Tuning the Brain

Principles and Practice of Neurosomatic Medicine

Jay Goldstein

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135185305
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Discover effective, outcome-oriented ways to help CFS patients who have endured useless or inappropriate treatments! From the author: For many years I have viewed brain function as a system of electrochemical impulses continually flashing through the brain. These neural networks can often be modulated fairly simply by 'tuning' them. The point I have been trying to make for many years is that this process may be pharmacologically regulated extremely rapidly in a manner which does not yet seem to be recognized by the medical profession. In this remarkable volume, Dr. Jay A. Goldstein clearly presents both the theoretical and the practical aspects of his revolutionary approach to treating CFS and other conditions that have often been termed psychosomatic. Dr. Goldstein (author of Chronic Fatigue Syndromes: The Limbic Hypothesis and Betrayal by the Brain: The Neurologic Basis of Chronic Fatigue Syndrome, Fibromyalgia Syndrome, and Related Neural Network Disorders) shows how he achieves results for patients with CFS and a variety of other syndromes in days, rather than months or years. This well-referenced book answers questions, from the most basic to the most complex, including:

• What is neurosomatic medicine?
• How did Dr. Goldstein come to pioneer and practice this specialty?
• What abnormalities in brain function produce neurosomatic disorders?
• How can an understanding of these abnormalities help you provide effective treatment?
• Why do these treatments sometimes work so rapidly?
• What is receptor profiling, and how does it indicate the type of receptor dysregulation in an individual patient?

In Part I: Inventing Neurosomatic Medicine, Dr. Goldstein describes the remarkable how and why of his life and his development of this new field of medicine, including his clashes with the medical/psychoanalytic establishment. One of the greatest medical innovators of the modern era, Dr. Goldstein has seen over 20, 000 CFS patients and has experienced most of the pitfalls that having such a large number of patients entails. He shares his insight on legal issues, such as how to deal with the law and court systems, how to best provide expert testimony, and how to defend against spurious legal actions. In addition, Dr. Goldstein describes how he learned to work effectively outside of the managed care system. In Part II: Society for Neuroscience Conference Proceedings, the author shares his expertise to bring you experimental results and pearls of wisdom relating to neurosomatic medicine from the 28th and 29th Annual Meetings of the Society for Neurosciencethe largest and most important neuroscience conference in the world. Dr. Goldstein sorted through thousands of experiments presented at the conferences to bring you the most relevant findings. Part III: Pathophysiology and Treatment is essential reading for anyone planning to practice neurosomatic medicine. In this section, richly illustrated with over 70 pages of color figures and diagrams that make complicated concepts clear, Dr. Goldstein shares his knowledge about dozens of the agents he uses to help CFS sufferers and others manage their pain, fatigue, and other symptoms. This is information that simply cannot be found anywhere else, and will prove invaluable to all fledgling neurosomatic practitioners. This one-of-a-kind volume is thoughtfully put togetherfrom the extensive list of abbreviations near the beginning to the exhaustive references and an appendix with diagnostic criteria, a treatment algorithm, a medication list of treatment options available now or in the near future, and a checklist of CFS symptoms.

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Part I:
Inventing Neurosomatic Medicine:
Rewards and Satisfactions versus
Problems and Pitfalls

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It's not easy bein ' me.

Rodney Dangerfield (1921- )

There are three major rewards for the physician practicing neurosomatic medicine: (1) Patients who have been miserable and nonfunctional for years can get significantly better in days. (2) Because this branch of medicine is largely terra incognita, someone who has learned its database (which takes several years) can greatly advance knowledge of pathophysiology and treatment with appropriately targeted interventions, which need not be very complicated. I am reminded of the possibly apocryphal story of Nikola Tesla, the inventor of the dynamo, and widely regarded as a genius in his era (1880s). A large power-generating corporation could not make its giant transformers operate, despite legions of expert consultants. Finally, they called in Dr. Tesla. He looked at the banks of machines, went over to one, and kicked it. Immediately, the entire system became operational again. “Thank you, Dr. Tesla,” said the chairman of the board. “What is your fee?” “$100,000,” replied Tesla. “$100,000!” exclaimed the chairman (a lot of money in those days, about $10 million today). “It only took you a minute to kick the machine!” “Ah,” said Tesla, “kicking the machine only cost you a dollar. Knowing where to kick it cost you the rest.” The same can be said for the practice of neurosomatic medicine—it is usually fairly easy if you know “where to kick” (Seifer MJ, 1998). Unlike the case of Tesla, however, moguls are not lining up with millions so that I can fix their neuroelectric systems. (3) You don't have to be part of managed health care. Indeed, it is virtually impossible for a primary care physician in a health maintenance organization (HMO) to adequately care for a neurosomatic patient. The physician (or the company) receives $10 to $20 per month to take care of each patient. This allocation means rationing not only expensive tests and consultations, none of which are really necessary if one understands neuro-somatic medicine, but also rationing time, the most precious commodity. Physicians must listen to their patients, educate them, and treat the underlying dysfunction. A Beverly Hills woman was referred to me by her psychiatrist after seeing ten other doctors. She arrived at the office with her mother and her medical records. I reviewed the records, and said, as I usually do, “Would you like to start treatment while we are talking, or would you like to talk first?” A look of consternation passed across her face. “You mean you're not going to check my T cells?” “No, I'm not, there's no reason to do so. You've had that test before, and the T-cell count was normal. I'd just like to help you to feel better.” “Come on mother, we're getting out of here,” she exclaimed, looking at me as if I were deranged. She later reported me to the California Medical Board, an occupational hazard of the practice of neurosomatic medicine.

