Are You A Mystery Case or a Complex Case?

Trust me: you’d rather be complex than mysterious! Another of these gems from Dr Yanuck today on being a patient with a complex case and how to manage it.

This is just so true. The real take-home point in this is that you start with a treatment strategy based on the info you can work out at that point, and then the real art is to take clues from how the body responds to each treatment step and any further testing, then gradually move the case forward. Complex illness can be so overwhelming – I know, since I have one! – but the trick is taking it step by step, not forcing it, despite your desperation to (been there too!) and letting it unravel at its own pace.

Because it will.

I’ve never yet not been able to move a patient forward to some improvement or, at least, more understanding of what processes might be going on so they have a place to start. If the patient can relax enough, let go of the overwhelm and desperation (often evidenced in constant Google research, questioning, emailing daily, ever-searching) and learn to trust the practitioner’s skill and, admittedly, slow inching forward, then improvement will inevitably happen. You may not get to a ‘cure’ or total resolution; it’s just not possible in some cases (like mine), but you celebrate the little wins and notice when they have suddenly built into a big win!

For example, I have MCAS (mast cell activation syndrome) which expresses itself as hypersensitivity to food (along with tons of other symptoms), but that’s my main mechanism. Today, I went for a walk on a beach in Cornwall, then sat in a pub and drank some coffee (in their cup) that I brought with me, made with my ‘safe’ water and fresh ground coffee. I happily chatted with the people on the two tables next to me. I drove home along Cornish roads (notoriously narrow and bendy) and am now working on your clinical stuff.

I couldn’t do that a few years ago.

I was in ‘freeze’ state from childhood-triggered PTSD and felt I couldn’t/didn’t want to engage with people, I couldn’t sit in a pub without reacting to smells, I couldn’t drink coffee – nor even water – I couldn’t use their cups because of washing up residue. I was panicked about going anywhere new, I couldn’t drive in Cornwall without feeling panic and came up with every excuse under the sun not to go out, and certainly not to drive! I would have been totally exhausted – sensory overload, physical fatigue – when I got back and would have had to go to bed, and that would have been the end of any activity for the rest of the day. (Amazing what you can hide behind a screen, isn’t it?!)

I do still have to have that sensory-break nap where, if I’ve done something like that, I have to just shut down in a darkened, quiet room for 20 minutes, and then I’m right as rain. I’m working on that bit! It’s neuroinflammation and poor vagal tone that causes that, in case you’re interested. I’m just finishing a new Vagus Nerve factsheet for you, and in fact a MCAS one, so keep your eye out for those.

It doesn’t seem much to someone who doesn’t even have to think about trips like that. I thank my lucky stars, to be honest. If I hadn’t known to go TrulyGlutenFree (grain and dairy free) and then full AIP (autoimmune paleo) years ago – despite the deprivation – I’d be in a much worse state now. I go on MCAS forums and hear the sad stories of people so sensitive they can’t even leave their houses, or even live in a house! Others who are in wheelchairs because the illness has attacked their joints. It makes me sad.

So, you take your little wins and celebrate them. It’s a complex case, which we can move forward, not a mystery case where we’ve no clue what’s going on!

Anyway, I am waffling, as per. Here’s the post that made me think of that for you. I hope you are enjoying these patient-support posts; I know many of you have complex – hopefully not mysterious – illnesses, even if you are not working with me. I just want you to trust in the process . I find, like Dr Yanuck, that the more patients understand what is going on, the quicker they get better – as he says, often because they are less stressed out and depressed about it all; less of a victim, more a partner in discovering successful treatment approaches!

One of the most important things I explain to patients, and I tell almost every patient this in the first visit, is that there’s a crucial difference between mystery and complexity.

Patients who see functional medicine clinicians for the first time have typically seen several other clinicians already. They may not have gotten a satisfactory diagnosis. Or, if the patient has received a clear diagnosis and is being treated, the treatment may not be getting the job done.

In either case, the patient typically feels like they haven’t found the way forward. The puzzle of how to make progress hasn’t been identified. The mystery is unsolved.

As you start to unpack the case, you identify factors that, taken together, create a map of the underlying biology of the case. That’s great. But now you have a different problem. As you describe the complex interconnected pattern of their dysfunction, your description isn’t the one-or-two-word declaration they were hoping for. The patient may begin to feel overwhelmed by the number of factors involved. They were wishing for a single diagnostic name. “Hey, my doctor figured out that I have Flerg’s Syndrome! Now I can just do the treatment for Flerg’s Syndrome. What a relief!”

The problem really amounts to this. The patient felt like their case was chaos when nobody understood what to do. When you start describing the complex interconnections in their biology, they also feel like it’s chaos! So they feel like you’re just talking about more chaos.

At this point, I will say to the patient, “There are two kinds of cases… the ones that are mainly about mystery and the ones that are about complexity. You’d much rather have complexity. Mystery means we don’t know what’s going on, so we don’t know what to do. That’s not where you want to be. Complexity means we’re figuring it out. We understand enough to get moving on helping you. Complexity means we have work to do. That’s fine. We can do the work.”

What you’ll find is that when you make this distinction for patients, it helps them un-blend the two kinds of chaos feelings. They typically have no trouble understanding the point. They can see how much better it is to have a clear focus on useful starting points. You don’t need to claim you know everything. You just need to explain the outlines of the case, the parts that are clear, and what you’re going to do to get more information to fill in other pieces of the puzzle. The initial impression is a starting point.

The way the patient responds to the first series of clinical steps will teach you more about their underlying biology. Your understanding will evolve and become more precise over time, as you tailor the treatment process to the information from their initial responses. Show them you’ve got a handle on it, that you’re not afraid of complexity, that you’re engaged with them, and they’ll quickly move to endorse the “ok, let’s get going” that replaces the “this is mysterious, and I feel like my case is too much” feeling they’ve been carrying around.

And the bonus is that their stress level will go down.

Dr Yanuck

Onward – to unravelling the complexity!

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