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Overcoming Chronic Pain

[3:24] Early childhood trauma [10:25] TMD and unreleased anger [14:03] Anxiety

[16:48] The freeze response

[21:03] Emotional repression and polyvagal theory [26:16] Chronic illness unfolding

[29:26] Scleritis

[33:05] Physical expressions of prolonged survival responses [35:57] The paleo diet

[40:42] Validation

[46:42] Priming the body for chronic pain [48:06] Pyroluria

[51:35] Befriending pain and releasing repressed emotions [58:43] Shaking, tremoring and nervous system energy

Danny Urbinder: There can be no doubt about the enormous and transformative contributions modern medicine has made to the management and treatment of disease. By the turn of the 20th century, medicine had discovered penicillin, antibiotics and vaccines, all of which proved invaluable in overcoming a raft of infectious diseases, many of which have plagued humanity for centuries. Rapid scientific breakthroughs and advances in technology have also seen the development of life-saving procedures and drugs, improving the lives of countless millions of people.

Although the scientific understanding of disease has driven these advancements, we also need to recognise that this has been underpinned by a philosophical assumption known as reductionism. This model of reasoning seeks to understand complex systems, such as human beings, by reducing them to their smallest component parts. So, for example, if you want to understand thyroiditis, you first need to examine the affected cells and structures of the thyroid gland.

Likewise, if we want to study tuberculosis, we need to look at the bacteria that cause the infection and how this affects the cells and tissues of the lungs.

This approach has been especially successful in the treatment of infectious diseases. Nevertheless, with all these advancements, we are also becoming increasingly aware of the limitations of this reductionist model of medicine. This focus on singular factors leaves little room for contextual information, such as how a person's lifestyle, diet, sleeping habits, psychology, emotions and environment collectively contribute to disease.

Reductionist medicine also defines disease states as deviations outside normal ranges. Health is characterised by singular linear and predictable factors that are viewed as a collection of static components, rather than dynamic and rhythmic interactions between body parts and systems.

It’s due to this disregard that we’ve not only seen a steady rise in the incidence and prevalence of chronic disease over the last 50 years but also why conventional medicine has failed to address this challenge. Chronic disease is a complex and multifaceted manifestation of a struggling system and it requires a comprehensive understanding of the whole person to identify underlying causes.

A systems-oriented approach such as that seen in functional medicine and naturopathy recognises that all biological systems possess emergent properties that are only expressed by the system as a whole and not by any isolated part of the system. We are networks of structure and function and health is determined by the dynamic relationships between these factors.

And, nothing demonstrates this fact better than the story we're about to hear. Nathalie Paul lived by most people's standards a very successful life, but this came at a price. She was stressed, disconnected from the messages her body was sending her and lacked awareness of her emotional needs. Down the track, she was faced with intense physical pain and chronic illness, which led to some deep discoveries about he                                                       Natalie first began her story by describing her childhood.

Nathalie Paul: From an external point of view, my childhood looks great. I was born in Africa, my parents are lovely, my dad is a doctor, was successful, my mother, lovely woman. I have a brother. Everything was going great. When I was 7 years old we moved out of Africa and we moved to France. We actually moved very quickly and for me, that was a major event that affected my life. And, I didn’t understand, like my parents didn’t give me an explanation. And, as a kid, what I did, and I remember myself, I was asking questions but I didn’t have the answers, so I remember myself switching a button and telling myself right now, you're just going to do what you're being told, and then one day you will realise your dreams and do whatever you want. I basically repressed all my emotions and yeah, that’s what happened.

Howard Todd-Collins: At a very young age, if any of our needs are not being met or neglected, or maybe denied, or even just in some way avoided emotionally, if not physically, at a very young age, kids at 7 will just internalise it.

Danny Urbinder: That’s Howard Todd-Collins, a psychotherapist and relationship counsellor with a special interest in meta-emotion. That is the feeling about feelings and the messages we’ve been taught regarding their emotional expression.

Howard Todd-Collins: And, in some respect, that kind of goes into the sort of dismissal, suppression, repression beginnings early on where, if a 7-year-old can’t express her excitement or her worry or her fear about moving to France, for example, exciting as it may sound, it may have kind of instilled some real fear for her at the age of 7 - leaving friends behind, leaving family members behind. So, if those conversations weren’t obviously apparent or they were denied too quickly or they were neglected, then she would have just internalised them in some way. Which kind of goes into that sort of early risk of repression suppression, not allowing to speak openly or being confused by feelings of excitement and fear for example at a very sort of early age. Which, I guess as a formative experience then, possibly for Nathalie she would have learnt to take that into her adult life, that she would have learnt to dismiss her needs and feelings, partly because of that experience and just to push on and move on.

And, you know, some parents with the best of intentions will just say, ‘you know this will be fun, France will be amazing’ but not really sort of paying attention to some of the fear or the unknown parts of that experience, you know. For a 7-year-old who has a language, 7-year-olds have some kind of formative language of being excited or scared or worried or anxious.

Dr Veronique Mead: If a child cannot express how they're feeling about something, if they completely have to follow the direction of the adults, if there’s no room for the emotions, whether it is grief or anger, those, that need to repress or suppress or hold back the ability to communicate, that’s actually an example of trauma. It's an example where you're unable to mobilise through regulating emotions.

Danny Urbinder: You're listening to Dr Veronique Mead, a physician and somatic trauma therapist whose research has led to a broader understanding of the origins of chronic disease.

