Just Another Manic Monday

Today I want to talk about the epidemic of anxiety, post traumatic stress, and sleep disorders that plague us. From a biological point of view, I think society is suffering from an epidemic of autonomic hyperarousal. Basically, our “fight or flight” system is amped up and causing all kinds of problems.

But first, some context.

Have you noticed how nutty the world has become? Everywhere you look the sky seems to be falling. News articles repeatedly tell us how anxious and depressed we all are. Sleep disorders were already at epidemic proportions, and since the pandemic they’ve skyrocketed. Each year feels like another installment in Die Hard where the “bad guys” get badder, and we feel even less equipped to deal with them. And yet we’re living in a time of the greatest abundance, security, and comfort in history. Just scroll your Facebook feed to see the array of super-optimized products available to make our lives ever more perfect. Apparently one of the Sharks wants to sell me a butter soft shirt designed by a navy SEAL that covers my gut and makes me look like an action figure. I bought one.

So what’s underlying all our anxiety? I’m sure life in the budding “metaverse”, where all our human contact is virtual, must be a big part of it. We all live in an online echo chamber perfectly tailored to generate maximum emotional charge and get us to click things so somebody else gets paid. And conveniently, we all walk around with these little electronic devices that beg for attention wherever we go. Every time we look at our phones, we escape the real world and get back into our heads, where we bathe in our worst insecurities, fears, and regrets. Satiated, of course, with occasional hits of dopamine to keep us coming back for more. So just leave your phone at home right? Wait… digitally connected clothing is coming soon.

In addition to all the anxiety generated by life in the modern world, a shocking number of people are living with real trauma. Among my patients I hear stories of child abuse, domestic abuse, sexual abuse, workplace toxicity, and other physically or emotionally traumatic events that shred people’s nerves beyond repair.

The end result of all this anxiety and PTSD is a set of neurobiological changes that have been hell to deal with for the medical community. We have meds for dealing with these things, but they’re blunt, dirty tools, rarely a game changer, and introduce all kinds of new problems for many people. Some patients will say a drug X saved their life. Another will say taking that drug was the worst mistake they ever made.

So what are these neurobiological changes?

A simplified way of describing these changes is autonomic hyperarousal. Your nervous system has different parts. Your autonomic nervous system is the “automatic” part that runs the back office, so to speak. It’s what maintains your blood pressure, triggers salivation and digestion of food, activates sweat glands, and governs sexual function. Autonomic hyperarousal is an imbalance favoring excess sympathetic, and not enough parasympathetic activity.

This is thought to be caused by, or associated with, abnormal thresholds in the limbic system (your emotional processing function). So thinking, emoting, and body function are all intertwined. That’s why a person with PTSD can be easily triggered by a simple sight or sound. Stay with me here… The trigger leads to a thought that activates an uber sensitive limbic system, which activates an already hyper-responsive sympathetic nervous system. The response is a flood of chemicals leading to emotional terror, a racing heart, skyrocketing blood pressure, and inability to calm down. This person lives in a chronic state of heightened vigilance.

Insomnia is thought to reflect a chronic 24/7 state of hyperarousal. Insomniacs have been found to have elevated levels of cortisol and circulating catecholamines (stress hormones), along with other signs that the body does not shut down normally at night. Elevated cortisol may be a cause of insomnia, but also a consequence. So perpetual insomnia is a self-reinforcing cycle. Other research reveals a more complex picture indicating the cortisol response to stress is abnormal among insomniacs (it’s heritable too), and fails to function as a protective mechanism against inflammation.

For years I’ve practiced interventional pain medicine. Basically we provide quick and easy fixes to difficult pain problems. People don’t come to my office for advice on exercise or suggestions on meditation, although I certainly provide that all the time. They come because they want me to DO SOMETHING. That’s the focal point of every visit.

So where is all of this going?

Well, in recent years we’ve found that a procedure typically done to treat pain, can have a huge impact on hyperarousal. The procedure is a “stellate ganglion block”. I have a whole page about the procedure, so be sure to check it out if you want to know more. I also have a video of one coming up, so stay tuned. The stellate ganglion is a part of the sympathetic nervous system. It’s located at the base of the neck, and injecting it with anesthetic is pretty straightforward and mostly painless. We don’t really know how it works. My suspicion is that it breaks a cycle in the nervous system that links thoughts, emotions, and the fight or flight system. The temporary break using local anesthetic is enough to allow new brain circuits to form, and that leads to lasting recovery. It’s not uncommon for patients to return about once every three months for a top up block, and generally they’re at a better baseline than when they started. My “stellate for PTSD” patients are some of the happiest in my practice, so I’m always excited to offer it new patients struggling with PTSD and hyperarousal disorders. Patients have posted their experiences with SGB all over Youtube, so there’s no shortage of anecdotes to review. Most of my patients report a rocky first week, and then a strong calming effect that lasts. Lately we’ve been doing the procedure to treat parosmia and having some good results. I have a new blog post and a video on that coming up soon.