Case Study: The Woman Whose Pain Was Real — Fibromyalgia, Central Sensitization, and Thirty Years of Unshed Tears

Category: Case Studies | All Four Directions | Composite Clinical Case

DISCLAIMER: This is a composite fictional case study based on common clinical patterns observed across integrative and functional medicine practice. It does not represent any single real patient. All names, identifying details, and specific circumstances are invented. The clinical patterns, lab values, treatment protocols, and healing trajectories described reflect well-documented presentations in the literature and are intended for educational purposes.

Presenting Complaint

Hoa, a 45-year-old Vietnamese-American woman, presented with a chief complaint of “I hurt everywhere, and no one believes me.” She described widespread, chronic pain that had been escalating over seven years and had become disabling in the last two. The pain was diffuse — neck, shoulders, upper and lower back, hips, knees, hands, jaw — with no single anatomical focus. She rated it 6-8/10 on most days, with flares reaching 9-10/10 that left her bedridden. The quality of the pain shifted unpredictably: sometimes burning, sometimes aching, sometimes a sensation she described as “my bones are vibrating.” Light touch — a hug from her daughter, the pressure of clothing seams — could be excruciating (allodynia). Cold weather, poor sleep, and emotional stress reliably triggered flares.

She had seen twelve physicians over five years: two primary care doctors, a rheumatologist, an orthopedic surgeon, a neurologist, a pain management specialist, an endocrinologist, two physical therapists, a chiropractor, an acupuncturist (three sessions, then stopped because “it made me worse”), and an emergency room visit during a severe flare. She had undergone: X-rays of multiple joints (mild degenerative changes consistent with age, nothing explanatory), MRI of the cervical and lumbar spine (mild disc bulging L4-L5, insufficient to explain her symptoms), comprehensive autoimmune panel (ANA negative, RF negative, anti-CCP negative, ESR 12 mm/hr, CRP 0.8 mg/L — all normal), nerve conduction studies (normal), and a bone density scan (normal).

The collective medical verdict, delivered in various ways: “Your labs are normal. There’s nothing structurally wrong. Have you considered that this might be stress?” The pain management specialist diagnosed fibromyalgia and prescribed pregabalin 75mg twice daily (caused weight gain and cognitive fog — she called it “being wrapped in cotton while someone beats me with a bat”) and duloxetine 60mg (helped modestly for three months, then the pain broke through). The rheumatologist had told her, with visible impatience: “Fibromyalgia isn’t really a disease. It’s just a name we give pain we can’t explain.”

Hoa arrived at the integrative practice with a thick folder of medical records, a face etched with exhaustion and barely contained fury, and the words: “If one more doctor tells me this is in my head, I will scream.”

She was accompanied by her 17-year-old daughter, who said quietly: “My mom used to be the strongest person I knew.”

History

Medical History

Normal childhood health. Three uncomplicated pregnancies and deliveries (ages 24, 27, 30). Appendectomy at age 19 (uncomplicated). Chronic tension headaches since her late twenties (2-3 per week, managed with ibuprofen — now 800mg ibuprofen 4-5 times weekly). TMJ (temporomandibular joint) dysfunction diagnosed at age 35 — night guard prescribed, partially helpful. Chronic insomnia since her late thirties (averaging 4-5 hours fragmented sleep per night). Restless legs syndrome in the evening (undiagnosed, untreated). The widespread pain began approximately seven years ago as persistent neck and shoulder stiffness, then progressively spread to involve the entire body. No identified triggering injury or illness. Current medications: duloxetine 60mg daily, pregabalin 75mg twice daily, ibuprofen 800mg PRN (4-5 times weekly), zolpidem 10mg at bedtime (nightly for three years).

Family History

Father: died of liver cancer at 64 in Vietnam (heavy drinker). Mother: alive at 78, chronic pain (“she’s always hurt, that’s just how she is”), depression (untreated). Maternal aunt: rheumatoid arthritis. Paternal uncle: chronic pain, disability. Older brother: alcohol use disorder, estranged from family. Younger sister: anxiety disorder, treated with benzodiazepines. Family pattern: pain and emotional suppression run through both lines. No family member had ever been in therapy.

Hoa was born in Ho Chi Minh City, Vietnam, and immigrated to the United States at age 12 with her parents and two siblings. Her father had been a teacher in Vietnam; in the US, he worked in a warehouse and drank. Her mother worked in a garment factory. Hoa learned English quickly and became the family interpreter — managing her parents’ medical appointments, tax documents, and school communications from age 13. She described this role without bitterness but with a telling fatigue: “I have been the responsible one since I was a child.”

She married at 23 to a Vietnamese-American man who was “a good provider.” She described the marriage as stable but emotionally vacant: “He goes to work, he comes home, he watches TV. If I try to talk about how I feel, he says ‘What do you want me to do about it?’ So I stopped trying.” They had three children: a son (21, in college), a daughter (17, living at home), and another daughter who died at age 4 of leukemia.

