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Origins of Chronic Illness Part III

Putting it all together

Introduction

It is increasingly understood that many, if not most, of all chronic illnesses are strongly influenced by interactions between genes and the environment and are not purely genetic. Indeed, environmental factors play a surprisingly strong role in the origins of chronic illnesses such as rheumatoid arthritis, type 1 diabetes, multiple sclerosis, and Parkinson's, among others.

Environmental factors can be difficult to pinpoint because they tend to occur months or years before the onset of a disease, in some cases occurring in prenatal life and early childhood. The challenge in integrating this data from a medical perspective has been the need for a comprehensive model for understanding the common thread that links risk factors to chronic illnesses as well as to each other. What, for example, is the common thread between cesarean sections, infections in early life, and jaundice, which are all risk factors for type 1 diabetes? What does it mean when one study finds cesarean sections to be a risk factor, and another fails to show increased risk?

Somatic psychology offers a new lens from which to understand the role of environmental factors in the origins of chronic illness. It proposes a comprehensive model for addressing the issues mentioned above and provides a perspective for explaining:
  1. the link between different risk factors
  2. a relationship between risk factors and disease
  3. why certain individuals at risk for a disease develop it and others do not
  4. why we develop a disease at a younger age, or with greater severity than others
  5. why we develop risk for one disease or symptom instead of another
  6. the role of the environment in affecting risk across multiple generations




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Model: Overview
Although ambitious, the model represents the logical next step for understanding these complex issues, and is supported by our increasing understanding of psychophysiology, neurological development and neurophysiology, behavior, gene-environment interactions, trauma, and the role of relationship in attachment and bonding, among others. Some of the information presented here draws specifically from research in posttraumatic stress syndrome and other consequences of trauma, including the existence of

I) an early stressor that initiates a conditioned response
II) a latency period during which the conditioned response grows
III) reinstatement of the conditioned response following a "final" stressor
IV) the onset of symptoms

These four stages represent four steps in the development of chronic illness and symptoms and are described below. The concepts are then summarized and the issues raised in the introduction are addressed.

According to this model, chronic illness and symptoms represent a conditioned pattern of nervous system activity which is driven by the moment to moment perception of threat in the environment. This perception is shaped by trauma and other stressors in early life. In the few individuals who ever develop chronic symptoms, the conditioned response grows following exposure to additional stressors. The resulting states of nervous system response are conditioned towards survival instead of oriented towards growth and recovery. Because each person has had a unique set of life experiences and exposure to particular stressors, each reacts in his or her own way to different situations. Similarly, symptoms vary in a unique way according to events that are perceived as stressful based on previous experience.

The following text presents this model in more detail and uses the example of type 1 diabetes (juvenile onset, insulin dependent) to illustrate this perspective. The model is applicable towards a better understanding of the origins of other chronic illnesses and is described in a detailed article (view or download PDF (200K)) published in Medical Hypotheses 2004, vol 63(6).


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I. The Pattern of Risk Factors in Chronic Illness

diagram showing 4 stages of origins of disease, sns dominance
Figure 1.  Stages in the Origins of Disease

1) Initiating Stressor in Early Life
2) Latency Period
3) The "Final" Stressor
4) Disease Onset
from changes in nervous system



The Nervous Systema is Influenced by its Environment in Early Life

The nervous system develops at its most rapid rate, and is the most easily influenced by its environment during the prenatal period and the first few years of life. During this time, genes dictate the rate and timing of development of the nervous system (and other organ systems) and environmental factors such as support, love and stress determine the quality, strength, and nature of connections that form between synapses. The formation of these synaptic links influence the manner in which the nervous sysytem regulates and responds to the stress of change and these patterns can last into adulthood.

The manner in which the nervous system learns to perceive its environment is shaped by interactions with primary caregivers in early life, and by the social as well as chemical environment. A strong bond and supportive relationships help the nervous system develop in a flexible manner and to respond easily to changes and challenges. Even the inevitable moments of misattunement between infant and caregiver have a positive impact when they are regularly repaired and responded to in a loving and supportive way. These types of events teach the infant (and his or her growing nervous system) that stressors are simply another part of life experience and are not a life-threatening event that cannot be overcome.