Dr Veronique Mead: Trauma is not just a, it’s often thought to be an extension of stress but, it's actually not a continuation of the stress response. This is some of the work from Rachel Yehuda who’s one of the big researchers in the field of trauma and traumatic stress and Alexander McFarlane who’s in Australia, another big researcher, where they talk about a difference happening in threat signalling so that an experience that cannot be overcome. We actually had to disconnect or dissociate, that was the only way to survive that particular kind of event. If we’re not able to successfully overcome something that has a negative influence potentially on us, it may or may not be life-threatening, it may just be a big threat, when we aren’t able to overcome that, our growing understanding is that our physiology, it all sends signals to the nervous system that this has not been completed. This threat response, this successfully overcoming has not actually happened. And, that seems to be what stimulates a threat signal which was sort of set up as a survival response to keep us alive, because there’s a sort of perception we’re still in danger.

Danny Urbinder: When we think of trauma, we commonly imagine an external life-threatening event or physical abuse. But, as somatic experiencing therapist Sally Stower explains, trauma can come in many different forms and is a highly subjective experience.

Sally Stower: So, traditionally people will think about trauma as being an event, yeah. So, it’s like a natural disaster or war or conflict, or it might be a sexual assault or it might have been sexual abuse, you know. It could be a car accident, a plane accident, those kinds of events per se.

People also attribute trauma to things like the early developmental traumas like childhood, you know, abuse or neglect, emotional neglect, misattunement, abandonment, those kind of things. But, I guess from this perspective, and a quote from Peter Levine, who’s the founder of somatic experiencing, and that is that trauma is not actually in the event, trauma takes place in the nervous system. And, another quote would be, from say, for example, would be from Gabor Maté which is, that trauma is not what happens to you, it’s what happens inside you as a result of what happens to you.

Dr Veronique Mead: My own favourite definition is by a neurologist in rehab medicine, Dr Robert Scaer, who talked about it as any negative experience that happens when you are in a state of relative helplessness. And, so, this concept applies and highlights how much more sensitive we are earlier in life from a perspective of our own stress response.

Nathalie Paul: From the age of 7 I had a problem with my jaw, with my teeth, and they, the, so I was seeing a dentist, and they were blaming my speech, my tongue, and they didn’t investigate what was going on. At the time it was more the way I was swallowing, the way I was breathing, you know the posture I was having. So basically, I always needed to relax my face and just open my mouth and so it was like oh, you should, you must have a problem with, you know the way you use your speech or how you speak. But, actually, there was a real, something that was remodelling inside the structure that was making me behave this way. And, it's only like years later that I actually you know connected the dots and when I went through my flares of Crohn’s and spondylitis that was actually, that’s where I got the answer. The problem with my jaw was an autoimmune problem. So it definitely started when I was 7, 8 and they were blaming the position of my teeth my tongue.

Danny Urbinder: What Nathalie is describing is a temporomandibular disorder or TMD. Depending on the severity, TMDs can affect a person's ability to speak, chew, swallow, make facial expressions and breath and can result in chronic unrelenting pain. Studies have shown that TMDs exist in some autoimmune diseases, but the cause of TMD is considered multifactorial.

Among others, sleep bruxism or teeth grinding and psychological factors seem to be involved in the initiation and maintenance of symptoms.

From a psychological perspective, extensive research shows that humans hold their emotions in their muscles. Different emotions when not released can be trapped in various parts of the body, and each emotion has a particular place in which it usually manifests. The unexpressed emotion associated with jaw pain is usually anger. Interestingly, anger is identified as a secondary emotion, meaning it’s an emotion fuelled by other emotions. Typically, we experience a primary emotion like fear, loss or sadness first. Because these emotions create feelings of vulnerability and loss of control, they make us uncomfortable and one way of attempting to deal with these feelings is by subconsciously shifting into anger. Interestingly, gender socialisation can affect how men and women handle their anger.

Traditionally, men have been encouraged to be more overt with their anger, women have been encouraged to keep their anger down. The physical manifestation of this might be to squeeze the mouth shut, commonly resulting in TMD. This may in part explain why TMD is up to 2 times more common in women compared to men.

Dr. Veronique Mead: I think this is a component. Women in our culture are not listened to as much as men. And, so this can begin very early in childhood because our parents grew up in that same environment. The more we westernise our culture, we value the hypomanic, disconnected phase, the less we are in touch with our emotions, the less we give permission to feel grief and express grief, and the less we communicate anger in a direct way.

Nathalie Paul: I remember that during my entire life until I was physically sick and until I was, I had excruciating pain in my body, I was always planning and looking for the next thing to do. So I was never able to really be in the present. I was always like okay, now I'm home, I'm going to plan for the next day, plan for the next moment. So, today I have an awareness that I was very anxious, but I didn’t know what it was. Like, I was always on the go, go, go, go, planning what’s next and yeah, that was definitely driving my life.

Howard Todd-Collins: Anxiety is a natural part of being human, you know. Most people want to avoid it, we think we can control it. So, when we’re trying t control it or avoid it, then we can’t be in the present. If we’re in the present moment, anxiety disappears, we don’t think about the future or think about the past. So, in some respects, the idea of hyper-vigilance, when we’ve been so used to living slightly ahead of ourselves or being stuck in the past, the brain itself can’t actually settle and regulate. We’re always looking for the next kind of thing to do, or for some people, it’s like the bear in the woods or the rabbit in the headlights, something is about to happen next. So we can’t stay present, we’re always looking for something around the next corner. Which makes us lose perspective of what we can control within our own thinking and being, in terms of our brain, our emotional lives.