This loss — the death of her second child, Ly, fifteen years ago — was stated matter-of-factly during the intake, with no visible emotion. When asked how she had grieved, Hoa said: “I had two other children. I had to keep going.” When asked if she had ever received grief counseling, she said: “Vietnamese people don’t do that.”

She worked part-time as an administrative assistant at a medical office, a job she described as “boring but it pays the insurance.” She had reduced from full-time to part-time two years ago because the pain made full-time work impossible. This reduction in hours caused significant financial stress and shame.

Emotional History

Hoa’s emotional presentation was flat — not depressed so much as sealed. She answered questions efficiently, without elaboration, without affect. The only emotion that broke through the surface was anger — at doctors who dismissed her, at a body that would not work, at a life that had narrowed to the dimensions of her pain. Beneath the anger, discernible to the trained eye but invisible to Hoa herself: a grief so vast and so long denied that it had calcified into something her body had to hold because her mind would not.

She described herself as “not an emotional person.” She had cried twice in the last decade — both times while watching movies, not about her own life. She had not cried about her daughter’s death since the funeral.

Spiritual History

Hoa was raised Buddhist and still accompanied her mother to temple on the first and fifteenth of each lunar month. She described these visits as cultural obligation rather than spiritual sustenance: “I light incense for my daughter. I don’t know if she hears me.” She expressed no interest in spiritual practice and described her worldview as pragmatic: “You deal with what’s in front of you. You don’t sit around asking why.”

When asked what gave her life meaning, she paused for a very long time and then said: “My children.” When asked what else, she could not answer.

Assessment Through Four Directions

Serpent / Ran (South) — Physical Body

Hoa’s pain was real. This must be stated first, clearly and without qualification, because the most damaging thing that had happened to her medically — more damaging than any missed diagnosis — was the implicit message from twelve physicians that her pain was not legitimate.

Fibromyalgia is a disorder of central sensitization: the central nervous system amplifies pain signals, reduces pain inhibition, and creates a state in which stimuli that should not be painful (light touch, clothing, temperature changes) become excruciating (Woolf, 2011). It is not “pain without a cause.” It is pain with a neurological cause that does not show up on imaging or standard blood work. The brain’s pain processing centers (anterior cingulate cortex, insula, prefrontal cortex, somatosensory cortex) are measurably hyperactive in fibromyalgia patients on functional MRI (Gracely et al., 2002). The glial cells in the spinal cord and brain are activated, releasing pro-inflammatory cytokines (IL-1-beta, IL-6, TNF-alpha) that sensitize pain pathways (neuroinflammation). Substance P — a pain neurotransmitter — is elevated 2-3 fold in the cerebrospinal fluid of fibromyalgia patients (Russell et al., 1994). The pain is as real as the pain from a broken bone. It simply originates in the nervous system rather than in peripheral tissue.

Hoa’s central sensitization was driven by multiple converging factors:

Chronic sleep deprivation: 4-5 hours of fragmented sleep for years. Deep sleep (stages 3 and 4) is when the brain downregulates pain sensitivity and clears neuroinflammatory metabolites via the glymphatic system. Without adequate deep sleep, pain sensitization accumulates nightly. The zolpidem she was taking produces sedation but does not reliably produce restorative deep sleep (Moldofsky, 2008).
HPA axis dysregulation: Chronic stress, unprocessed grief, and sleep deprivation had almost certainly driven her HPA axis into Stage 3 dysfunction (exhaustion phase), characterized by low cortisol output — cortisol is a potent anti-inflammatory, and when it is depleted, neuroinflammation goes unchecked.
Chronic NSAID use: 800mg ibuprofen 4-5 times weekly for years. NSAIDs, paradoxically, can perpetuate chronic pain through medication overuse headaches and by disrupting gut barrier function, driving intestinal permeability, and increasing systemic inflammation (Bjarnason et al., 1993).
Neuroinflammation: The convergence of sleep deprivation, HPA exhaustion, gut permeability (from NSAIDs), and emotional suppression creates a neuroinflammatory environment in which glial cells remain chronically activated and pain signaling is permanently upregulated.
Nutrient depletion: Chronic pain patients are frequently deficient in magnesium (involved in NMDA receptor modulation — the receptor most implicated in central sensitization), vitamin D (low levels are independently associated with chronic pain), and B vitamins (required for nervous system function and myelin maintenance).

Jaguar / Bao (West) — Emotional Body

The Jaguar direction held the key that no physician had looked for: the relationship between Hoa’s unprocessed grief and her pain.

