Total Recovery, page 14
With bright young staffers nipping at her heels, she knew she had to be at her best to hold on to her position. Luckily, Lindsay’s best was extraordinary. She had always been at the top of her class. But then, so had they. To stay ahead of the pack, she set her sights on “perfect” and ran as fast as she could.
She was always the first to arrive in the mornings and the last to leave. Breakfast meetings with congressional committee members might start at 7:00 a.m. A community event with constituents at the end of the day could easily last long into the night. In between, Lindsay had to summon the energy and brain capacity to brief the senator for back-to-back meetings, often scheduled at 15-minute intervals, while they rushed around Capitol Hill.
If she’d had any time to go to the gym, she would’ve burned fewer calories than she did at work. The whole culture in DC was in constant motion. There was no such thing as a lunch break. Every activity was laser-focused on a political agenda. Eating for the sake of eating—what would be the point of that?
When she actually started to feel dizzy or couldn’t think, Lindsay would try to inconspicuously grab a sandwich from a vendor. Taking the time to eat it felt vaguely self-indulgent. Worse, it was a sign of vulnerability—the last thing she wanted the senator or her colleagues to see.
If any of them knew how close she was to being incapacitated by migraines each day, Lindsay dreaded to think what would happen. If they ever found out she fell into bed at night on the brink of exhaustion, flushed with anxiety, sobbing, and falling to pieces, she’d never work in Washington again.
COMMON MISDIAGNOSES
When she accepted the job, Lindsay knew the migraines were likely to come with her. They’d started in high school when she was 16. She always did well in school, but some mornings, she just couldn’t get her brain to work right. It was like a fog was drifting in and out. One moment she was raising her hand in class, eager to answer the teachers’ questions, and the next she was struggling to remember what she’d wanted to say.
As soon as the migraines became frequent, her mother started taking her to neurologists. “It’s not just migraines. There’s some sort of visual distortion going on as well. It makes me feel dizzy,” Lindsay explained. A few doctors dismissed these symptoms as common side effects of migraines. Others diagnosed her with vertigo, an inner ear disorder completely unrelated to migraines.
The most promising insight came when she was told she had hypoglycemia. “Your levels aren’t all that bad,” the doctor told her. “But if you eat more frequent meals and less sugar, it should reduce your dizziness and mental fog.” Lindsay adjusted her eating habits on the doctor’s advice, and things got better for a while, but then she had an alarming experience on the way to college.
She had always loved to drive. It gave her a satisfying sense of independence and empowerment. When she enrolled in a university that was hundreds of miles away, she looked forward to driving to the campus by herself. After driving all day, the excitement of her arrival seemed to snap her out of a daze. Lindsay suddenly realized that the last thing she remembered was kissing her mother good-bye. She didn’t remember driving at all. The implications were terrifying.
She felt a knot of anxiety in her gut that soon became familiar. After that, whenever she got behind the wheel—even for a short distance—Lindsay had to suppress a quiet sense of fear. What if I get lost in some mental fog and drive off the road?
It didn’t help that this mental fog kept returning all through college. English lit majors are continually writing long papers after reading long books. The ability to concentrate well enough to remember what she’d read—much less think critically—was sometimes nearly impossible. And, of course, the migraines continued.
Wondering if she needed to adjust what she was eating even more, she met with a dietician, who thought her symptoms might be a close match for gluten intolerance. In 2007, no one was really talking about gluten intolerance. Lindsay had never heard of it. When she asked her doctor if she should try to avoid gluten, he told her not to bother. From his point of view, the dizziness, mental fog, and visual auras she described were common in people with migraines. He changed her migraine medication and added antiseizure pills.
Knocking back the migraines with stronger drugs should also eliminate the other symptoms, he said. “Besides, I don’t believe in gluten intolerance.”
NOT A CRAZY PERSON
By the time she got to Washington, Lindsay was having debilitating migraines that lasted a week at a time. She thinks of that year now as “the migraine period.” Powering through, she lived with little sleep, crummy food, and constant stress. If she kept going at all, it was from force of will and heavy meds.
