From “Hysteria” to Neuroplastic Pain - it's been a journey

An 1893 depiction of a woman with hysteria. By Albert Londe - La photographie médicale : application aux sciences médicales et physiologiques. Public Domain, https://commons.wikimedia.org/w/index.php?curid=92886323

Last week I listened to a podcast episode that has left me feeling very thoughtful. The podcast is called Feel Better, Live More by the wonderful Dr Rangan Chatterjee. The episode - “The Revolutionary Science of Recovering From Chronic Pain, Fatigue, Anxiety & Depression” - features another wonderful human, Dr Howard Schubiner. They talk about the mind-body connection in great detail and offer incredible and useful advice, and I strongly recommend the episode.

The conversation taught me a new term: neuroplastic pain. Simply put, neuroplastic pain is pain for which we, the healthcare providers, are not able to find a structural cause. The pain is real but may not be connected to any physical reason. Dr Schubiner says that a large majority of patients who live with the diagnosis of “chronic pain” have neuroplastic pain. In his book - Unlearn Your Pain - he offers a volume of high-quality research to support the growing medical understanding that neuroplastic pain can be treated, even reversed. I look forward to reading this book (for myself and for my patients). Please message me if you’re reading this book and want a study-buddy.

As I was listening to the episode, I realised that even though the term is new, I know this idea. In the psychiatry classes in final year of medical school, I learned about “psychosomatic pain” which had a similar definition – pain that does not have a physical cause. The difference was that these were taught as diagnoses of dismissal, bordering on disrespect; we were taught that the pain is not real, the patient is making it up, and the best thing we can do for them is humour them and treat them with placebos.

We have other wonderful labels on this theme of not-real pain. One is “malingering” (which continues to be used and included in DSM classification even though it has frequently been challenged as being very prone to misdiagnosis). Another, even better one is “hysteria” which thankfully was already outdated by the time I was in med school. (Fun facts about “Hysteria” which was only removed from DSM-III in 1980: it was a popular diagnosis among physicians in Western Europe for hundreds of years; symptoms included anxiety, high libido and “a tendency to cause trouble for others”; treatment included genital stimulation, asylum stays and hysterectomy.)

We live in difficult times, but at least some kinds of barbarisms are behind us. Psychosomatic pain (or illness) has been renamed to neuroplastic pain (or illness). Modern practitioners are taught that these symptoms are not imaginary, and dismissiveness is not acceptable. Treating physicians are offered a detailed step-by-step pathway to diagnose and treat this type of pain. A core technique is cognitive reappraisal or somatic tracking which has been shown to be an effective pain management tool in RCTs. In the landmark Ashar et al. RCT (JAMA Psychiatry, 2022; n=151), 66% of chronic back pain patients were pain-free or nearly pain-free at the end of treatment, compared with 20% on placebo and 10% on usual care.

The renaming of psychosomatic pain to neuroplastic pain is, for me, a powerful example of how modern healthcare is evolving towards becoming a more respectful, patient-centric practice. It fills me with gratitude that we’re not diagnosing people as “hysterical” any more and are cautious about labels like “malingerers”. It makes me want to list other, similar, evolutions that I am grateful for.

• Hormone Replacement Therapy (HRT) for menopause was dreaded and feared for years; women experiencing awful menopausal symptoms were prescribed HRT with a lot of warnings and judgment (largely a hangover from the 2002 Women’s Health Initiative findings, which were later re-analysed and substantially revised). It is now Menopausal Hormone Therapy (MHT), and with every passing year, increasingly large number of women are utilizing their agency to demand it and receive it from their healthcare practitioners.

• TB patients who stopped their TB treatment for any reason (horrible side effects, drug stockouts) were called “defaulters”. WHO revised the definition in 2013, and we now recognise the fault where it actually belongs and call them “Lost to Follow-Up”, or LTFU.

• If someone had symptoms that looked like TB (cough, fever, weight loss), my medical textbooks labelled them as “TB suspects”. We now say “people with presumptive TB” or “people with symptoms suggestive of TB”. It might make TB documents longer, but we say the respectful thing.