Fifteen years ago, Hoa’s four-year-old daughter Ly died of leukemia. Hoa nursed her through 14 months of treatment, held her when she died, and then — in her own words — “got up the next day and took care of my other children.” She never grieved. She did not cry, except at the funeral. She did not talk about Ly. She removed Ly’s photographs from the main living areas of the house (they were placed in her closet — she looked at them when she was alone, but she would not have admitted this). She returned to work within two weeks. She performed the rituals of mourning as Vietnamese culture prescribed — the 49-day ceremony, the annual death anniversary — but the rituals were performed outwardly, without the inner process of actually letting the grief move through her body.

The grief did not disappear. It went into the body.

The research on grief and chronic pain is substantial: unresolved grief activates the same neural circuits as physical pain (the anterior cingulate cortex, the insula), elevates inflammatory markers, dysregulates the HPA axis, disrupts sleep, and — when it is chronic and unprocessed — can drive central sensitization through the same neuroinflammatory mechanisms as any other chronic stressor (O’Connor et al., 2008). The bereaved have elevated rates of chronic pain conditions, including fibromyalgia, that significantly exceed baseline (Shear et al., 2011).

In IFS terms, Hoa’s system had responded to the catastrophic loss by installing the most powerful Manager imaginable: “The One Who Keeps Going.” This part’s function was to ensure that Hoa would never collapse, never be overwhelmed, never be destroyed by the grief. It suppressed all emotion, maintained rigid functionality, and kept the family running. For fifteen years, it succeeded. But the cost was borne by the body.

Beneath the Manager was an exile of staggering proportions: the mother who lost her child. This exile carried not only the grief of Ly’s death but the guilt (“Could I have done more?”), the rage at the universe (“Why my child?”), the existential terror (“If this can happen, nothing is safe”), and the forbidden thought that Hoa could barely allow into consciousness: “Part of me died with her.”

The pain, in this framework, was both neurological and meaningful. It was the body’s expression of a grief that had no other outlet. Every morning Hoa woke up in pain was a morning her body said: “You have not cried. You have not screamed. You have not mourned. I will hold this for you until you are ready.”

This is not to say the pain was “psychosomatic” in the dismissive sense. The central sensitization was real neuroinflammation. But the neuroinflammation was driven, in significant part, by decades of emotional suppression. The pain was both biological and biographical. Both/and.

Hummingbird / Chim Ruoi (North) — Soul

At the soul level, Hoa was living a half-life. The death of Ly had fractured her narrative — the story of who she was and what her life meant. Before Ly’s death, Hoa’s identity was organized around motherhood: she was the protector, the nurturer, the one who kept everyone safe. Ly’s death shattered this identity because the fundamental promise of motherhood — “I will protect you” — had been broken by a universe that did not care about promises.

Rather than reconstructing a narrative that could hold the loss, Hoa had simply walled off the chapter. Her life story had a fifteen-year gap that she would not look at. She went from “Before Ly died” to “now” with nothing in between — no meaning-making, no integration, no transformation of the loss into something that could be held without being destroyed by it.

Her sense of purpose had contracted to raw functionality: provide for the children, manage the household, endure the pain. There was no vision for her future, no sense that her suffering might have meaning or that her life might expand beyond survival. When asked what she wanted for herself (not her children, not her husband — herself), she looked genuinely confused. The question did not compute.

Eagle / Dai Bang (East) — Spirit

The Eagle direction held a paradox. Hoa’s temple visits — lighting incense for Ly — were presented as empty ritual, but they were not. They were the one place where she allowed herself to be in relationship with her dead daughter. She would not have called this spiritual practice, but it was: a regular, ritualized encounter with loss, with the invisible, with the boundary between the living and the dead. The temple was the one place where “The One Who Keeps Going” softened, just slightly, because the cultural container allowed it.

The spiritual question that Hoa could not yet articulate: “Is Ly still somewhere? Does my suffering have meaning? Is there something beyond just enduring?”

Testing & Diagnosis

Functional Medicine Laboratory Workup

Comprehensive Blood Panel:

CBC: WBC 5.2, RBC 4.3, Hgb 12.8 g/dL, Hct 38.2%, MCV 88.8 fL — all within normal limits
Ferritin: 24 ng/mL (conventional “normal” >12; functional optimal: 50-100) — depleted
Vitamin D, 25-OH: 16 ng/mL (optimal: 50-80) — deficient (strongly associated with fibromyalgia severity; Makrani et al., 2017)
Vitamin B12: 298 pg/mL (conventional normal >200; functional optimal: 500-1,000) — suboptimal
RBC Magnesium: 3.4 mg/dL (optimal 5.0-6.5) — severely depleted (magnesium modulates NMDA receptors; deficiency directly contributes to central sensitization; Bagis et al., 2013)
hs-CRP: 1.2 mg/L (optimal <1.0) — mildly elevated (not as high as expected — fibromyalgia inflammation is primarily neurological, not peripheral)
ESR: 14 mm/hr (normal)
ANA: negative (confirmed — not lupus, not RA)
Thyroid: TSH 3.8 mIU/L (high-normal — subclinical), Free T4 1.0 ng/dL (low-normal), Free T3 2.3 pg/mL (low — poor conversion), TPO antibodies 52 IU/mL (mildly elevated — subclinical Hashimoto’s)
Fasting glucose: 94 mg/dL (normal)
Fasting insulin: 9.8 uIU/mL (borderline — insulin resistance developing)
HOMA-IR: 2.27 (optimal <2.0) — early insulin resistance
Homocysteine: 14.2 umol/L (optimal <8) — significantly elevated (methylation impairment, increased neuroinflammation)

