disease, count yourself lucky).  I was cleaning his penis in preparation to place a catheter so we could monitor his urinary output.  This man was very ill and a little delirious.  He looked at me and said “Doc, I’ll give you 10 minutes to stop that”.  It never crossed my mind to take offense at this.  It added a bit of levity (ha, ha) to a very serious situation.  I got to know this gentleman quite well during his ICU stay and he was a totally stand up guy.  On the gastroenterology rotation during my third year, I was doing a colonoscopy on an elderly man and he twisted his torso and neck to look me right in the eye and asked “What is a pretty little thing like you doing here?”  At the time, I thought that was actually a very good question!  This fellow grew up in a time where women rarely worked outside the home and certainly did not become surgeons.  Again, since I was the one with the scope, I felt no animosity towards him.

Dr. Henry Neal in 1990 with his girl residents, me, Sue Wermerling and Kimberley Goh. Can you tell that he secretly loves us?

My first year of my plastic surgery residency (after 6 years of general surgery) three of the four residents were women.  This was a fluke of the computer based residency matching system.  The chairman of plastic surgery, Dr. Henry Neale was a good old boy from the south.  He kept a bull whip in his desk drawer.  Really.  He was a great surgeon and ran a powerful department.  We operated our brains out and he had our back every day.  Dr. Neale was very, very politically incorrect.  He pondered if Sue, Kim and I would start cycling together and once stated he should put a Kotex machine in the resident’s office.  Well, the three of us just dished it right back at him and we did end up cycling together.

There was one occasion where I really felt harassed.  I was a 4th year general surgery resident on call at a private hospital in Ogden, Utah.  Late one night there was knock on my call room door.  I opened it to find an elderly staff surgeon with alcohol on his breath with a fifth of Southern Comfort (yuck!) in his hand.  He wanted to know if I wanted to party.  This scene was so ludicrous that I laugh out loud just thinking about it.  Most residents given the choice of sleep vs. party would pick sleep no matter whom was holding the bottle.  This man’s son was a medical student who had rotated on my service a few months previously.  I told the party hound horn dog that he had three seconds to leave or I would tell his son.  I think he was gone before I hit “two”.  I never assisted him on a case again which was no loss on my part because he was a lousy surgeon.  No, I did not file a complaint or make a fuss of this.  Again, he grew up in a different time.

I’ve had a few really weird patient encounters in private practice related to my gender.  Years ago when I was pregnant with my twin sons and could barely fit through a door, I had a mentally unstable older man with a skin cancer on his scalp the size of a poker chip.  This, gentle readers, is what we surgeons call a GREAT CASE.  The mentally unstable older man was quite the cad with many comments about my huge belly and the certain studhood of my husband.  He also had many bizarre ideas about selenium deficinecy and sexual function.  I was not sad to send him on his way once he had healed.  A few years later I had an elderly woman come in with another neglected and ginormous skin cancer who shrieked when she saw me and declared that “women are stupid and I won’t have one for my doctor”.  Oh well, that great case went to my partner who has a Y chromosome.  She was nasty to him too.

As I write this blog, I can’t really think of any weird encounters in recent years.  I think in the 26(!) years since I started practice that being a woman surgeon or woman astronaut or woman programmer or even race car driver has become sort of a no big deal which suits me just fine.  Recently my 17 year-old daughter took a field trip with her computer science class to the Microsoft campus just outside of Seattle.  She attends an all girl high school and they were given a tour by an all female coding team.  The advice given to these bright young students by these bright young and not-so-young techies was to work hard, advocate for yourself and don’t take things too personally.  I think that is good advice regardless of your gender or your workplace.

Thanks for reading and follow me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder, girl surgeon.  And there will be an upcoming blog about delayed childbearing which is something I don’t recommend but sure worked for me.

Not a good time to be having that eyelid lift.

Seattle Plastic Surgeon nags because she cares.

