Dissociation, Anxiety and Depression – Uncontrolled emotion in cervical spine instability patients

Ross Hauser, MD.

Many of the patients who we see in our neck center have conditions of anxiety, depression, and dissociation. These challenges can be termed psychiatric-like because, in some people, these problems are a manifest of cervical spine and craniocervical instability and are symptoms of nerve, vein, and arterial compression caused by the unstable bones of the neck pressing and compressing these vital structures.

In the video below, Ross Hauser MD will discuss the challenges people with cervical spine and craniocervical instability face with dissociation, anxiety, and depression. Below the video is a Summary transcript with explanatory notes and supportive research.

We see many people at our center who suffer from a vast myriad of symptoms related to neurologic-type and vascular-type symptoms and conditions. These health challenges can be traced to their problems with their neck, cervical spine, and craniocervical instability. For a comprehensive review of these symptoms please refer to my article Symptoms and conditions of Craniocervical Instability. In this article and video, I will focus on the problems of dissociation, anxiety, and depression.

Here is an example story of someone who contacts our center, it represents what we may hear from many people.

I have already scheduled surgery for cervical spine fusion. I am having fusion from C2-C4. It is the only way, according to my doctors, to handle my upper cervical instability. As my surgical date approaches, I am researching what I hope would be a better approach to my extensive list of symptoms.

I can’t drive, I can’t look down, I have significant occipital neuralgia, migraines, cervical stenosis, vertigo and dizziness, concentration and memory problems, cervical neck-related insomnia, digestive disorders, Trigeminal neuralgia, and dissociation episodes.

The list of symptoms is so extensive that a problem of dissociation episodes comes last even though it may be just as impactful.

Dissociation and cervical spine and craniocervical instability.

The word dissociation often presents a problem for people who suffer from it and are trying to research help for it. The problem is that the word dissociation is often used to describe, and accurately so, the displacement between the bones of the cervical spine. If a C3 has slipped well in front of a C4 for example it could be said that the C3 is in a position of dissociation with C4. It is out of place, it doesn’t belong where it is. Many of you reading this article may be thinking, “I am like the C3, sometimes I feel out of place like I don’t belong in my space.” For many of you, you are like the C3, sometimes you do feel out of place.

Let’s briefly look at some research studies to help reassure you that this is not a made-up diagnosis to try to explain your episodes.

Here is a study in the journal Current Psychiatry Reports (1) that looks for a cause of dissociation. The study does not mention cervical spine instability, it talks about the problem from a psychiatric viewpoint, but we can make some connections. First here is what the study highlights:

It may be possible to visualize a cause of dissociation through brain-blood flow tests.

In other words, it may be possible to visualize a cause of dissociation through brain-blood flow tests. Let’s continue with the study.

“Dissociation is a complex heterogeneous phenomenon. (It is diverse in its cause, its symptoms, and the conditions it may cause). It has been defined as a “disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning, including – but not limited to – memory, identity, consciousness, perception, and motor control.” Here the world of psychiatry and the world of cervical spine instability share many symptoms that can be applied to both fields.

Here is one more area that is shared, the ability to visualize the problem with certain testing. Back to the study:

Over the past decades, neuroimaging has become one of the most important tools in clinical neurobiology. Techniques such as magnetic resonance imaging (MRI), MR spectroscopy (MRS), positron emission tomography (PET), and diffusion tensor imaging (DTI) are used to study abnormalities in the brain.”

What the researchers of this study are suggesting is that this problem of dissociation may have something to do with blood flow to the brain and it should be explored. Let’s be clear problems of dissociation can be caused by many problems, the problems of blood flow in and out of the brain may be the primary cause in some, not all.

Cervical spine and craniocervical instability patients can be seen as having psychiatric-like, or neurologic-like, or vascular-like conditions

At our center, the many problems, including dissociation that we see in our cervical spine and craniocervical instability patients can be seen as psychiatric-like, or neurologic-like, or vascular-like, but, in our world of neck pain, these conditions and symptoms may be a manifestation of nerve, vein, and arterial compression caused by instability in the neck, from C0-C7.