DUTCH Complete (Dried Urine Test for Comprehensive Hormones):

Morning free cortisol: below range — bottomed out
Afternoon cortisol: below range
Evening cortisol: low-normal
CAR (Cortisol Awakening Response): essentially absent — 8% rise (normal: 50-75%)
Total cortisol metabolites: significantly low
DHEA-S: 68 mcg/dL (optimal for age: 150-300) — severely depleted
Progesterone metabolites: very low (approaching perimenopause)
Estrogen metabolites: declining, with unfavorable 4-OH-E1 elevation (inflammation-driven)
Melatonin metabolite (6-OH-melatonin sulfate): severely low — explaining the catastrophic sleep

Interpretation: Stage 3 HPA axis dysfunction (exhaustion phase). The cortisol system is depleted. The absent CAR explains why mornings are the worst (no cortisol surge to suppress overnight inflammation — she wakes into a body full of uninhibited neuroinflammatory signaling). The severely low DHEA-S and melatonin confirm that the entire HPA/HPG axis is in a state of resource depletion. The subclinical Hashimoto’s adds a thyroid component — the low Free T3 contributes to fatigue, pain sensitivity, and depression.

Comprehensive Stool Analysis (GI-MAP):

Elevated zonulin: 124 ng/mL (optimal <60) — intestinal permeability (NSAID-driven)
Elevated calprotectin: 68 mcg/g (normal <50) — intestinal inflammation
Low Lactobacillus and Bifidobacterium species
Elevated Klebsiella
Low short-chain fatty acid markers (butyrate production impaired)
Secretory IgA: low at 280 mcg/mL (optimal 510-2,040) — mucosal immune depletion
Elastase-1: 320 mcg/g (suboptimal; optimal >500)

Interpretation: NSAID-induced gut barrier damage with secondary dysbiosis and intestinal permeability. This is contributing to systemic inflammation that feeds the neuroinflammatory cycle. The chronic ibuprofen use, while providing short-term pain relief, is perpetuating the very inflammatory state that drives the pain.

Organic Acids Test (OAT):

Elevated quinolinic acid (marker of neuroinflammation and microglial activation)
Elevated quinolinic/kynurenic acid ratio (tryptophan being shunted toward the inflammatory kynurenine pathway rather than toward serotonin and melatonin production — this explains both the depression and the insomnia)
Low 5-HIAA (low serotonin production — confirming the tryptophan shunt)
Elevated markers of oxidative stress (8-OHdG elevated)
Elevated tartaric acid (yeast/Candida metabolite — secondary to NSAID-disrupted gut)

Interpretation: The OAT confirms neuroinflammation (elevated quinolinic acid from activated microglia), explains the insomnia biochemically (tryptophan diverted from melatonin to inflammatory metabolites), and confirms the gut-brain inflammatory loop.

TCM Assessment

Tongue: pale-purple (Blood Stasis with underlying deficiency), thin body (Blood and Yin deficiency), thin dry coat Pulse: thin, choppy, deep — Blood Stasis with Qi and Blood Deficiency Pattern: Blood Stasis + Qi and Blood Deficiency (Yu Xue Jia Qi Xue Liang Xu), with Kidney Yang Deficiency

This TCM pattern is profoundly descriptive: Blood Stasis (Yu Xue) in Chinese medicine represents energy and emotion that is not moving — stuck, congealed, blocked. Grief that does not flow becomes stasis. The underlying Qi and Blood Deficiency reflects the system’s depletion: there is not enough vital energy to move the stagnation, creating a vicious cycle of stasis and deficiency. Kidney Yang Deficiency reflects the deep constitutional exhaustion, cold extremities, and depleted adrenal reserves (the Kidney in TCM encompasses adrenal function).

Somatic Assessment

Widespread myofascial trigger points: 16 of 18 classic fibromyalgia tender points positive. Particularly severe in upper trapezius, suboccipital muscles, infraspinatus, gluteus medius, and quadratus lumborum. Fascial restrictions throughout thoracolumbar fascia. Jaw clenching pattern with hypertonic masseter and temporalis muscles. Breathing pattern: paradoxical — chest rises while abdomen pulls inward (inverted breathing pattern associated with chronic pain and guarding). Heart rate variability (HRV) measured via 5-minute resting assessment: very low (SDNN 22 ms; healthy average for age: 40-60+ ms) — confirming profound autonomic dysregulation with sympathetic dominance and parasympathetic withdrawal.