Experiences of love and support protect the individual and the nervous system by training it to perceive its environment accurately, to use appropriate degrees of response, and to recover easily and quickly. Positive early experiences act as "buffers" because they train the nervous system to easily maintain states of inactive alertness, where rest, recovery, creativity and growth are all supported. Sufficient exposure to stressful events and lack of caregiver support, on the other hand, train the nervous system to react as if in perpetual threat and consequently increase risk for chronic illness and symptoms.


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Stage 1 in Origins of Disease: The Initial Stressor in Early Life

The nervous system is shaped by its environment and is particularly influenced by stress. When exposed to a significant stressor in early life such as trauma, an insecure attachment bond with caregivers, or exposure to caregivers whose nervous systems regulate predominantly in states of survival, individuals are at greater risk of developing nervous systems that perceive their environments as threatening. These individuals are consequently also at greater risk of responding to changes in their environments with survival responses such as fight or flight (sympathetic nervous system), faint (parasympathetic), or freeze (sympathetic and parasympathetic). In the long run, such states may become persistent, and result in physical and emotional symptoms.

Perception It is not the specific type of an event that influences whether it is experienced as traumatic or life-threatening, but the manner in which it is perceived. In other words, some individuals may experience a car accident as traumatic (life threatening and inescapable) while others may not.

Conditioning The perception of threat can be conditioned (imprinted) in memory following a single event of high intensity perception of life threat, such as in severe trauma, and may also result from repeated exposure to stressful experiences such as frequent misattunement without repair of the ruptured bond, subtle abuse, low level stress, etc).

Type 1 Diabetes: The Initiating Stressor(s)



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Stage 2 in Origins of Disease: The Latency Period
There is usually a lag time between exposure to significant stressor(s) in early life and onset of disease. This latency period may last days, months or years and during this time new perceptions and nerve pathways associated with survival responses are developing and "kindling".

Kindling The term "kindling" is used in trauma theory and in neurology to describe the way in which some nerve pathways can be stimulated to develop over others. After a traumatic event, for example, events that evoke the memory of the trauma stimulate the same survival response that was experienced during the original trauma.

Following a car accident, events that evoke the survival response can include thinking of the accident, driving by the site, or hearing the sound of screeching brakes. Over time, the survival response is evoked more and more easily as the pathway of the survival response "kindles" and becomes increasingly familiar. The more a nerve pathway is used, the stronger the connections become, and the more easily the various responses can be triggered to act together as one. Gradually, a kindled survival response can be evoked by increasingly smaller and unrelated stimuli ... such as the smell of burning rubber, a particular time of day, or the sight of someone in a sweater the same color as the car that was involved in the accident...

External vs Internal Stimuli. Stimuli that trigger the kindled response occur outside of conscious awareness. They may be external, as in the car example above, or internal, such as when an increase in heart rate due to excitement or joy triggers the well-known survival response of fight or flight, which is also associated with an increased heart rate.

Pace and Progression of Kindling. The pace of kindling is influenced by the strength of the initial conditioning and the intensity of initial event(s). Kindling is also affected by the nature, intensity, and frequency of subsequent exposures to relevant stressors, commonly referred to as triggers. Kindling may occur rapidly if many regular stressors occur or it may occur slowly if stressors are mild or moderate, if they occur infrequently, and if buffers exist. Kindling may fail to occur if few reminders of an event take place or if the bonding relationship with caregivers is highly supportive.

In summary, the latency period varies according to the intensity of the initial exposure(s) to stress and the quality, frequency, and intensity of subsequent life stressors and buffers. Because the nervous system is inherently capable of fluidly adapting to its environment, only a small number of individuals exposed to significant life stressors will ever develop disease or symptoms and those who do develop symptoms may be able to relearn how to perceive their environments more accurately once again. Working with perception is the role of somatic psychology.