At our center, we offer diagnostic testing to check for blood flow in and out of the brain. These tests are done in real-time while the patient moves and rotates his/her head. As you may suffer from many of the conditions already highlighted in this article, you may know first hand that when you turn your head to the right, for example, your symptoms get worse, when you turn you had all the way to the left or up or down or back and forth you can manipulate the severity of your symptoms simply by repositioning your head. Motion is the key to finding the root cause of cervical spine instability.

Please refer to the following articles:

What are we seeing in this image?

Dr. Hauser is using ultrasound to examine the blood flow through the carotid artery. Blood in and out of the brain has to pass through the neck in its journey back and forth to the heart.

For a more comprehensive review please see our articles:

 

How cervical spine instability disrupts blood flow into the brain and causes many neurological problems

Another patient story example

“My worst symptom is an intense desire to sleep. I have suffered from it for eight years. All the drugs doctors have tried, stimulants, antidepressants, did not work and some gave me severe  side-effects like sobbing, shaking, feeling hopeless, disconnected from the family and everything I love. . . “

We see many people with terrible brain fog, excessive sleepiness, the desire to take naps, sometimes incapacitating fatigue, most of the day they feel horrible or terribly depressed. These emotions can come upon them instantly, without warning, they start sobbing, shaking, a feeling of hopelessness has come over them. They feel like they are disconnected from themselves, they feel dissociation. They feel psychologically that you are not even yourself. Like you’re not even in your own body.

Whiplash and Dissociation

Symptoms of dissociation found in people with cervical spine instability are often documented in the medical literature about people with whiplash injuries. As people with untreated or mistreated whiplash injury often fall into the problem of long-term chronic symptomology, or post-traumatic osteoarthritis, also they are sometimes considered as suffering from Post Traumatic Stress Disorder (PTSD) they share symptoms with those non-whiplash associated cervical spine instability caused by degenerative wear and tear.  Let’s make a connection.

We are going to start by looking at a 2013 paper in the journal Clinical Practice and Epidemiology in Mental Health. (2)

“With PTSD symptoms and somatization representing important features of the whiplash associated disorder, traditional pain management may miss important features. Clinicians may be misguided in their interventions, because patients with symptoms of whiplash, may primarily seek treatment for pain complaints. In relation to affect regulation, factors such as PTSD, somatization, and attachment insecurity may be overlooked despite being highlighted as potential vulnerabilities.”

A brief note: The quoted research suggests that people with Whiplash Associated Disorder are seeking medical treatment for pain. Doctors should not ignore however the fact that some of these people may need counseling. In our office, we feel it’s critically important that the patient have a good support system behind them, whether family or partner or friend or support group.

A brief note:  Attachment insecurity is a disorder where people lash out or have widely varying emotions towards some in close relationship with them, family member, loved one, partner). A 2019 study updated by the same lead researcher as the 2013 study just noted, and published in the Journal of Psychosomatic Research (3) wrote: “when attachment avoidance (avoiding need of relationship or family support) and attachment anxiety (the fear of not having a relationship or family support) were high there was a significant positive relationship between depression and disability.”

Let me stress again: In our office, we feel it’s critically important that the patient have a good support system behind them, whether family or partner or friend or support group.

In October 2020 a team of Italian university research and medical hospital doctors writing in the journal Frontiers in Psychology. (4) investigated whether chronic pain patients with somatization reported higher alexithymic (isolation, the inability to make an emotional connection with others) traits than those without somatization and to study the different relationships between psychological characteristics, pain, health-related quality of life, and somatization.

Results: Patients with somatization (37.04%) reported significantly higher feelings of isolation and emotional detachment and difficulty in identifying feelings than those without somatization. The somatizer group had also a significantly higher disease duration, severity, and interference of pain, distress, and lower health-related quality of life than the non-somatizer group.