Treatment Plan

Phase 1: Stop the Damage, Rebuild the Foundation (Months 1-3) — Serpent Work

The immediate priorities were: (1) address the sleep catastrophe, (2) wean off medications causing more harm than benefit, (3) replete severe nutrient deficiencies, (4) heal the gut, and (5) introduce nervous system regulation.

Sleep Restoration (the single most important physical intervention):

Melatonin: 3mg sustained-release at bedtime (addressing the severely low melatonin production)
Magnesium glycinate: 600mg at bedtime (NMDA receptor modulation, muscle relaxation, sleep promotion)
L-tryptophan: 1,000mg at bedtime (precursor to both serotonin and melatonin; bypassing the inflammatory kynurenine pathway with direct supplementation)
Phosphatidylserine: 400mg at bedtime (cortisol modulation — even though cortisol is low overall, the evening cortisol relative to the depleted daily curve was still dysregulated)
Sleep hygiene: bedroom completely dark, temperature 65-67F, no screens 90 minutes before bed, consistent sleep-wake times, gentle stretching routine before bed
Gradual zolpidem taper: 10mg to 7.5mg (month 1), 5mg (month 2), 2.5mg (month 3), discontinue (month 4) — supervised, slow taper to avoid rebound insomnia

NSAID Cessation and Alternative Pain Management:

Ibuprofen taper: reduce to 400mg max 3x/week (month 1), then 2x/week (month 2), then PRN only (month 3)
Replace with: Curcumin (Meriva phytosome form) 1,000mg 2x daily (bioavailable anti-inflammatory with evidence in fibromyalgia; Sahebkar, 2014), Boswellia serrata 300mg 3x daily (anti-inflammatory, neuroprotective), PEA (palmitoylethanolamide) 600mg 2x daily (endogenous lipid mediator that reduces neuroinflammation and glial cell activation — specifically indicated for central sensitization; Paladini et al., 2016)
Topical magnesium chloride applied to painful areas 2x daily (transdermal absorption, local muscle relaxation)
Low-dose naltrexone (LDN): 1.5mg at bedtime, titrating to 4.5mg over 6 weeks (LDN modulates microglial activation and reduces neuroinflammation — growing evidence base for fibromyalgia; Younger et al., 2014)

Nutrient Repletion:

Magnesium glycinate 600mg at bedtime (as above)
Vitamin D3: 10,000 IU daily for 8 weeks, then 5,000 IU daily maintenance (aggressive repletion of severe deficiency; target 50-80 ng/mL)
Vitamin K2 (MK-7): 200mcg daily (required with high-dose D3)
Iron bisglycinate: 36mg daily with vitamin C 500mg (raising depleted ferritin)
Methylcobalamin (B12): 5,000mcg sublingual daily
Methylfolate: 800mcg daily (with B12, to address elevated homocysteine and impaired methylation)
CoQ10 (ubiquinol form): 200mg daily (mitochondrial support — mitochondrial dysfunction is implicated in fibromyalgia; Cordero et al., 2010)
NAC (N-acetyl cysteine): 600mg 2x daily (glutathione precursor — addressing oxidative stress seen on OAT)

Gut Repair (to reverse NSAID-induced damage):

L-glutamine 5g 2x daily
Zinc carnosine 75mg 2x daily
DGL 400mg before meals
Butyrate 600mg 2x daily
Probiotic: multi-strain Lactobacillus/Bifidobacterium, 50 billion CFU daily
Prebiotic fiber: partially hydrolyzed guar gum (PHGG) 5g daily (gentle, well-tolerated prebiotic that supports butyrate production)

Thyroid Support:

Selenium 200mcg daily (for subclinical Hashimoto’s — reduces TPO antibodies)
Zinc picolinate 30mg daily (T4-to-T3 conversion cofactor)
Myo-inositol 600mg daily
Monitoring thyroid labs at 3-month intervals; thyroid medication deferred unless labs worsen

Movement (gentle, non-provocative):

Daily walking: 10-15 minutes initially (more would trigger flares)
Warm water pool therapy 2x weekly if available (buoyancy reduces gravitational pain; warm water is analgesic; aquatic exercise has the strongest evidence base for fibromyalgia physical intervention; Bidonde et al., 2014)
Gentle tai chi or qi gong 2-3x weekly (low-impact, nervous system regulating; Wang et al., 2018 demonstrated tai chi superior to aerobic exercise for fibromyalgia)
No high-intensity exercise, no aggressive stretching, no “pushing through” pain

Phase 2: The Grief That Lives in the Body (Months 3-7) — Jaguar Work

The emotional work was introduced at month 3 — after sleep had improved, pain had reduced modestly, and Hoa had enough resilience to approach the grief without being destroyed by it. This timing was deliberate: attempting deep emotional processing in a body that sleeps 4 hours, lives in 8/10 pain, and has no cortisol reserves would have been retraumatizing rather than therapeutic.