One day, while researching a complicated piece of legislation that the senator was planning to take to the Hill, she felt an odd sense of numbness and tingling in her left arm. Before she knew it, she was short of breath. Her chest felt tight and was getting tighter. In seconds, she couldn’t catch her breath. Things started closing in. It felt like the weight of the world was on her chest. A heart attack? At 23? This cannot be happening!
As much as she wanted to keep it to herself, she knew she needed help, so she confided in a friend at the office. She tried not to make a big deal out it, but he recognized how serious it was and took her directly to the emergency room. The ER doctor and his nurses rushed her in for a series of tests. When the doctor returned, he was oddly calm, almost smug. “Nothing’s wrong with you. You’re incredibly healthy. You had a panic attack. Have you ever been diagnosed with an anxiety disorder?”
Lindsay was stunned. Her thoughts were racing. A heart attack would have been frightening and potentially fatal, but some sort of fluke. Now this doctor was saying there was really something wrong with her. As far as she knew, only crazy people had panic attacks. But I’m not a crazy person. I’m a “perfect” person. I do all kinds of things. How can I be crazy when I’m so . . . efficient?
When she called her doctor the next day, he sent her to a psychiatrist. It felt embarrassing, but at that point, she was so desperate that she was willing to try anything.
The experience was surreal. When the psychiatrist asked Lindsay what she did as a congressional aide, she ran through an impressive list that included attending hearings, gathering information, tracking issues, answering questions from the media, delivering press releases, drafting documents, making public announcements, and answering some of the thousands of letters and e-mails the senator received every week.
The psychiatrist saw a lot of red flags. “That’s a lot for one person to take on! What were you doing just before you had this panic attack? Was something making you nervous? Maybe performance anxiety?” His tone was meant to be compassionate, but to a high achiever like Lindsay, it sounded patronizing and misguided.
“No. You don’t understand. I don’t get nervous. I was the student speaker at my high school graduation, the president of my sorority in college. I love speaking in public. When the panic attack hit, I was just sitting quietly at my desk, working.”
“Have you ever experienced a fear of crowds?”
“No.”
“Sometimes it shows up as a feeling of foreboding or loss of control.”
“No. I don’t have that.”
“Do you ever have a fear of being trapped in situations you cannot escape?”
“What?” Lindsay frowned. Where did that come from? “No.”
As the psychiatrist ran through the list, a quiet sense of relief came over Lindsay. If these were the characteristics of an anxiety disorder, maybe she had nothing to worry about. These anxieties were so unfamiliar, they almost sounded imaginary. A Gary Larson cartoon flashed through her mind. It described a strange anxiety called luposlipaphobia—the fear of being pursued by timber wolves around a kitchen table while wearing socks on a newly waxed floor.
“I’m not afraid of any of those things. My heart just starts racing. I get shortness of breath, and there’s a tightness in my chest—”
As if Lindsay’s remarks were irrelevant, the psychiatrist wrote a note on a little white pad. “Let me give you this prescription. I think it’ll help.”
It didn’t seem logical to medicate a condition she clearly didn’t seem to have, but Lindsay didn’t ever want to feel the way she’d felt that night again. If medication was the answer, so be it.
Curiously enough, the SSRI antidepressant was so soothing that it did make her feel better. “I guess I am crazy then,” she shrugged, but she knew she wasn’t.
FOOD-INDUCED PANIC
Three years later, Lindsay was still taking the medication and still suffering from inexplicable bouts of anxiety.
The panic attacks and anxiety were genuine, but they produced a strange cognitive dissonance in Lindsay. She continued to insist that she did not have the personality of someone who was prone to anxiety. She was healthy, confident, and well adjusted. She had no history of emotional issues, no family problems, or stress on the job. Her life was great.
It was not clear what was triggering the attacks, but her doctor should have asked what else might be causing those symptoms. Instead, he prescribed an antidepressant to mask the only clues he had for solving the mystery.