People who have chronic pain for long-duration can shut themselves off emotionally if they feel that no one understands that they have more pain than they should.

Treating the physical aspect of pain in dissociation

In the patients we see, dissociation can be associated with the cervical spine and craniocervical instability. We refer to this as a problem of cervical dysstructure, there has been ligament damage in the neck, which causes cervical spine instability, and craniocervical instability, which causes destructive changes in the cervical spine natural curve which can cause blockage of the cerebrospinal fluid flow. This will increase pressure in the brain.

These are all physical manifestations that may lead to the emotional challenges we have described above. In patients, we see they recognize changes in their emotional and mental state. They have become anxious all the time, they can’t focus, they have obsessive tendencies, depression, alienation from the family.

What are we seeing in this image? Arterial and venous obstruction of fluid into and out of the brain

At 3:15 in the video with Dr. Hauser, Dr. Hauser describes the arterial and venous obstruction of fluid into and out of the brain. In explaining to patients this vital component of their brain health, the analogy of a Brain Toilet Obstruction seemed to resonate with our patients as the best way to understand fluid in and fluid out.

In this split image, the image to the left shows a stable neck with a normal cervical spine curvature. Everything is in its proper place. Cerebrospinal fluid drains and refills within the brain.

In the image to the right, we see cervical dysstructure, a condition of cervical spine instability. The displacement of the C1 is now exerting pressure on the arteries and veins leading into and out of the brain. The Cerebrospinal fluid is now backing up into the brain. In this situation, frontal lobe damage can occur.

To reiterate: The brain needs to drain out or flush out toxins and refill itself with fresh fluids. In the image to the right, it is pointed out that obstruction of the veins and arteries will cause a “clogged toilet.” What happens when the toilet clogs?

Cerebrospinal fluid and intracranial blood levels need to be maintained at all times, think of it as the water in your toilet bowl. That level is always maintained and does not fluctuate until the time the toilet is flushed. When the toilet is flushed the water goes down the drain and as soon as the dirty water is flushed, freshwater now drains in from the toilet tank to the toilet bowl.

If the drain is clogged the toilet overflows, if there is no water in the tank, the fluid in the brain does not refill.

Ultimately this will result in an accumulation of cerebrospinal fluid in various parts of the brain including the frontal lobe. This will destroy neurons and brain tissue. This can be one explanation for the problems of emotional detachment, anxiety, depression, memory, cognitive function, and brain fog described by some patients with cervical spine instability.

For a more comprehensive discussion on these topics please see our articles:

Above we talked about various tests that could show pressure within the brain. The toilet analogy is one way to understand this pressure buildup. Testing is of course the documented way to demonstrate pressure within the brain.

One way we document that the venous outflow from the brain is obstructed by extracranial Doppler ultrasound examinations. This will help reveal if internal jugular veins and other veins are being blocked. We also do ultrasounds of the eye which will show that the optic nerve sheaths are swollen which is a sign that the pressure inside the brain is high. Together with the information gleaned from a digital motion x-ray we then come up with a treatment regime to help get the brain functioning back to normal.

Please see my article:

Transcranial Doppler to test blood flow

We document the blood flow of the vertebral artery with Transcranial Doppler. So our ultrasound machines can measure blood flow to the vertebral artery and then we can move a person through a range of motion to see if the blood supply goes down (is reduced). Please see our article Using Transcranial Doppler & Extracranial Doppler Ultrasound Testing at the Hauser Neck Center for further information and explanations.

We document the blood flow of the vertebral artery with Transcranial Doppler. So our ultrasound machines can measure blood flow to the vertebral artery and then we can move a person through a range of motion to see if the blood supply goes down

We document the blood flow of the vertebral artery with Transcranial Doppler. So our ultrasound machines can measure blood flow to the vertebral artery and then we can move a person through a range of motion to see if the blood supply goes down

What are we seeing in this image? Ultrasound measurement of the optic nerve.