Somatic Experiencing (SE) — Weekly Sessions:

The first goal was not to process the grief but to increase Hoa’s capacity to tolerate sensation and emotion without shutting down. “The One Who Keeps Going” (her dominant Manager part) had been on duty for 15 years and did not trust that it was safe to step aside.
Sessions 1-4: Building the therapeutic relationship. Hoa was skeptical, guarded, and efficient: “Just tell me what to do.” She wanted a protocol, not a relationship. The therapist met her where she was.
Sessions 5-8: Somatic awareness work. Hoa was profoundly disconnected from her body except through pain. The therapist helped her notice non-pain sensations: warmth in her hands, the weight of her feet on the floor, the movement of breath. This was radical for someone whose body had been nothing but a source of suffering.
Session 9: The grief surfaced without being called. The therapist asked Hoa what she noticed in her chest. She said: “Heavy. Like something is sitting on it.” The therapist asked: “If that heaviness could speak, what would it say?” Hoa was silent for almost two minutes. Then she said, in a voice that was almost a whisper: “I miss her.” And she began to cry.

She cried for forty minutes. Not the polite, controlled tears of a movie — the raw, guttural, animal sounds of a mother’s grief that had been sealed in her body for fifteen years. The therapist held space. Hoa’s entire body trembled, then shook, then stilled. Afterward, she said: “I think I was holding that since the funeral.”

IFS (Internal Family Systems) — Integrated with SE, Months 4-7:

The Manager (“The One Who Keeps Going”): The protector that had kept Hoa functional for 15 years. Its core belief: “If I let her feel this, she will be destroyed.” The IFS work honored this part — it had done an extraordinary job of keeping Hoa alive and her family intact. But it was asked: “What would happen if you let her feel just a little bit, with support?” The Manager’s answer: “She might never stop crying.” Therapist: “What if that’s okay?”
The Exile (The Bereaved Mother): The part carrying the grief, guilt, rage, and love for Ly. The exile carried the forbidden thoughts: “I should have known sooner” (Ly’s leukemia was diagnosed at Stage 3 — Hoa blamed herself for not recognizing the symptoms earlier). “I wasn’t enough to save her.” And the most painful: “Part of me wanted to die with her.” When this exile was finally witnessed — when Hoa’s Self could be present to this part without the Manager shutting it down — the physical pain shifted visibly. In the session following the first full exile encounter, Hoa reported: “My shoulders don’t hurt today. For the first time in years, my shoulders don’t hurt.”
The Inner Child: A part younger than the Bereaved Mother — the girl who had been responsible for her family since age 12, who had never had the luxury of being taken care of, who had been carrying others’ burdens for three decades. This part was exhausted and angry: “When is it my turn? When does someone carry me?”

Acupuncture — Weekly, Months 3-7:

Points selected based on the TCM pattern (Blood Stasis + Qi/Blood Deficiency):
- SP-10 (Sea of Blood — moves Blood Stasis)
- BL-17 (Back-Shu of the Diaphragm — influential point for Blood)
- LI-4 + LV-3 (“Four Gates” — strongly moves Qi and Blood stagnation)
- ST-36 (tonify Qi and Blood)
- KI-3 (tonify Kidney)
- HT-7 (calm the spirit, for grief)
- Yin Tang (calm the mind)
- Auricular points: Shen Men, sympathetic, zero point (nervous system regulation)
Electroacupuncture at 2 Hz at selected points (stimulates endorphin and enkephalin release; evidence supports electroacupuncture for fibromyalgia pain; Deare et al., 2013)
Note: Hoa’s previous negative experience with acupuncture was likely due to overly aggressive treatment (too many needles, too strong stimulation) in a sensitized nervous system. The approach here was gentle — fewer needles, lighter stimulation, building tolerance gradually.

Phase 3: Who Am I Beyond the Pain? (Months 6-9) — Hummingbird Work

Narrative Reconstruction:

Hoa’s life narrative had been organized around endurance: “I survive. I carry. I keep going.” This narrative had served her — but it had also imprisoned her. The Hummingbird work was about expanding the story to include not just survival but meaning.
Grief journaling: Hoa began writing letters to Ly. Not every day — she could not sustain that intensity — but once a week. The letters began as guilt (“I’m sorry I didn’t protect you”) and gradually evolved into connection (“Let me tell you what your sister did today”) and eventually into a conversation with death itself (“Why? And what am I supposed to do with this life you can’t have?”).
The pivotal letter, written at month 7: “I have been in pain for seven years. I think the pain started because I would not let myself miss you. My body did the missing for me. I am ready to do it myself now.”