Type 1 Diabetes: The Latency Period




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Stage 3 in Origins of Disease: The "Final" Stressor
A conditioned response kindles slowly or rapidly over time and can eventually "extinguish" and disappear, or become fully activated. Stressors stimulate and kindle a conditioned response, and it eventually takes only one final stressor to make a conditioned response fully operational. Chronic illness and symptoms develop when a conditioned response becomes the dominant or repeated mode of functioning, and frequently begin within two or three years of exposure to a significant stressor. Research supports this finding in multiple sclerosis, chronic fatigue, Parkinson's, and type 1 diabetes, among others. This is also common in chronic pain, which may have originated with abuse in childhood and become evident only in adulthood after a fall, a car accident, or a significant traumatic event.

Symptoms of chronic illness often occur following an apparently minor stressor, such as an infection. The role of stress in the onset of disease is confusing from a medical perspective, where stress is generally assessed in isolation from early life events such as trauma and where no obvious connection between particular types of stressors and particular diseases appears to exist. From a somatic psychology perspective, it is not the particular type of stressor that initiates a disease, but the manner in which it is perceived and the degree to which it stimulates and reinstates an existing conditioned response.

Type 1 Diabetes:
The "final stressor" and Risk Factors Occurring Prior to Diagnosis




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Stage 4 in Origins of Disease: Onset
The onset of symptoms of a disease represent the full activation of a strong conditioned response of altered nervous system regulation. In this context, internal and external events serve as ongoing and repeated triggers that stimulate perceptions of threat and states of sympathetic dominance, parasypathetic dominance, or freeze. From this perspective, chronic illness and symptoms are not the result of a genetic, "broken" , or faulty body part but are the result of moment-to-moment stimulation of a familiar conditioned pattern.

In chronic illness associated with an autoimmune process, the conditioned response may have directed the immune system to inactivate or remove certain tissues or chemicals because they are perceived as unnecessary in certain states. In sympathetic arousal, for example, glucose levels are increased to provide fuel for muscles and organs involved in fleeing and fighting, while insulin activity and secretion is inhibited in order to reduce any loss of fuel through storage. This state is the hallmark of type 1 diabetes, in which the immune system destroys insulin producing cells over a period of months to years prior to the unmasking of the disease, which occurs when a critical number of insulin producing cells have been destroyed.

Type 1 Diabetes: Disease Onset



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II. Symptom Variability and Severity

Symptom Variability

Many chronic diseases and chronic symptoms fluctuate in intensity over time. There are "good days" and "bad days", exacerbations and periods of remission, moments when a symptoms suddenly becomes inexplicably severe, or may temporarily disappear completely. Although stress has been found to play a role in symptom variability, the relationship to symptom expression has been difficult to understand. In some studies, for example, participants feel better when exposed a particular stressor while others feel worse and still others experience no change.

From a perspective that sees illness as related to conditioned patterns of perception and nervous system activity, this makes perfect sense. Indeed, each conditioned response is triggered by unique internal and external events that have a relationship, however distant, to individuals' initial experience of stress/trauma as well as to stressors that have occurred in their life during the kindling proceess. In this context, one would expect different responses by different individuals exposed to the same specific stressor (such as a math test).

Working from a somatic psychology perspective involves beginning to identify the unconscious triggers that stimulate or improve symptoms. Mindful, nonjudging attention and curiosity about this process utilizes a different part of the nervous system than the one involved in the conditioned response, and helps symptoms and nervous system patterns and perceptions to shift.

Symptom and Disease Severity

The severity of a disease is probably related to complex interactions between many factors, such as the intensity of the conditioned response, the degree and frequency with which threat is perceived in the environment, and the level of nervous system arousal that is triggered. From this perspective, intensity, duration, and degree of life-threat that is perceived during the initial and subsequent stressors influences the severity of symptoms of a disease. A more intense initial exposure, for example, may result in a disease with a conditioned response that is kindled more easily and that stimulates a larger survival response. Intense initial stressors may result in:
  • greater severity of symptoms, such as rapidly progressive deterioration of multiple sclerosis, or a high number of complications of diabetes such as neuropathy, high blood pressure, blindness, and heart disease
  • younger age of onset
  • greater frequency of exacerbations
  • reduced response to medications
  • greater risk for side effects
  • Exposure to a greater number of triggers during latency may stimulate kindling and:
  • reduce the age of onset
  • reduce the length of the latency period
  • increase the speed and intensity of symptoms, which are responses to triggers