It’s that time of year again.  Roll up your sleeve and get your flu shot already.  Why should a “surgical sub-specialist” like me care about whether or not you’ve had your flu shot?  First of all, I’m a physician and it is my duty promote good health.  Second of all, I don’t want any of my patients coming down with the flu.  If a patient falls sick before surgery, we have to cancel and then reschedule the case which is hard on us meaning surgeons, anesthesiologists, surgical techs and nurses and it is also really hard on the patient because he/she has to carve more time out of a busy schedule and many times arrange for child care,  not only for surgery but for recovery.

If a patient comes down with the flu in the early postoperative period, he/she may end up wishing they had never been born.  That would make for a less than excellent plastic surgery experience and could also be down right dangerous.

And we tend to think of the flu as just an inconvenience with a little misery added but really, the flu can be very, very serious.  I am old enough to remember the Hong Kong Flu of 1968.  I was sicker than a dog and missed a week of school but was not one of unlucky million or so who died.  And then there was a Spanish Flu of 1918 that killed 50 (!) million mostly healthy, young people.  Sorry to be such a fear monger but I really want you to get a flu shot.

Thanks for reading!  Dr. Lisa Lynn Sowder

P.S.  Get your flu shot.  Today.

Seattle Plastic Surgeon implores patients not to fall for “Botox on Sale”.

Occasionally I have patients come in for Botox or fillers who have flitted around from doctor to doctor looking for the “best price”.   I hear statements like  “the last Botox didn’t work” , “the Restylane didn’t last”, “I’m not sure what she used but I didn’t like it”, and this is my favorite, “it was on sale but it didn’t last”.

This flitting around in search of a “deal” makes it very hard for a hardworking plastic surgeon (moi, for example) to figure out what, where and how much injectable to inject.  In my practice, we keep very accurate records of all of the above so I can judge what works best for any given patient.   And believe me, every patient is different.

Sometimes I think just because it is “cosmetic”,  patients don’t take these treatments seriously enough.  I cannot imagine anyone shopping around for the “best” price on, say, steroid injections into a bum shoulder or the “best” price for an hour of psychotherapy!

Usually continuity of care provides the best value of all, even if the prices are not bargain basement.  So for injectables, find a good doctor and stick (nice pun, huh?) with him/her.

Thanks for reading and follow me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

Seattle Plastic Surgeon (and mother of three) Dr. Lisa Lynn Sowder nags her children and you about lawn mower safety.

It is such a wonderful thing to get some yard work out of my offspring now that they are old enough to mow, rake, sweep, weed, water, trim, edge, poop scoop, etc.  As much as I love the smell of newly mown grass and the thought of them working (instead of me), I worry.  I worry about the lawn mower thus the little nag session each and every time one of my boys has been nagged into mowing the lawn.

Here is my list of lawn mower safety tips.

• • • • Only children over 13 should mow a lawn.
      • One person only should be on the lawn being mowed.  That would be the person behind or on the mower.
      • NO PETS unless it’s a rabbit you really wish you had never adopted.
      • Always wear socks and heavy shoes and gloves.
      • Always wear eye protection.
      • Ear plugs okay but not no ipod listening.  They need to hear you yell, “Watch out for the dog!”
      • No mowing until the offspring has cooled down from his/her rage at having to actually perform agreed upon chores for agreed upon bennies.  Rage and lawn mowers should never coexist.
      • If the mower malfunctions, turn it off and don’t even think about flipping it over unless a knowledgeable and responsible adult is present.
      • Leave sharpening to the experts.  Oh, unless you work in a lawn mover sharpening shop, you are not an expert.
      • No using the lawn mover for anything other than mowing the lawn.  This calls for a cautionary (and I swear to God true) tale.  Two patients in the same day present with nearly identical lawn mower injuries sustained while attempting to trim a hedge with a lawn mower.  Patient #2  happen to see patient #1 (prior to his mishap) trimming his hedge with the lawn mower while Patient #2 was driving to get gas for his lawn mower and thought “Hey, what a great idea.” Not.

Stay tuned.  One of these blogs I will tell you about my dad’s snowblower injury.  His bloody glove is still nailed to the wall of his shop some 30 years later.

Thanks for reading.  Dr. Lisa Lynn Sowder