Vietnamese Grief Rituals — Reclaimed with Intention:

Hoa’s therapist (Vietnamese-American, culturally informed) helped her reclaim the Vietnamese mourning rituals not as empty obligation but as genuine spiritual practice. The 49-day ceremony, the annual death anniversary (gio), the offering of food and incense — these rituals are designed to maintain relationship with the dead, to honor that the bond does not end with physical death. Hoa had been performing them mechanically; she now performed them with presence.
She created a small altar for Ly in the living room — not hidden in the closet anymore — with photographs, fresh flowers, and incense. Her daughter said: “Mom, I’m glad we can see her now.”

Meaning-Making:

Hoa began volunteering at a pediatric cancer support group — not as a therapist but as a mother who understood. This was not prescribed; it emerged organically as her grief processing deepened and she asked: “What do I do with all this? It can’t just be for nothing.” The work with other grieving parents gave her suffering a context larger than her individual pain.

Phase 4: The Witness Beyond Pain (Months 8-12) — Eagle Work

Contemplative Practice:

Beginning month 8, Hoa was introduced to a meditation practice rooted in Vietnamese Buddhist tradition — not the stripped-down, secular mindfulness of an app, but a practice connected to her cultural lineage. The practice was simple: sitting, following the breath, reciting the name of Quan Am (Guanyin, the Bodhisattva of Compassion) silently with each exhale. The instruction: “You are not sitting to fix anything. You are sitting to be present to everything — the pain, the grief, the love, all of it — without needing it to be different.”
This was Eagle work: developing witness consciousness — the capacity to observe experience without being consumed by it. For Hoa, this meant learning to have pain without being pain. To feel grief without drowning in it. To hold the love for Ly without the love being inseparable from anguish.
She began attending temple not out of obligation but out of genuine seeking. She described the shift: “Before, I went because my mother expected it. Now I go because it’s the only place where the world is big enough to hold what happened to me.”

Timeline & Progress

Month 1

Began sleep protocol: melatonin, magnesium, L-tryptophan
Began zolpidem taper (10mg to 7.5mg)
Started ibuprofen reduction
Initiated curcumin, boswellia, PEA, topical magnesium
Started LDN at 1.5mg
Began nutrient repletion
Began gut repair protocol
Started gentle walking (10-15 minutes daily)
Pain: unchanged (6-8/10). Sleep: marginal improvement (5-5.5 hours, still fragmented but slightly less so). Mood: hopeful but skeptical.

Month 2

LDN titrated to 3mg
Zolpidem reduced to 5mg
Sleep improving: 6 hours average, fewer awakenings, one night of 7 hours (“I woke up and couldn’t believe it”)
Pain: 5-7/10 — first reduction in years. Allodynia less severe (could tolerate a gentle hug from her daughter without flinching)
Began warm water pool therapy 2x weekly — reported feeling “lighter” in the water, pain reduced during and for 2-3 hours after sessions
Ibuprofen use reduced to 2x/week
Started tai chi class (beginner, gentle form)

Month 3

LDN at 4.5mg (target dose)
Zolpidem reduced to 2.5mg
Sleep: 6.5-7 hours most nights. First reports of feeling somewhat rested upon waking.
Pain: 4-6/10 on most days. Flares less frequent and less severe (7-8/10 instead of 9-10/10)
Repeat labs: vitamin D 34 ng/mL (rising), ferritin 38 ng/mL (rising), magnesium 4.2 mg/dL (improving), homocysteine 10.8 umol/L (improving)
Began Somatic Experiencing therapy
Began acupuncture weekly
Emotional state: the somatic work was beginning to unsettle the sealed emotional system. Hoa reported feeling “strange” — not worse exactly, but as if something inside her was shifting.

Month 4

Zolpidem discontinued entirely. Sleep maintained at 6.5-7 hours with supplement support.
Pain: 4-5/10 baseline. Flares now 6-7/10 and lasting hours rather than days.
Session 9 of SE: the grief breakthrough. Hoa cried for the first time in 15 years about Ly’s death.
Physical response to grief release: pain flared to 7/10 for three days following the session, then dropped to 3-4/10 — the lowest it had been in years. This pattern (temporary flare followed by significant reduction) is characteristic of somatic emotional release.
Began IFS work integrated with SE
Began writing letters to Ly

Month 5

Pain: 3-5/10 baseline. Good days now outnumbering bad days for the first time.
The shoulder pain that had been constant for 5 years was intermittently absent. “Some mornings I wake up and reach for my shoulders because I expect them to hurt, and they don’t.”
IFS: working with the Manager part. The Manager began to soften but remained vigilant.
Repeat DUTCH: morning cortisol slightly improved (still below range but rising), CAR 22% (up from 8%), DHEA-S 98 mcg/dL (slowly recovering)
Tai chi becoming a regular practice — 3x weekly. Hoa described it as “the only time my body feels like it belongs to me.”
Acupuncture: reporting deeper relaxation during sessions, some sessions with no pain for 24-48 hours afterward