For a brief period around 1983 I was medical director of the local HMO started by a group of neighboring physicians. I eventually had to resign because I couldn't tolerate financial considerations dictating the nature of the doctor-patient relationship. I found myself being angry at patients who talked too long or had too many questions, and I abhorred the adversarial relationship I necessarily found myself in with patients who had expensive illnesses and/or wanted expensive health care, because I had to pay for it. If I did not see patients quickly enough, or spent too much money on their care, either I would go bankrupt, or later, when managed health care became more pervasive, I could be dismissed from a health plan, losing possibly a thousand patients because of “overutilization.” I lay awake too many nights wondering whether I had missed a life-threatening problem by not ordering a certain expensive test, such as a CT scan. Today flow charts called “algorithms” instruct doctors how to manage almost every common medical problem, so compliant physicians do not feel that they are placing their careers in jeopardy in a difficult case as long as they go by the cookbook. Neurosomatic patients are not in the cookbook, take up a lot of time, and can tremendously overutilize medical resources if the physician does not understand how to manage them, which he or she almost always does not. They are thus frustrating to deal with, and many physicians shun them. About three years ago I gave a lecture on CFS to doctors at a large local hospital. The following is how I was introduced by the moderator: “Ladies and gentlemen, we all have two or three “patients from hell” in our practices. Dr. Jay Goldstein, here to talk to us about chronic fatigue syndrome, has two or three thousand.”

Medical practice algorithms are very useful to maintain a basic level of competence among primary care physicians. When I opened my office in 1975 for family medicine, I was the first physician in the county (as far as I knew) to have had residency training in this “specialty.” I had also had training in psychiatry.

There were tremendous abuses of patient care and insurance billing in this bygone era, now regarded as the “Golden Age of Medicine” by physicians who were in practice then, because the insurance companies paid for everything that was billed. This policy was like Nirvana for most physicians. Those who were primarily interested in providing the best care for their patients could do so, because medical ethics provided that the physician had a fiduciary responsibility, i.e., they would charge a fair price for services and not overutilize them for personal gain.

Many, perhaps most, primary care physicians from Pasadena to San Diego that I encountered during these years abused the system unconscionably for maximum monetary gain. I knew lots of them who became quite wealthy. For example, during my family practice residency, a friend and I moonlighted at a local community hospital owned by obscenely wealthy doctors where we were paid $100 to cover the emergency room and $10 each to perform a history and physical exam on each newly admitted patient. Although the compensation was low, the work was easy. Hospitals that were so busy that moonlighters had to stay awake all night paid more, but one was exhausted the next day. My friend and I used to tell each other horror stories that eventually became amusing because they were so commonplace.

Doing surgery paid a lot more than caring for patients medically. Some doctors would admit entire families to have their tonsils removed. One doctor in particular, who did a lot of surgery, apparently had such a poor technique that he got a wound infection on every single patient we saw while we were there. We even made a wager of $100 for the first one of us who examined a female patient over thirty years of age at this hospital who had not had a hysterectomy. After a year, the money was unclaimed.

It seemed that every patient, no matter what the diagnosis, had several thousand dollars worth of tests. The patients thought they were getting the best care (“I wanted to go into the hospital and have a complete physical to find out what's wrong with me”), and the doctors who owned the hospital (almost all of those who admitted patients there) made a fortune, since the tests were done there. Since then, state regulations have been tightened, limiting self-referrals. That is, a doctor cannot refer his or her patient to his or her own lab, etc.