In this photograph, an optic nerve measurement is taken via ultrasound.  We are looking for swelling of the optic nerve that may explain vision problems by way of demyelinating optic neuritis (swelling of the nerve sheath and optic nerve) or non-arteritic anterior ischaemic optic neuropathy (loss of blood flow to the optic nerve). Characteristic symptoms of compression or entrapment of the nerves and arteries in the cervical spine.

Digital motion X-Ray C1 – C2

At our center, we use a Digital motion X-ray so we can watch your head in motion. The digital motion x-ray is explained and demonstrated below:

You can also visit this page on our site for more information on Digital Motion X-ray (DMX)

Research on cervical instability and Prolotherapy. A mechanical approach to Dissociation, Anxiety, and Depression

In the research above, a case is laid out for the treatment of cervical spine instability in patients with dissociation, anxiety, and depression. As also stated, not every case of these psychiatric-like disorders can be attributed to cervical spine instability. Certainly, at our center, we see many people with this connection because this is what we treat.

Prolotherapy is an injection technique that stimulates the repair of unstable, torn or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can stress tendons, atrophy muscles, pinch on nerves and cause other symptoms associated with cervical instability including neurologic-type, vascular-type, and psychiatric-like symptoms and conditions.

In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal. (5) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.

In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck can eliminate the instability and the sympathetic symptom. We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders.

A Digital Motion X-Ray or DMX is a tool we use to help understand a patient’s neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2. This hypermobility can result in common symptoms of neck pain, headaches, dizziness, vertigo, tinnitus, concentration difficulties, anxiety, TMJ, and other symptoms.

A Digital Motion X-Ray or DMX is a tool we use to help understand a patient' neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2. This hypermobility can result in common symptoms of neck pain, headaches, dizziness, vertigo, tinnitus, concentration difficulties, anxiety and other symptoms common in TMJ/TMD patients.

The curvatures of the neck -What are we seeing in this image?

In our practice, we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to “S” shape curve.

In our practice we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to "S" shape curve.

What are we seeing in this image? Restoration of normal curvature in one of our patients

In this video, a demonstration of a Prolotherapy treatment is given

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

Many of the patients who we see in our neck center have conditions of anxiety, depression, and dissociation. These challenges can be termed psychiatric-like because, in some people, these problems are manifest of cervical spine and craniocervical instability and are symptoms of nerve, vein, and arterial compression caused by the unstable bones of the neck pressing and compressing these vital structures. By identifying cervical spine instability, disruption of blood flow into and out of the brain, disruption of normal Cerebrospinal fluid flow and by treating the damaged cervical spine ligaments and addressing the problems of the cervical spinal curvature, we hope to be able to help the right candidate get back to a better lifestyle.

We hope you found this article informative and it helped answer many of the questions you may have surrounding cervical spine instability and anxiety, depression, and dissociation. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 Krause-Utz A, Frost R, Winter D, Elzinga BM. Dissociation and alterations in brain function and structure: implications for borderline personality disorder. Current psychiatry reports. 2017 Jan 1;19(1):6. [Google Scholar]
2 Andersen TE, Elklit A, Brink O. PTSD symptoms mediate the effect of attachment on pain and somatization after a whiplash injury. Clinical practice and epidemiology in mental health: CP & EMH. 2013;9:75. [Google Scholar]
3 Andersen TE, Sterling M, Maujean A, Meredith P. Attachment insecurity as a vulnerability factor in the development of chronic whiplash-associated disorder–A prospective cohort study. Journal of psychosomatic research. 2019 Mar 1;118:56-62. [Google Scholar]
4 Lanzara R, Conti C, Camelio M, Cannizzaro P, Lalli V, Bellomo RG, Saggini R, Porcelli P. Alexithymia and Somatization in Chronic Pain Patients: A Sequential Mediation Model. Frontiers in Psychology. 2020 Oct 27;11:2929. [Google Scholar]
5 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]

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