Sally Stower: The mind logically knows that the trauma’s over. I mean, I hear this so many times in sessions where ‘oh that’s not a trauma, I know that I'm safe right now, that happened in the past, that it’s irrelevant. But, then when I tap into the behaviours or the responses or the reactions, all of a sudden we realise that what was happening in the past is still present in their body, in their nervous system right now. It’s as if the tiger is still chasing them.

Nathalie Paul: Initially, so I studied finance auditing, so I was a consultant for a big firm which was very stressful, yeah. I was out of my place Monday to Friday and then working 12 hours a day, travelling a lot, so pretty stressful job.

Sally Stower: Trauma is like trapped energy in the nervous system. So, not only does it affect our health and our wellbeing, and of course, I went straight there because I work with a lot of chronic illness, but it absolutely, it affects all of our behaviours, how we react to things, how we respond, the decisions we make in our lives, you know. If I think back on my history, the types of jobs that I went for, you know, the studies that I did, in the relationships that we get into, so it affects every part of our lives.

Nathalie Paul: On the paper, I was married, I had a career, I had a good life, I had friends, I had a lot of money, but inside I was not speaking up. I was not sharing what was going on, always faking, I was on the go-go. I was very strong, and I could feel that I needed to speak up. There was something that needed to explode inside me, but this, this is what I went through with, for me, a message to really embrace myself and stop living pleasing people.

Dr Veronique Mead: There’s not a problem if we disconnect once in a while. We focus so intensely on something that we’re not paying attention to what’s going on around us. But, I think this is a hallmark of those of us who develop a chronic illness. That, at some level, at some point, something got disconnected. So, it may be that something within our physiology had to shut down, which is a form of disconnecting. It’s like, in the cell danger response, when cells may actually stop communicating with each other, that’s a form of shutting down and disconnecting. It can happen emotionally, because if you can’t get support for difficult emotions in your family system, what else can a child do. It may be that they get support from another adult such as a teacher or coach, but if that isn’t in the environment then shutting down can be the only option.

And, this is not a conscious choice, this is actually an automatic, autonomic, physiological response where our bodies go into a survival mechanism.

And, this people-pleasing thing is much more of a feminine trait, but it can happen in men as well. But, it’s, it’s a survival response where we can end up trying to take care of the caregivers so that they can show up more for us. And, so that can mean sort of adding more layers to this, where the child may become more of a caregiver, where they may disconnect from themselves in order to do what will keep them surviving and keep the family system happy, or with less conflict.

And it can then mean that we stop actually listening to what our system is saying or what our gut’s, you know, we always talk about listening to your gut and that’s something that we don’t validate or support a lot in our western culture. And, so if you're not listening to your gut, you may end up in a very successful career, but it may not be one that feels particularly satisfying. Or, it may be way more stressful than you want because, if you're disconnected, you're not actually doing self-care, you’re not listening day to day to the rhythms or the cycles of what your system needs, like more sleep, or more rest, or different food. And, so that begins to layer upon layer the things that we do and our experiences that can keep feeding and strengthening that cell danger response pathway that we have, or that our systems have tucked away, waiting to know that we’ve overcome it, overcome or survived.

Howard Todd-Collins: In some way, back in the day, it served her reasonably well. She had a career, she made choices and she and she found herself in a very stressful job. Ultimately, I think she began to realise that that level of living and way of coping was not working for her, it was showing up physically, but also in terms of her emotional experiences. But, back in the day, it was a survival thing, it worked for her pretty well. These things have a use-by date, they tend to, where we have to stop running and start being.

Nathalie Paul: Then, I decided to change, and so I became a personal trainer and fitness instructor. And, yeah, I had this revelation that okay, I want to do that and I was super happy at that level, like career-wise. So, what happened is I felt a relief, some sort of renewal in my body. But, the truth is, in my personal life, there was still something that I was, I was hiding. And, so that job, being a personal trainer, fitness instructor, I was happy all day but, to be honest, when I was going home in my personal environment, there was still things that I couldn’t, I was not sharing.

Even with my friends, I would say I was very always on the surface, like faking. I was heavily emotionally repressed.

Dr Veronique Mead: I have come to feel that there isn’t really a difference between repressed emotions and trauma. Repressed emotions may be one subset of trauma and I don’t know that it’s 100% conscious. It may be that we're aware of having kind of made that decision, but we’ve also made that decision because of circumstances. And, when that description arises, there’s a whole context in which if a child cannot express how they're feeling about something, if they completely have to follow the direction of the adults, if there’s no room for the emotions, whether it is grief or if it’s anger, that’s actually an example of trauma. It’s an example where you're unable to mobilise through regulating emotions and that actually leads to this concept of polyvagal theory, where we go beyond fight flight freeze.

Polyvagal theory is the work of Stephen Porges in the US who does research in this area. And, our common understanding is that there are two branches to the autonomic nervous system, the sympathetic and the parasympathetic and that the sympathetic manifests the fight-flight and the parasympathetic regulates freeze. What Porges’ polyvagal theory adds is a second branch in the parasympathetic and that second branch in that parasympathetic is actually the very first line of defence that mammals, animals, that humans use and that he refers to as the social nervous system or the social engagement system.

It’s also known as the smart vagus, and that’s where bonding is involved. This is the use of our voice, our language, and our facial expressions.You can look at someone and know if they want you to approach or to stay back. It’s a very energy-efficient use of communication as a way to regulate our systems where safety is, and bring others in to support us. This is what babies do with parents and bonding and that facial, face to face gazing contact and that’s part of why it’s so supportive of a sense of safety that gets conveyed to our whole system.