There are more examples. People who inject drugs are now called exactly that neutral term, not addicts or abusers. It’s hard to believe now that “AIDS victims” was an actual term in 1980s and 90s (UNAIDS formalised “people living with HIV” in its terminology guidelines in response to the “Denver Principles,” written in 1983 by people living with HIV themselves).

Words have infinite power. I am thankful for the work that activists and advocates have done and continue to do, to teach us the right words. Words that do not shame the people who are navigating healthcare systems. Tell me about other semantic evolutions that make you happy and grateful.

What is Lifestyle Medicine? Part 2 (of 2)

[I am a Lifestyle Medicine doctor (in-training). About a month ago, I submitted a (less opinionated) version of this piece as my Term 1 assignment for the year-long course I am doing with the Indian Society of Lifestyle Medicine (ISLM). ISLM has partnered with the British Society of Lifestyle Medicine (BSLM) to develop the course for Indian physicians. The views expressed here, although informed by my ISLM-BSLM curriculum, are my own.]

The Case for Lifestyle Medicine (LM)

As a new entrant to this community, I cannot help observing that Lifestyle Medicine physicians are simply a different kind of doctor. I find them sincere, kind, enthusiastic and mildly evangelical in their passionate desire to spread the understanding that good health is achievable through human effort. I am grateful for the series of chance encounters that brought me to this training, and I have embarked on this year long learning journey with the discipline and excitement it deserves.

Despite the many encouraging trends (a large and growing evidence base, thematic agreement across societies, surging physician interest), no country has yet formally recognised LM as a stand-alone postgraduate medical specialty. The UK currently comes closest: in 2024, the Royal College of General Practitioners (RCGP) established a recognised role: a GP with Extended Role in Lifestyle Medicine or a “GPwER-LM” (I bet these new GPs wished they had an easier name). Across UK, GPwER-LMs are leading dedicated lifestyle medicine clinics in primary or secondary care settings, heading multidisciplinary LM teams, and using lifestyle interventions specifically oriented toward treating (and in some cases reversing) type 2 diabetes, obesity, and metabolic liver disease. To my knowledge, this is the most significant step toward formal health-system integration that LM has achieved anywhere in the world.

The limited recognition is a mixed blessing. On the one hand, it makes the science accessible with minimal gatekeeping. On the other, it comes with limited regulation and oversight - which carries its own challenges, particularly when separating evidence-based practice from wellness marketing.

For me, five themes have emerged in the last two months of learning that define LM’s value in these complicated modern times.

1. Human behaviour >>> medical interventions

LM uses individual behaviour - rather than medical interventions - as the primary lever to manage health. As Dr Michael Greger puts it pithily in a BSLM course video, “exercise and nutrition are the penicillin of Lifestyle Medicine.” Each of the six pillars has independent evidence on health linkages. The LM ethos establishes that while medicines can treat conditions, behaviours can do more: treat the condition, treat underlying (or root) causes AND bring in additional whole-health benefits.

2. Evidence-based, but not at the cost of agility

The evidence-to-practice lag in conventional medicine is, on average, about seventeen years. Let me say this again: when scientists prove that some treatment modality works, it can take an average of 17 years for it to become part of global guidelines and recommendations. It can take longer for it to be taught in medical schools. For me, one of the most interesting examples of this knowledge-to-practice gap is the possibility of remission in type 2 diabetes (T2D). In 2011, the Counterpoint study first showed that T2D could be reversed through an 8-week very-low-calorie diet. Seven years later, the DiRECT Trial (Diabetes Remission Clinical Trial), published in The Lancet in 2018, confirmed this with a proper RCT which showed 46% of participants achieved remission at one year, 36% at two years. Hope was expressed that primary care physicians would use these findings to help people with T2D get off their medications. Is this taught in any medical school I know of? Nope. I asked around in my physician network, and the only doctor friend using this evidence with her patients is a family medicine practitioner who is also a trained Lifestyle Medicine doctor. “Deprescribing” - the opposite of prescribing, or the work of helping people taper off their medications - is now one of my favourite words, and one of my favourite lines of study.