But she was about to catch a break.
In Kansas, Lindsay’s mother happened to go to a doctor who practiced integrative medicine. Tests showed that she had celiac disease. Since there is a genetic proclivity for celiac disease and her symptoms seemed to fit, Lindsay flew to Kansas City. Her blood tests showed that she did not have the markers for the more destructive celiac disease, but given her symptoms, there was a good chance she did have gluten intolerance. The doctor told her to “try to avoid gluten” and sent her home.
Lindsay started taking gluten out of her diet, but since her local medical doctor didn’t accept the diagnosis, she wasn’t really sure what else to do. A few months later, her mother sent her an article connecting gluten intolerance with anxiety disorders and migraines. If these connections were correct, then Lindsay’s anxiety was brought on by the gluten.
Instead of asking, “What were you feeling before the panic attack?” someone should have asked her, “What were you eating?” Most likely, the problem wasn’t pathological anxiety, it was the sandwich she had eaten for lunch.
According to the article, if someone with gluten intolerance ate a sandwich, it could backlash throughout the body and lead to an inability to concentrate, brain fog, anxiety, even migraines. The article was written by the Kaplan Center, a few minutes away in McLean, Virginia. Lindsay made an appointment immediately.
MEETING LINDSAY
When Lindsay walked into my office, she looked vibrantly healthy. Like many people who work on the Hill, her walk was brisk and determined. She exuded intelligence and an unmistakable aura of confidence that made it easy to believe she was a rising star.
As usual, I interviewed her for well over an hour. After hearing her history and doing an examination, I told Lindsay I was fairly certain that she did not have a psychiatric disorder. The medications, while somewhat helpful, were really only addressing her symptoms and not the cause of her problems. I strongly suspected that her diet might be at the root of her problems. Initially, I recommended a comprehensive treatment plan, including blood and stool testing, acupuncture treatments, as well as craniosacral therapy to address her migraines and neck pain.
When her blood tests came back, the results were startling. Lindsay was extremely deficient in a number of essential vitamins and minerals in her body. Ironically, this bright, up-and-coming congressional aide in one of the richest countries in the world was suffering from malnutrition.
“Of course you’re dizzy and can’t concentrate,” I told her. “Of course your body overreacts to stress. You don’t have enough nutrients to support your normal bodily functions. You’re severely malnourished.”
Lindsay’s intolerance of gluten had created an inflammatory state in the lining of her small intestine. No matter what she ate, that inflammation prevented her from absorbing the nutrients.
Food directly affects our nervous systems. If we are eating the wrong things, it can show up in any number of effects: depression, migraines, anxiety, peripheral neuropathy, panic attacks, or pain, among others. The emotional symptoms are not caused by psychological issues, any more than are the physical symptoms caused by an acute injury.
Lindsay was right when she told the psychologist that giving speeches and working in high-stress conditions had not caused her panic attacks. In her case, the cliché was true: It was not what was eating her, it was what she was eating.
If anything, the fact that the inflammation was showing up as anxiety only made her intestinal inflammation worse. To a degree we do not yet understand, our emotions are seated in the gut. We already have strong evidence that emotions affect digestion. In extreme cases, severe stress can damage the lining of the entire gastrointestinal tract enough to cause life-threatening diarrhea.
So Lindsay had been caught in a positive feedback loop. Because she had been eating gluten with undiagnosed gluten intolerance, the lining of her intestines had become inflamed and stopped absorbing nutrients. The inflammation and lack of nutrients had imbalanced her system enough to cause jumpiness, anxiety, then full-blown panic attacks. All of those emotions had damaged the intestinal lining even further.
The medication the psychiatrist had given her and the NSAIDs she was taking to cope with the condition were inadvertently making it worse by increasing her intestinal permeability, which heightened her reaction to gluten, which caused her anxiety attacks.