So, coming back to an experience like Nathalie’s, children are not actually able, our systems are not mature enough to be able to fully regulate our emotions at birth. We also, as humans, can’t regulate our physiology, our blood pressure, temperature, our respiratory rates, and heart rates, they all are less stable when we’re not in the presence of an adult caregiver. So in an experience like Nathalie’s where it seems like there was really no opportunity to get support for regulating difficult, painful emotions around an event she had no control over, that would kind of fit the definition of a traumatic event, or something that could not be overcome through communication. That first line of defence of the social nervous system, or fighting or fleeing, is not an option for a

child in her situation. It could be if she was an adult if she chose to stay home in Africa, and so that leads you to the freeze state. That’s where things get repressed, that’s where things get held back, that’s where the cell danger response, or the nervous system response, actually has to shut down, turn off, to wait until things get better. Which is kind of the way it sounds like Natalie understood and recognised what she kind of had to do at that point.

Nathalie Paul: I know that during those years between 7 and 30 years old, every year I had a weird disorder. I had something going on and it was very, for a very short period of time. It was weird, I had a thyroid problem, I had a skin problem, I had a stomach problem. But then you know, it was resolved with a pill, maybe some Panadol maybe something like that, ibuprofen and it was gone. So obviously doctors were saying, oh, yeah we don’t know what’s going on, but now its resolved. So I would say that’s after 24, so gradually stomach, thyroiditis and the jaw, the jaw pain was becoming worse.

Danny Urbinder: By the age of 24, Nathalie’s jaw problem was becoming more painful and seemed to coincide with the development of chronic gut pain. At the age of 25, she also developed subacute thyroiditis, an uncommon immune condition thought to be the result of a viral infection. Subacute thyroiditis first results in hyperthyroidism, followed by hypothyroidism until hormone production returns to normal over a 2-6 week time frame. Most cases of subacute thyroiditis are caused by a variety of viruses, including coxsackie, cytomegalovirus, adenovirus and the Epstein Barr virus. Interestingly, Nathalie later tested positive for Epstein Barr virus- specific antibodies.

Most of us get the Epstein Barr virus early in life and it’s inconsequential. We manage to suppress the virus until the amount is negligible. It’s still there, lying dormant in the background, but without causing any symptoms. However, under certain conditions, such as a suppressed immune system, the Epstein Barr virus can be reactivated.

We know of several factors that can contribute to immune suppression including lack of sleep, low vitamin D, a high sugar diet, alcohol and certain medications. However, one of the most significant factors is stress, which has been shown to suppress immune function and paradoxically exacerbate autoimmune and inflammatory diseases. Researchers have also found that the presence of traumatic experiences before the age of 16 altered the immune function and was connected with stress-related inflammatory markers, such as highly sensitive c reactive protein, which indicate a compromise in the immune system.

There’s also a link between an Epstein Barr virus infection and autoimmunity. A study published in 2018 showed that Epstein Barr virus infection drives the activation of genes that contributes to an individual's risk of developing autoimmune diseases, including inflammatory bowel disease and ankylosing spondylitis, two conditions that Nathalie would later be diagnosed with. Another grave and debilitating condition, as Nathalie would soon discover, and which may be the initial manifestation of these underlying diseases, is scleritis.

Nathalie Paul: Because I had eye surgery maybe 6 months before I got the diagnosis of posterior scleritis, I started to have headaches, a lot of fatigue, brain fog and said I don’t know what’s going on. Like, I have a lot of pain in my head, I'm tired, and he looked at my eyes and he said ‘yeah, there’s nothing wrong, so you must be stressed’. And, I was really enjoying my job at the time so I was loving training people, loved it. So, basically, I went to see the surgeon and I asked him what was going on with my eye and there was nothing wrong. So that was, you know, that was really hard to feel invalidated like that.

So I kept, I kept living, kept taking some Panadol and ibuprofen, like 3 times a day, and nothing was working. And, so what happened just, we had this plan with my ex-husband to come to Australia, and I was like well, we are going anyway. I just want to sort out this problem because it’s becoming really, really annoying. It’s impairing my ability to focus and to work. So, I actually mentioned it to my doctor, but no one did, no one wanted to investigate. I went to see my GP and nothing was obvious, like my eyes look really good, I just felt like okay, I must be stressed.

The thing is, a month before we left France, I woke up as if I had been stabbed in the eye. So you know, like you're sleeping and get a stab, horrible. So, it was like 3 or 4 am and I called the, you

know, emergencies and I said this is what’s happening and, for the first time, they said yeah. They almost didn’t consider my case. I was really surprised. They just said yeah, if it happens again. So I just felt really lost, to be honest, and it had to happen like the third time probably in a month. The third time, one morning I was so exhausted that I had to tell my clients I could not move, I was on the floor. I was just on the floor, the eye pain alone, I could not move anymore. And my ex- husband was like ‘what’s happening’ because he had never seen me like this. He was like ‘well usually you are strong, just do something’. And, I was like, I just can’t and it was the first time, and I heard myself, that’s a very, very tipping point in my experience, to say I can’t do it. When I said that to my ex-husband, I said I can’t, I can’t do it, I was like feeling so much embarrassment and yeah, like, shame that I can’t. It’s like my body, I would love to, I have to talk to my client now and I cannot go. And it was just the most horrible thing I did, to pick up the phone and say I'm on the floor, and I just cannot honour this session right now, because my body just, I have too much pain, I can’t move.