Lifestyle Medicine teaches practitioners to use evidence-based strategies and also to evaluate and apply research more quickly. To do this, it uses something called the Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM) framework, which says there are five types of evidence that, taken together, can build a credible case for any lifestyle intervention: randomised controlled trials (RCTs), prospective cohort studies, case-control studies, mechanistic research, and ecological or population-level data. The clever move is that HEALM doesn’t insist on RCTs as the sole gold standard: it accepts that for questions about lifetime effects of how we eat, move, sleep and relate, you often can’t run an RCT, and the honest thing to do is triangulate across different types of evidence. This dedication to agility and to using science faster is important because evidence is coming in thick and fast. I have to admit that even this framework is too strict and can be exclusionary towards other kinds of evidence like qualitative research, patient-reported outcomes, and the “long-but-less-scientifically” knowledge of traditional medical systems.

3. Human centricity

Conventional medicine can tend to be hierarchical: doctors hold more power than patients, and senior doctors hold more power than junior ones. At its worst, this manifests as violence against patients. Twenty years out of med school, I remain traumatised by what I have witnessed in labour wards, a phenomenon the global literature now formally names obstetric violence. At its most benign, the unequal power in the medical profession shows up in the excessive “sirs” and “ma’ams” still used in hospitals across South and Southeast Asia, long after these forms of address have been abandoned in other professional settings. And then there is the everyday friction of patients who arrive having googled their condition - a keenness to be prepared that some doctors (not all, to be fair) experience as a challenge to their expertise rather than as engagement with their own health.

LM, with its whole-person, behaviour-driven approach, upends this dynamic. The work of healing is done through the patient’s own actions - which makes the patient the entity with greater agency in the partnership. The doctor’s role shifts toward coach, partner, and evidence-translator rather than the authority figure who dare not be challenged. As someone long troubled by the power inequities in healthcare systems, I find a quiet poetic justice in this reversal. Perhaps this is why one of my textbooks describes Lifestyle Medicine as “as much an art as a science.”

It would be fair to wonder whether lifestyle medicine can potentially create new forms of paternalism. Lifestyle advice can easily slide into moralising, can place the burden of disease on individual choice and can be experienced by patients as judgmental (“you got diabetes because you ate badly”). Although we are taught to avoid this by paying attention to social determinants of health and by being intentional about shared-decision-making and behavioural coaching, it is an important red flag to watch for.

4. It’s what the people want

It won’t surprise anyone that “How to lower my blood pressure” is one of the most-googled health questions globally. Various studies have shown that one out five patients who are prescribed statins (the medicine to lower serum cholesterol) are unwilling to take the drug - not because they don’t believe that the drug works, but because of concerns around side effects. LM can empower people keen to take charge of their own health, with or without medication.

Another noteworthy societal trend is the growing scrutiny of capitalism, and the possibility that alternative economic systems are not just possible but perhaps urgently necessary; LM is one of the few medical fields that explicitly engages with the “commercial determinants of health” and acknowledges that there are many ways in which commercial interests are hurting wellbeing.

5. Alignment with the “Anthropocenic” challenges

As other climate-change-obsessed readers might know, Anthropocene is the name of the geological epoch we’re living in. It started sometime between the Industrial Revolution and the mid-20th century, and it is defined by the dominant presence and impact of human activity on Earth’s climate, ecosystems, and geology. There are four Anthropocene-era that challenges keep me awake at night, and LM speaks directly to each.

Ageing demographic. The factors that keep healthcare costs in check within a fast-expanding elderly demographic - staying mobile, eating well, sleeping well, staying socially connected - align neatly with LM’s six pillars.

Mental health. Roughly 1 in 7 humans now lives with a mental health disorder, and the need for mental health support is rising disproportionately faster than the available support. Lifestyle interventions offer a parallel, scalable, lower-cost adjunct to pharmacotherapy and psychotherapy. An RCT-backed dietary intervention (the SMILES trial) achieved depression remission in 32% of participants with moderate-to-severe depression versus 8% in controls.