The good news was, we knew what was happening now. “We will get you through this,” I assured her. “We know how to resolve it. We can reduce the inflammation in your intestines and your brain. Then, once you can absorb the nutrients again, we’ll replace them. You don’t have to worry anymore. We’ve found the problem.”
As she listened to me, Lindsay had tears in her eyes. “Everyone kept telling me I was fine, that it was all in my head! You’re the first person to say, ‘No. You’re unhealthy and here’s why.’”
I explained she was suffering from a condition known as leaky gut.
LEAKY GUT
Whenever I mention “leaky gut,” most of my patients look at me with a slight sense of alarm, as if they’re wondering, “My gut is leaking? What does that even mean?”
Our intuitive understanding of the gut is reflected in our vernacular. We have “gut reactions” to people and situations. When we “know” something deep inside, without knowing how, we say we “feel it in our gut.” But other than our discreet trips to the bathroom every day and the ubiquitous pharmaceutical ads about “acid indigestion,” what happens in our digestive tract is a mystery to most of us.
And yet, digestive issues are the number two reason people seek medical advice, after the common cold. As many as 60 million to 70 million Americans have digestive diseases—almost half of all adults. How many more must have digestive complaints?
Our digestive tract is made up of a series of hollow organs, linked together in segments like a long, twisting hose compacted inside us. Unwound, it would be 25 to 35 feet long, the height of a two-story building.
Our survival depends on it. None of the food we eat comes in a form our bodies can use for energy and nourishment. We rely on our digestive tracts to convert meat, vegetables, bread, and anything else we ingest into microscopic molecules that can be absorbed into our bloodstreams.
All along the route—from the mouth, down the esophagus, to the stomach, then the small intestine, large intestine (colon), rectum, and anus—the hollow organs are lined with mucosa containing tiny glands that release digestive juices. Every organ along the digestive tract has a layer of muscle to help the food move through the tube. The rippling motion (peristalsis) of muscle movement is like an ocean wave traveling through the organs. One muscle contracts to create a narrow passage, then pushes off, propelling it down the length of the organ, as waves of food and fluid ebb and flow through our bodies.
It begins in our mouths. By chewing our food, we mix it with saliva, which contains enzymes to aid the digestive process. When we swallow, the first major muscle movement takes place. We decide to swallow, but once we start, the process is taken over by the nerves and muscles. The whole process of digestion becomes involuntary.
The food is pushed down to the stomach through the esophagus. A ringlike muscle (the lower esophageal sphincter) at the opening to the stomach relaxes and lets the food in. Stomach acid serves an immune function, killing off many of the harmful viruses and bacteria that might try to invade our body via the foods we eat. It also chemically breaks down our food into smaller molecules that can be absorbed. At the top of the small intestines, juices from the pancreas, liver, and gallbladder mix with our food to further process the nutrients. Muscles lining the digestive tract continually push the partially digested food into and through the intestine.
The “small” intestine continues the process, absorbing most of the nutrients, but, at 15 to 20 feet long, the small intestine is not especially small. Spread out flat, it would cover the surface of a regulation tennis court. In our bodies, of course, it is folded repeatedly to fit into a small space.
Inside the mucosal lining of these folds lies the secret to our ability to absorb nutrients. Tiny projections (villi) aided by even more microscopic projections (microvilli) absorb the vitamins, minerals, and other nutrients from our food, making it available to our bloodstream, where it spreads throughout our body to feed and nourish us. Waste products that could not be used, such as undigested food, are pushed into the colon and eventually expelled in those discreet trips to the restroom.1
Allowing us to harvest nutrients from what we eat is such a vital function that it has been easy to assume that the processing and elimination of food was the primary activity of our digestive system. As we are only just beginning to discover, our gut does a lot more than that. As Emeran Mayer, MD, professor of physiology, psychiatry, and biobehavioral sciences at UCLA, points out, “The system is way too complicated to have evolved only to make sure things move out of your colon. A big part of our emotions are probably influenced by the nerves in our gut.”2