I just, that’s when things started, I was taken seriously, and then from that day I took, the whole week I went to do some tests and it took oh, one to find out that I actually had the back of my eye completely cracked open, bleeding. And, they said oh, yeah, okay, you must be in severe pain and so they put me on prednisone, prednisone 60 milligrams per day, which is a big dose. And then, I was like relieved, but until like, it took them like a week, or 10 days of testing and brain scans and stuff because we could not see anything at the front. And they said ‘oh yeah, you must be in pain’. Yes, I am! So that’s the first moment when they gave me some prednisone and I was relieved.

Dr Veronique Mead: We need to also not forget the freeze response. Robert Scaer’s definition of trauma is that it actually doesn’t happen unless you have a freeze response. We may get stuck in whatever was happening at the time, which may be, we're trying to flee or fight, and then freeze happened. Your system shut down because you aren’t going to be able to escape the bear. We think of these as maladaptive, but they're only maladaptive because they’ve gotten stuck and the reason a freeze response comes in is to help us survive something that we actually don’t have the capacity to deal with.

A child not being able to regulate their emotions, it’s so overwhelming that you actually disconnect so that you don’t go crazy so that you don’t go out of your mind so that you don’t lose it. So this would be the kind of thing I would be looking at throughout her life, and I would be curious about whether the back pain, the eye pain, these autoimmune components, and the thyroid component, are each their own expression of a survival response that’s gotten prolonged. So the thyroid is involved in the threat response, what it would be doing if it was caught in a snapshot of time and that moment was prolonged. Would that look like hyperthyroid, or hypothyroid?

The gut is involved, when we prepare for fight or flight, we might actually shut down all the things that aren’t necessary for this moment. And the scleritis, I'm not familiar with in great detail, but looking it up, the sclera helps hold the globe of the eye in a certain shape and the muscles for eye movement or the ligaments attach there. And, so I would be curious, is there, was there some sort of experience for her around eye movement and what she could look at or could not or even a significant event where she may have had to avert her gaze, for example, could that be an original? And, we're not always going to know this and I suspect it’s going to be completely different for every person but, once you start to think in this more global context, then you can start to think all the symptoms may be being linked instead of separate disease with separate causes.

Nathalie Paul: So, I flew you know, I flew to Australia with 2 bags and a script of prednisone for yeah, they told me we’re going to have to stay in contact because you're going to have to wean off this medication at some point. So, in my mind I was like oh great, I feel so good now, the pain is gone. So, I took my pills for you know, maybe it was a week or 2, very high dose, and then the moment I started to ween off, then the pain was coming back. And, then I started to communicate with a new doctor in Australia because I had to find a new doctor you know, where I was living.

So, they kept me on prednisone, so I stayed on prednisone for a long time. I carried on with okay, now I have to fix, I have to fix, I have to be fixed, I have to fix the pain in my eye and also there is stomach pain and it’s getting worse and as I'm taking prednisone it’s getting worse and worse.

So, again, I didn’t pay attention to my emotions and I was trying to get fixed. It was only getting worse, and I was lost with the doctor telling me, just giving me scripts of PPIs and prednisone. And, because that was the only solution they were giving me, I started to question nutrition.

Because I was still, I was working as a trainer and being a personal trainer, I was hiding what was going on, and I was not sharing with anyone that I was taking some prednisone. And, I was listening to the conversations around me, and one of the trainers one day mentioned the paleo diet. And, I was just like hmm, what is that? And the stuff they were talking a lot about, it like oh, you know it’s, you know, can help you with inflammation. And, I did my research and, one day, and because I’m kind of, when I decide on something, I go full for it.

I was eating well, I was still eating some grains and it’s interesting because at the time I thought okay, I'm eating organic food, it’s good, but I was not connecting the dots with how do I feel when I eat this. And, that’s when I actually became, I started to become aware of that when I actually decided to go on this paleo diet full on. And, the truth is, after 1 week, my pain went down. It was like, oh my god, that’s miraculous. I did the paleo diet super strict, no grains, I was eating salmon every day, greens every meal, and after 1 week, my pain went down. And, the truth is I think after 6 months I managed to wean off prednisone and I stopped, so I was really happy with that. So, diet works, I thought diet was doing the thing. So, I was like that’s the diet, the problem, so I'm going to stick to paleo all my life and that’s going to work.

Danny Urbinder: The paleo diet is a dietary plan based on foods that approximate what may have been eaten during the Palaeolithic era and limits foods such as dairy products, legumes and grains, which only became common when farming emerged about 10,000 years ago. It also avoids processed foods, a typical feature of industrialisation. The reasoning behind this thinking is that the human body is genetically mismatched to the modern diet that emerged with sedentary agriculture, and has outpaced the body's ability to adapt.

This mismatch of genomic evolution and the modern-day diet is believed to be a contributing factor to the prevalence of many chronic inflammatory diseases including diabetes, heart disease and autoimmune diseases. Recommendations vary, but in general paleo diet guidelines include fruits, vegetables, nuts, seeds, grass-fed animals, omega 3 rich fish, and oils from fruits and nuts. Grains, legumes, dairy products, refined sugar, salt, potatoes, and refined foods should be avoided.

A number of randomised clinical trials have compared the paleo diet to other dietary plans such as the Mediterranean diet or the diabetes diet. In one study over 2000 participants in each group consumed the list of foods that would fit into each diet pattern. The results were similar in both groups, although the consumers of the Palaeolithic diet decreased their all-cause mortality, decreased oxidative stress, and also decreased mortality from cancers, specifically colon cancers. Nathalie found that this diet had allowed her to come off prednisone, which she was taking to decrease the inflammation associated with her scleritis. However, while her pain had significantly diminished, it was not the solution to all her problems.