Because I made two or three urgent calls a night to physicians who had totally botched a patient's care, I eventually came to formulate the rule that a primary care physician's income (above a certain reasonable level) was inversely related to his or her competence in medicine. This rule remained unchanged while I was in private practice, and was true to a certain extent for specialists as well, since incompetent specialists tended to receive referrals from incompetent generalists.

The public seemed generally unable to discriminate between good and bad physicians and went to see a doctor because he or she was convenient or likeable. Although at one time I had the largest solo family practice in my part of the county, cared about my patients, and was on call every single day because even then no other physician could deal with my unusual mix of “treatment-resistant patients.” Some other physicians whom I knew seemed to have primarily a pecuniary orientation. They made ten or twenty times as much money as I did, largely by performing unnecessary tests and procedures. I shall not belabor this point, except to say that most family doctors in 1975 had no additional training past internship and that the amount of medical knowledge doubles every five years. I'll talk about psychiatrists, the other group of physicians with whom I am most familiar, a little later. In the meantime, I describe my “education” as a neurosomaticist in Chapter 1.

Chapter 1

The Education of a Neurosomaticist

To understand other aspects of my early life please refer to Portnoy's Complaint, by Philip Roth (1969). I am ten years younger, my father was a doctor, and my sex life was far more mundane. Otherwise, the depictions are fairly accurate.

I went to medical school solely to get my ticket punched for a psychiatric residency because I became fascinated as a teenager by how the brain worked. I realized that psychologists knew a lot about how the brain worked as well, but they could not prescribe medication, which I saw as a necessary partner to psychotherapy in helping people to feel better. Chlorpromazine (Thorazine) was invented in 1951, when I was nine years old, and by the time I was in my teens had made a tremendous impact on psychiatric practice, even though no one knew how it worked in the treatment of schizophrenia.

I started to read psychiatry, which in those days consisted of psychoanalysis and psychoanalytically oriented psychotherapy, which was just psychoanalysis done once or twice a week, not four or five times a week, for five years or so. Although there were different brands of psychoanalysis (“schools,” they were called), psychiatry consisted of learning psychoanalysis, using medications which worked by unknown mechanisms, and doing electroconvulsive therapy (ECT). Insulin shock therapy was on its way out, as was hydrotherapy, or wrapping a difficult patient in wet towels for a long time. Prefrontal lobotomy, popular for a time and performed more or less by putting an ice pick into the brain through the nostrils and wiggling it around, was also losing favor.

In high school I read the collected works of Sigmund Freud. Because I was a tabula rasa at that time when it came to psychiatry, almost all of it just soaked in, although it didn't seem like any other kind of science I had learned before.

Although I went to high school, I spent most of my time playing basketball, posing purposely ridiculous arcane intellectual arguments to my teachers, and trying to score with girls who preferred to be “friends” with me. I also dated cheerleaders but didn't know what to say to them. They usually got headaches and had to go home early. Because I was a curious child who regularly read two or three books a day, I regarded high school itself as an outlet for adolescent urges, as did almost everyone else I knew.

The Ivy League university I attended made the mistake of putting me into a special program in which I could pretty much do anything I wanted for four years. My being in this program was like giving a loaded gun to a child (a simile only in those days!), since I was far too undisciplined to make good use of the opportunity. I chose this college because the girl who allowed me to be the most “friendly” with her was going there. As soon as we matriculated, she informed me that she had fallen in love with a wealthy medical student, although she still wanted to be my friend, just less “friendly” than before.

While in college I did little but play basketball and show up for exams. I would usually spend one day cramming for each exam and otherwise ignore the class. Besides wasting four years of possible learning, I dropped in on some of my classes on the day that a midterm was being given, without warning from my usually reliable sources. Usually I could fake it well enough to at least get a C, but not in my calculus course, since I had somehow neglected to learn calculus in my preteen years when I was reading most of the books in the neighborhood library. I had a chance to snatch a passing grade from the jaws of ignominy by getting a good mark in my final exam, but calculus was my last final of six in the semester. I crammed well enough to get As and Bs in the first five, but found to my horror that after being awake for 48 hours, I could not cram four months of calculus into the next 24 hours. I got a D minus on the exam and failed the course. I repeated it the next term and actually went to class fairly regularly, getting a B. I took the precaution of...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• About the Author
• Table of Contents
• Foreword
• Preface
• Abbreviations
• Part I: Inventing Neurosomatic Medicine: Rewards and Satisfactions Versus Problems and Pitfalls
• Part II: Society for Neuroscience Conference Proceedings
• Part III: Pathophysiology and Treatment
• Conclusion. Closing the Circuit: The Role of the Nucleus Accumbens in Neurosomatic Disorders
• Appendix
• References
• Index