Rising cost of healthcare. Non-communicable diseases (NCDs) - cardiovascular disease, cancers, diabetes, and chronic respiratory disease - account for about three-quarters of all deaths globally and are the biggest drivers of hospital admissions and healthcare spend. By tackling the modifiable risk factors that underlie these conditions, LM can meaningfully reduce healthcare costs. COVID-19 amply (and tragically) demonstrated the lifestyle–healthcare-cost linkage: people with poorly controlled cardiometabolic conditions had dramatically worse outcomes and accounted for a disproportionate share of hospitalisation costs.

Climate change. LM is planet-forward! It can impact one of the most influential climate change levers: transitioning toward plant-predominant diets can reduce diet-related greenhouse gas emissions by up to ~49% and freshwater use by up to ~21%. The same dietary patterns that lower cardiovascular risk also lower the carbon footprint of food.

Next:

I Ran 10K This Morning. I am still a “sedentary human”. (Why physical inactivity and sedentary behaviour are different things - and how both, independently, can shorten your life)

What is Lifestyle Medicine? Part 1 (of 2)

[I am a Lifestyle Medicine doctor (in-training). About two weeks ago, I submitted a (less opinionated) version of this piece as my Term 1 assignment for a year-long course I am doing with the Indian Society of Lifestyle Medicine (ISLM). ISLM has partnered with the British Society of Lifestyle Medicine (BSLM) to develop the course for Indian physicians. The views expressed here, although informed by my ISLM-BSLM curriculum, are my own.]

What is Lifestyle Medicine?

To paraphrase the American College of Lifestyle Medicine (ACLM): Lifestyle Medicine (LM) is a medical specialty that uses therapeutic lifestyle interventions to treat, prevent, and (where possible) reverse chronic conditions such as cardiovascular disease, type 2 diabetes, and obesity.

How it began

The philosophical foundations of Lifestyle Medicine go back at least two millennia, probably around the time Hippocrates famously said, “Let food be thy medicine and medicine be thy food.” His contemporary Galen of Pergamon prescribed specific exercises for specific health conditions. Many Greek-Roman writings of this time reflect the understanding that diet, exercise, rest, emotional state, and environment are the primary determinants of health and disease. In Asia - sometime before Hipocrates and Galen - Ayurveda was documenting the wisdom of dincharya (daily routine for health) and ahara (the link between nutrition and health), and Traditional Chinese Medicine (TCM) was emphasising the value of movement (through Qi Gong) and dietary balance (through Shi Liao).

The parallels across traditions are interesting: the Greek ideal of sophrosyne (“moderation in all things”) and the Ayurvedic dictum of ati sarvatra varjayet (“avoid excess in everything”) say essentially the same thing. The idea that how one lives determines one’s health was near-universal. And then we sort of forgot about it. The rise of germ theory in the 19th century and the pharmaceutical revolution of the 20th gradually displaced lifestyle-centered thinking from mainstream medicine, reducing it to background context against the powerful promise of drugs and surgery.

How it began, again (for the modern times, via modern methods)

LM began its comeback in the mid-20th century through two parallel developments: (a) the leading causes of death started to shift from infectious diseases to non-communicable diseases (NCDs) like diabetes and cardiovascular diseases; and (b) evidence that linked human behaviour to NCDs started to pile up. Landmark studies like the Framingham Heart Study (1948) and the Seven Countries Study (1958) were among the first to show the relationship between habits and disease. Further research made it clear that humans had vastly underestimated the toll that modern sedentary, processed-food-driven lifestyles were taking and that reversals were possible with data-backed behavioral changes. LM thus coalesced into a recognised, structured discipline based on the evidence that could no longer be ignored.

It’s all fairly new though. The American College of Lifestyle Medicine (ACLM), the first LM-focused professional medical association, was set up in 2004; the American Journal of Lifestyle Medicine (AJLM), the first LM-focused scientific journal was published in 2007. At this point, there are just over thirty national and regional Lifestyle Medicine societies. A recent entrant is the ISLM in India - a key geography for LM, not only because we are home to the largest population in the world, but also because we hold the dubious distinction of being the diabetes capital of the world. These national societies are linked through two umbrella bodies at the global level: the World Lifestyle Medicine Organisation (WLMO) and the Lifestyle Medicine Global Alliance (LMGA).