Nathalie Paul: So, I managed to wean off the prednisone, I had no pain in my eye but there was still something going on with my stomach. And, someone said ‘hey, maybe you should have a test and see if you have an IBD’. And I said like what is that, and they said you know these inflammatory bowel diseases. And, I was like yeah, but no one has that in my family, and they said oh yeah but, you know, with your story, maybe. And, so it’s almost like I pushed my doctor to ask for a test and I actually, I was at the stage where I was very thin. I could not eat too much because of the pain in my tummy, in my stomach.

And, I did that test and then the guy just sat next to me and said, you have Crohn’s disease. And, he said yeah, you need to take those immunosuppressant drugs, and he got a script and he said now you can talk to the doctor, and he gave me the gastroenterologist's name. And, I went home and I was like, I have Crohn’s disease, and that was just you know, coming out of nowhere.

The thing is, I was in shock, but I didn’t have the tools as well to handle my emotions. So, I was like, my only way to cope was to spend time at my desk and then I started to study like crazy, what is Crohn’s disease. And, so it was giving me a reason to, I was okay because I could

understand. So I started to yeah, print out all the research I could find about Crohn’s disease and I thought okay, now I'm going to do my best to heal this. I don’t know how, so I had, I was obsessed with my diet. I was seeing a nutritionist, naturopath and I was on a mission. I was like okay, now I have Crohn’s disease. But it was really hard to believe it because it's like you, you are labelled now with a, you are sick.

Danny Urbinder: Crohn’s disease is a type of inflammatory bowel disease resulting in inflammation that may occur anywhere in the digestive tract, and often spreads into the deeper layers of the bowel. This autoimmune disease can be both painful and debilitating, causing abdominal pain, severe diarrhoea, fatigue, weight loss and malnutrition. However, while Crohn’s is best known for its impact on the gastrointestinal system, its expression isn’t limited to digestive problems. Many people living with Crohn’s also experience psychological or emotional effects including depression and anxiety. This may be compounded when there are repeated negative medical encounters over a long time frame. Nathalie’s experience with her doctors for her jaw, scleritis and now Crohn’s disease had often involved dismissal and invalidation. Nathalie managed to cope by diving into the medical literature and taking responsibility for the understanding and management of her condition. Had she not made that decision, her experience may have not only involved physical suffering, but also needless emotional suffering

Howard Todd-Collins: The opposite of validation is invalidation. Psychologically, if we stretch that out a little bit, it tends to look like self-criticism, self-loathing, self-hatred, self dismissal, self- harm, you know. We can expand it out to people that eventually suicide, where the need to be understood, acknowledged, heard, seen, recognised, and empathised with, they're all parts of what I would call ‘holding therapeutic space’. Those are the ingredients that need to happen in lots of professional practice modalities, including you know, doctors. This needs to be held within intimate relationships and friendships, as well as parenthood.

So, the strand of validating is so important to feel heard. Most of us sometimes feel like if we're struggling with something, we're the only one struggling with it, which of course is generally not true. Most of us have some sort of shared humanity in dealing with life and even in Nathalie’s story, there are plenty of stories probably very similar to hers who showed up in all these kinds of similar ways. So, validation, I would say, validation and empathy and acknowledgment is the sort of, the life source of humanity and it’s an essential part of any kind of treatment modality, but certainly an incredible part of being a human being.

Sally Stower: You and I have had this conversation before and it’s something that I am incredibly passionate about and that is the trauma of the medical system. And, you know, like these interviews that you're having with these people, I'm having them with every single client that walks in through the door that I see, has had a medical system experience of trauma, yeah. Where they’ve been not listened to, they’ve been not heard, they've you know, being dismissed and they’ve gone from doctor to doctor to doctor. And I’m, I gave a presentation 18 months ago to a group of doctors, and at the end of it I said, ‘if there’s just one thing that you can take from me today, and that is that this may be the first time that they’ve ever been heard or listened to or understood. And don’t ever underestimate that.’

Nathalie Paul: What happened is my jaw started to flare, I could not eat because of massive pain in my digestive system, was very, very weak, my skin, my body was really, really weak to the point, I should not touching my, it was horrible. I was just very, very sensitive. I could feel pain, nerve pain, fatigue and the thing is the eye pain for some reason started again and I had this pain in my face and then the jaw started to be painful, as well. Everything, slowly, it was like a systemic pain, it was my whole body in pain.

Ananda Mahony: Trauma can act to prime the body, more specifically, the central nervous system, brain and immune system and drive chronic pain outcomes.

Danny Urbinder: That’s Ananda Mahony, a naturopath and clinical nutritionist with a particular interest in the holistic treatment of chronic and neuropathic pain.

Ananda Mahony: Maybe, we need to step back and say, we are bioplastic and changeable and in chronic pain, what has been identified, apart from priming of that neuro-immune interface, and

perhaps sections of the brain such as the amygdala, generally the peripheral and central nervous system undergo changes. And, that means that those threat messages, obnoxious stimuli that come in from either actual or threatened damage, are routed and processed in different ways.

And, so there are no plastic changes if you like, or maladaptive changes all the way across the central nervous system and brain. And, this helps drive that progression to chronic pain, so there might be priming there but there are also maladaptive changes. I guess we could call them maladaptive changes, in acute pain, they’re appropriately adaptive but, they become prolonged and persistent and they sensitise our nervous system and brain to all sorts of triggers that might contribute to a painful experience.

Nathalie Paul: I did see a naturopath, I did some testing and then she, she helped me find food I was intolerant to. So yeah, she definitely helped me, you know, healing my gut. She found out that I had candida and so she put me on a very strict candida diet and gave me some supplements.