Type 1 Diabetes: Symptom Variability




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III. Risk for One Disease versus Another

diagram of 4 stages in origins of disease, sns(pns) dominance diagram of origins, disease from freeze state diagram of origins, disease from ans exaggeration
Fig 1. Disease:
SNS Dominance

Fig 2. PNS Dominance


Fig 3.Disease:
Freeze

PNS dominates over SNS arousal
Fig 4.Disease:

Exaggerated Cycling



Critical Period Programming The nervous system and other organs are most affected by their environments when they are developing new synapses and connections during periods of growth. This is referred to as critical period programming in the attachment literature (Alan Schore). Early events thus predispose an individual towards different states of nervous system patterns and result in different diseases (such as with dominance or exaggeration of the sympathetic or parasympathetic nervous system), also described in environmental factors contributing to origins of disease.

Chronic illness is proposed to result from exposure to life-threatening experiences during periods of development in early life. From this perspective, the initial stressor in individuals who are at risk for chronic physical illness may occur during organ system development in the prenatal period, or in the first few years of life when the nervous system is growing and developing the structures that give it the ability to regulate these organ systems. A baby who's mother is exposed to war, famine, or the loss of a loved one during her third trimester of pregnancy may develop risk for a different disease than one who's mother experiences this in her first trimester or during infant's first year of life.


Disease Models The epidemiology of a number of diseases is consistent with the somatic psychology model. Events in early life, along with a latency period, and a "final stressor" are seen in type 1 diabetes, type 2 diabetes, and multiple sclerosis, among others.

Smaller birth size can reflect stress during the prenatal period and has been found to be associated with increased risk for hypertension, high cholesterol, obesity, type 2 diabetes, and heart disease. Together, these chronic symptoms form the disease complex referred to as "Metabolic Syndrome" or "Syndrome X". (for more see Fetal Programming)

Many of these symptoms, if not all, are consistent with states of sympathetic dominance with the exception of obesity, which is more consistent with parasympathetic dominance. Because the nervous system innately incorporates two polarities, sympathetic and parasympathetic, it appears to be common to find some symptoms that represent both ends of the regulation spectrum in many diseases. Depression, which is consistent with states of parasympathetic dominance, for example, is twice as common in individuals with diabetes (both type 1 and type 2) than in the general population.

Interventions at Birth

Interventions at birth, such as vacuum extraction and forceps have been associated with increased risk for multiple sclerosis, type 1 diabetes, and asthma.

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IV. Transgenerational Transmission
Genes are Influenced by their Environments
Chronic illness or symptoms that show up in multiple generations or in many relatives in one family are commonly assessed as having a genetic cause. Genes are also identified as causal when both individuals in a set of twins get the same disease.

While genes do carry information from one generation to the next, they are activated and turned on or off by environmental factors. The perception of fear, for example, turns certain genes on that secrete glucose for fuel of fight or flight. The experience of hunger, on the other hand, may stimulate these same genes to turn off while turning others on that prepare for the storage of glucose.

An Individual's Experience Influences the Way He or She Parents
The nervous system is strongly influenced by experiences in early life, particularly by interactions with the primary caregivers. The attachment bond, which begins to form prenatally, affects the ability of the parent and child to be attuned to one another and shapes the quality with which the nervous system learns to regulate.

Parents' experiences of stress and trauma, and the manner in which their own nervous systems have learned to perceive their environments affect the way they parent. In addition, the way parents have been raised by their parents also influences how they parent their children.

The fact that children learn patterns of perception and regulation from their families and life experiences provides an additional perspective for understanding the risk for disease across generations and within multiple individuals in a given family. It also helps explain why some individuals get the disease (they may have had exposure to more stressors or additional trauma) when others do not despite being at high risk from a "family history" perspective.

When we understand that genes are affected by their environment, we can better understand why some individuals get better and why some heal "spontaneously" (the conditioned response has been extinguished). Somatic psychology may be helpful in changing familiar learned patterns of altered perception and regulation, even in diseases that have been in a family for generations.


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Article:
View or Download PDF (200k) of a published article (Medical Hypotheses 2004, vol 63(6), pp 1035-1046) for references and more detail on these perspectives.



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