The six pillars of Lifestyle Medicine

Although the many LM-focused institutions in the world have evolved autonomously, they are in firm agreement about the six pillars that make the foundation of health: (1) Mental wellbeing, (2) Healthy relationships, (3) Physical activity, (4) Healthy eating, (5) Sleep, (6) Avoidance of harmful substances and behaviors.

It would be fair to observe that the Eastern traditions (Ayurveda, TCM, and probably others) never lost their lifestyle-medicine orientation in the way Western medicine did during the pharmaceutical revolution, only to rediscover it a century later. However, it is also worthwhile that with wisdom and means of modern times, we have built that much-cherished resource: evidence. Each of the six pillars has independent evidence on health linkages:

1. Mental wellbeing: Positive psychological well-being independently predicts lower all-cause mortality in both healthy and diseased populations

2. Healthy relationships: Strong social ties are associated with a ~50% increase in odds of survival over follow-up - an effect comparable to quitting smoking and larger than obesity

3. Physical activity: Structured exercise is at least as effective as pharmaceuticals in treatment for several chronic conditions like coronary heart disease and rehabilitation after stroke

4. Healthy eating: A Mediterranean dietary pattern reduces major cardiovascular events by roughly 30% in high-risk adults

5. Sleep: Both short (<7h) and long (>8–9h) sleep duration independently linked to all-cause mortality risk in a U-shaped curve

6. Avoidance of harmful substances: Lifelong smoking shortens life by about 10 years; quitting by age 40 recovers about 9 of those years

So what?

We know most of this already. Of course if we could all eat less, move more, sleep well and have healthy relationships, we’d be invincible. What is the big idea about creating a whole medical discipline about it?

LM is not just building the evidence for the value of lifestyle interventions; it is also building evidence for actionability. It acknowledges that giving people generic advice to “Eat less, move more” does not work. And therefore, it teaches clinicians the specific dose-response parameters that turn each pillar into a prescription. Physical activity comes with explicit targets based on meta-analyses. Dietary interventions are operationalised through scored, validated patterns (like the Mediterranean Diet Adherence Screener and the DASH score) rather than vague advice to “eat healthy.” Behaviour change itself is taught as a structured clinical skill which uses evidence-backed models of behavior change. The result is a structured clinical medicine rather than well-meaning wellness advice: a specific protocol, individualised to each patient, with measurable outcomes at each follow-up.

What is fascinating for me is that because many of these fields of expertise emerged during the lifetime of currently practising clinicians, this is not something they were actively taught during their training. I graduated from med school in 2004. While my textbooks certainly instructed me to “advise lifestyle improvements” to people with chronic diseases, it was as an adjunct to medical treatment, rather than as a possible, achievable, alternative. And there was no clarity on what that advice might look like. Even today, most formal medical training does not yet cover the science behind the impact of lifestyle factors on health and how to best support people with sustainable lifestyle change. But at the same time, there is an increasing recognition - both among patients and providers - that non-pharmacological-non-surgical treatment modalities are valuable and necessary.

And so, the doctors are learning. As of early 2026, about 10,000 clinicians from over 90 countries have earned Lifestyle Medicine certification from one of the four certifying institutions: the American Board of Lifestyle Medicine (ABLM), the International Board of Lifestyle Medicine (IBLM), the British Society of Lifestyle Medicine (BSLM), and the Australasian Society of Lifestyle Medicine (ASLM). This is the cohort of people leading the charge towards the creation of healthcare system where prevention and wellbeing receive as much attention as (if not more than) medical and surgical interventions.

When I started this course, I half-expected something closer to a self-help book in a white coat: well-meaning prescriptions to eat your greens and walk more. Instead, I’m two months in and learning to score Mediterranean diet adherence on a validated 14-item screener, to titrate exercise the way I’d titrate a statin, and to measure my patient’s loneliness on the UCLA scale before I measure her HbA1c. It is, unmistakably, medicine. What has surprised me more is that it is also the most patient-respecting medicine I have ever practised. More on that next week.

Next:

Part 2 (of 2): Five themes that define this science and underscore its value at this moment in history.