And, what happened over a period of 5 years, as I was seeing a naturopath, nutritionist, I was getting better and then I was relapsing, and then I was getting better and relapsing. And, it was like that from 2010 to 2014, you know.

I did a pyroluria test as well, because I was stressed out and had brain fog, so they helped with fine-tuning which supplements I should take. They did a test with zinc and copper levels and my copper was like through the roof. In a week I remember taking the mix of supplements, B6, B5 and magnesium, and it really helped me because, yeah, I had suicidal ideas, I was like how come. I really want to heal, I’m a strong person, so yeah. Within a week after having this diagnosis and then taking zinc, B6, magnesium and then also my, I was paying attention to the foods I was eating. I was eating liver every day, taking some cod liver oil, that really helped me as well. Eating oysters every second day, I was really like paying attention to super-high nutritious foods, and within a week I was like ooh, that’s working.

Danny Urbinder: After doing a urine test, Nathalie was found to have pyroluria, a chemical imbalance involving an abnormality in haemoglobin metabolism which results in the excess production of a bi-product called kryptopyrrole. Kryptopyrroles bind to vitamin B6 and zinc and remove them from the bloodstream to be excreted into the urine as pyrroles.

The effect of pyroluria and the deficiency of zinc and B6 can be mild or severe, depending on the extent of the imbalance. The combined effect of B6 and zinc deficiency can have a significant impact on brain function, neurotransmitter production and the immune system. Deficiency symptoms may include the inability to deal with stress, nervousness, anxiety, mood swings, severe inner tension, episodic anger and depression.

The onset of pyroluria usually occurs during childhood and is typically triggered by a traumatic incident or stress, such as a change in school, loss of a loved one or moving towns. Even though the disorder does show up in teenagehood, it is thought to be genetic.

Copper toxicity is also a frequent finding in pyroluria as it acts as an antagonist nutrient with zinc. Symptoms of copper toxicity include yeast infections or candidiasis, Epstein Barr virus infections, racing mind, panic attacks, brain fog and suicidal ideation. Pyroluria is managed, in part, by restoring vitamin B6 and zinc using bioavailable supplement forms of these nutrients. Diet is also considered extremely important and should include zinc-rich foods, while grains, cereals and pulses should be limited as they contain phytates that may bind with zinc.

Nathalie Paul: I definitely noticed that the zinc helped me, the combo, everything yeah, everything was improving. I kept seeing my naturopath, nutritionist, I had a holistic doctor. The fact is, I relapsed and I didn’t understand what was going on because I was following strictly their advice and I was relapsing.

So, it’s actually through, I started to meditate that I understood that I had never faced my emotions, I had never let it out. And, so it’s actually 2014, I was 34, that I one day, I decided to be with my pain. By really being with and stopping the resistance and I cried for the first time and I had never cried during the whole time, I never cried at all. So, I decided to be with it and question why I am in pain. And, so I took the time every day after that, maybe 2, 3 hours a day and that’s

actually, I got these answers that I’d never acknowledged my pain as a child, you know. Just leaving a country, losing all my friends, I never cried about it. Also, throughout my, you know, teenage years being so focused on being a good girl, playing the piano, and being the best at work at school, I decided to just be with that and to let my emotion be.

Howard Todd-Collins: If you do it safely, you can, you can kind of gently confront and see pain as being a really important thing to accept. It’s not quite surrender, but it’s similar to that, and, we reduce the resistance that we feel, it’s paradoxical in effect. And, then we reduce negative stories about the pain itself. We somehow learn to accept and tolerate and we stop thinking overly anxiously, and judgmentally about the experience we have. So, we’re going from experiential avoidance to gently confronting and seeing pain as just part of us, not all of us.

Ananda Mahony: I do suggest that repressed emotions can either act as a persistent threat or danger within the mind or body and so thereby exacerbating pain. Or, they might prime the individual to be more susceptible to chronic pain development and persistence. And, I would think that yes, repressed emotions are quite similar to trauma in that way.

Nathalie Paul: I was really going one day at a time, and so at that moment I remember myself on the floor having my hand on my stomach, my abdomen, and crying. And, I thought wow, this is relieving me, so I'm just going to do that. So, it was really like okay, this feels good, feels good, I'm just going to do this. And, I really followed the thread of looks like, I'm guided here to do this. So yeah, I cried for days and I allowed myself to be with those emotions. And, so I felt like my, my health started to get better and even more steady, where like, that’s when, I didn’t relapse since then, since 2014.

Ananda Mahony: If there’s acceptance of these feelings without the negative responses of thoughts about the nature of the pain, it really can lead to - and the research bears this out - it can lead to better day to day function, less anxiety, less depression, and it can also be associated with reductions in pain. So, it’s a powerful tool, depending on the individual's readiness and ability to just accept the pain, without the kind of negative thought processes that go along with it. And in Nathalie’s case, she did just that and it was powerful.

Howard Todd-Collins: We’re going from experiential avoidance to gently confronting and seeing pain as just part of us, not all of us. Which is what she did with her, her meditation and her capacity to sort of sit with it and make friends with it. So, there is something about accepting the fact that humans suffer, if we resist the pain, we suffer more and when we accept the humanity of our feeling life, somehow we dissolve the struggle with it. And, I think that is a lot in talking therapy and in some of these more mindful practices that certainly Nathalie found herself in. And, somehow, if you do meditation really well or mindfulness really well, you can sit and you can stick with an uncomfortable feeling in the body and watch it. And, you can watch it change, or you can just see it move around your body instead of struggling with it and judging it or telling it to go away or dismissing it. If we accept it for what it is, somehow it dissolves a bit. It kind of shifts in terms of its experience.

Sally Stower: Through the meditation, through that stillness, through that presence now, without knowing the type of meditation that she was using, but in that presence, she was able to tap into her natural instincts or her natural impulses. And, the wisdom came, so all of a sudden she’s saying okay, so I'm going to actually listen to my body and befriend this pain. So, she’s accessed the wisdom of her body at that moment and followed that impulse and then as she’s sat with the experience, and I love that word befriending the pain, you know.

For me, I talk about the work that we do as befriending the nervous system. My job is to learn and to really dive deep into the other person's experience and their world and really try and sense and get to know their nervous system. But, more importantly, I'm helping them to befriend and get to know their nervous system. And, so she’s done this through this process and sat on the edges of, what I imagine it to be, uncomfortable moments. But, with that, the body loves to be seen. I’ve seen it over and over again how many times, where, as soon as you bring just a bit of awareness to something that’s happening in the body, it comes out of, you know it can, it’s in constriction, and then it can gently come out and into expansion.

Dr Veronique Mead: In Nathalie’s case, one of the biggest things that she did that I think is probably helpful for everybody, if not critical, is she began listening to herself. She began listening to her own gut, she began listening to her own intuition and her own impulses. And, this experience where she decided to hang out with the pain, this desire to avoid the pain I think tends to link to past events of things that were intolerable or overwhelming. So, it may be that it’s linked to the emotions that were intolerable as a child or when she moved. And, just even listening to myself, it almost sounds like I'm talking psychology here, but what we're talking about is thawing the freeze response, it’s physiological.

Danny Urbinder: From that point in 2014, Nathalie gave herself an hour or two each day for three months to surrender to her pain. During this time, as she was crying and breathing with intent, she experienced tremors in her upper body that were relieving her of her physical pain. She found herself steadily improving and, by 2015, was pain-free and had no remaining inflammation.

Sally Stower: So there’s that threat response cycle that happens and, with animals in the wild, they have that innate ability to follow through that response cycle and discharge whatever survival energy is in their nervous systems. They’re able to move it through, whereas we as human beings interrupt at various stages of that threat response cycle. We can interrupt that process and then it becomes that bound, trapped survival energy that hasn’t been released in our system.

Dr Veronique Mead: For someone like Nathalie to access the repressed, frozen emotions that had to be put outside of our conscious awareness, that does seem like it’s unlocking. And, there’s also something in her story about shaking that I think is very important and under-recognised.

Peter Levine, the founder of somatic experiencing discovered that this happens in wild animals. Wild animals, like gazelles and impalas on the African plains, they're regularly chased by predators and they don’t, well either they, if they escape, they seem to come out of it and don’t seem to get left with chronic problems. Those that do will get called from the herd, but those that survive, and what he noticed talking to game wardens and park wardens, people who work with the wildlife, was that after a near miss, those animals will shake. And, that shaking may be huge and clunky or it may be very fine tremors. And, what he’s found in the training, for those of us trained in SE, somatic experiencing, you can feel this tremoring in all kinds of different ways. And, this appears to be one of the ways that held energy when the fight/flight response, for example, gets suppressed. And, when an animal that’s being chased suddenly falls to the ground before it's actually caught, that’s a shutdown response. It’s holding back a tremendous amount of energy.

Nathalie mentioned that she felt like she wanted to explode, that’s very common underneath a freeze response. So the shaking, tremoring, and trembling seems to be one way that our body can let go of this very high charge.

Nathalie Paul: It's’ been my blessing. Its’ been my wake up call. Its’ been the first way to see myself. Like, it started with this in the eye, and now I'm like, it was telling me to look at it, look at yourself. And, it’s been horrible but, I think my, yeah I'm blessed that I received a message. And, you know what I want to share today is something incredible. Before I had all this excruciating pain, in my personal life, I never had any pleasure and I was really ashamed of that. You know with women, it’s like oh, it’s a taboo. And, I was feeling like I was not normal because I didn’t have the sexual experiences and orgasms and I was like, I must be abnormal. But, through living pain, I have unlocked something in myself. Like, having so much sensitivity and awareness of my body, then the amount of pain I’ve been through, it’s like I can have the same amount of pleasure. So, you know, it’s like, it’s a blessing in that in that sense. It’s crazy that I never thought it would teach me this, how to unlock an orgasmic life.

Danny Urbinder: What an inspiring story and while Nathalie’s story is unique, the underlying themes aren’t. I’ve done about a dozen patient interviews now with people who have recovered from a range of chronic illnesses and there seems to be a common thread that is all too often overlooked and that is a history of trauma or adverse childhood events. All the science points to this being a critical factor in setting up our biological landscape for chronic illness later in life.

And, it’s also through these interviews that I’ve become acutely aware of the need for healthcare practitioners, and for that matter, our wider society, to better understand the nature of trauma and how we might address this as part of a wider approach to the treatment of chronic disease.

There are numerous therapeutic strategies and techniques currently being researched, and one area that I'm particularly interested in is psychedelics, and we’ll be exploring many of these over the coming episodes.

Now there were also a number of really important concepts and theories that were touched on by our guests in this episode that I think is worth exploring more deeply. So, keep an eye out for the full interviews on IMH Podcast with Dr Veronique Mead, Sally Stower, Howard Todd-Collins and Ananda Mahony and these will be released over the coming weeks.

And, I'm also super excited about our next Patient Journeys episode because this one will feature Dr Terry Wahls and her inspiring story about overcoming multiple sclerosis. We also have some fantastic guest experts for that one, too.