Month 6

Comprehensive labs: vitamin D 52 ng/mL (optimal), ferritin 56 ng/mL (optimal), B12 620 pg/mL, RBC magnesium 4.8 mg/dL, homocysteine 8.4 umol/L, hs-CRP 0.6 mg/L, TSH 2.6 mIU/L (improving), Free T3 2.8 pg/mL (improving), TPO antibodies 38 IU/mL (declining toward normal)
Zonulin recheck: 68 ng/mL (near normal — gut healing confirmed)
Pain: 2-4/10 most days. Flares rare (1-2 per month), manageable without ibuprofen (using curcumin, PEA, hot bath, and breathing)
Ibuprofen: discontinued entirely
HRV improving: SDNN 34 ms (up from 22)
IFS: first encounter with the exile (the Bereaved Mother). Hoa allowed herself to feel the full weight of Ly’s death in the presence of her Self. Reported afterward: “I didn’t break. I thought I would break, and I didn’t.”
Began narrative therapy and grief journaling

Month 7

Wrote the pivotal letter: “I have been in pain for seven years because I would not let myself miss you.”
Created the altar for Ly in the living room
Pain: 2-3/10 most days. Three days this month with 0-1/10 — the first essentially pain-free days in seven years.
Sleep: 7-7.5 hours consistently, waking refreshed
Began reclaiming temple visits as intentional spiritual practice
Energy improving dramatically — returned to full-time work

Month 8

Began meditation practice (Quan Am recitation)
Began volunteering at pediatric cancer support group
Pain: 1-3/10 most days. The pain was no longer the organizing principle of her life.
DUTCH repeat: cortisol curve normalizing — morning cortisol now within low-normal range, CAR 42%, DHEA-S 138 mcg/dL
OAT repeat: quinolinic acid reduced (neuroinflammation decreasing), 5-HIAA normalizing (serotonin production recovering), oxidative stress markers improved
HRV: SDNN 42 ms (approaching normal)
Tapering supplements: reduced vitamin D to 2,000 IU, reduced magnesium to 400mg, discontinued CoQ10 and NAC

Month 9

Described a moment at the pediatric cancer support group: a newly bereaved mother was sobbing, and Hoa held her. She said later: “I held her and I cried too. Not because I was falling apart — because I was whole enough to hold someone else’s pain without losing myself.”
Pain: 1-2/10 most days. The fibromyalgia diagnosis, while still technically applicable, no longer defined her experience. She described the residual pain as “weather” — something that came and went, that she noticed without fearing.
Acupuncture reduced to biweekly, then monthly maintenance
SE/IFS therapy reduced to biweekly

Months 10-12

Continued meditation practice, tai chi, temple visits, volunteering
Pain: stable at 1-2/10, occasional flares to 3-4/10 during periods of stress or emotional processing, self-resolving within hours
Sleep: stable, restorative
Final labs (month 12): all nutrient markers optimal, HPA axis function restored (cortisol curve normal, CAR 58%, DHEA-S 186 mcg/dL), thyroid normalized (TSH 1.8, Free T3 3.2, TPO antibodies 28 — below positive threshold)
Pregabalin tapered and discontinued (months 10-11, under physician supervision, slow taper)
Duloxetine tapered and discontinued (months 11-12, very slow cross-taper with 5-HTP support)
Continuing: LDN 4.5mg (elected to continue for maintenance neuroinflammation modulation), magnesium 400mg, vitamin D 2,000 IU, curcumin 1,000mg daily, probiotic
Final session reflection: “I came in because I hurt everywhere and no one believed me. What I found out was that the pain was real — AND the grief was real — AND I needed to deal with both. Not one or the other. Both.”

Key Turning Points

Turning Point 1: Sleep Restoration (Months 1-3)

Before anything else could heal, Hoa needed to sleep. Sleep deprivation perpetuates central sensitization, neuroinflammation, HPA dysfunction, and pain hypersensitivity in a vicious cycle. Restoring even marginal sleep (from 4-5 hours to 6-7 hours) created the biological conditions for everything else — nutrient absorption improved, cortisol rhythm began to normalize, neuroinflammation began to reduce, and pain tolerance increased. Sleep is the foundation of fibromyalgia treatment.

Turning Point 2: The Grief Breakthrough in SE (Month 4)

The forty minutes of crying in session 9 was the hinge point of Hoa’s entire treatment. Fifteen years of sealed grief broke open, and the physical response was immediate: a three-day pain flare (the body discharging stored emotional energy through its primary language — pain) followed by the most significant pain reduction in years. This was the proof — not just theoretical but experiential — that the pain and the grief were connected, that addressing one without the other would never be sufficient.

Turning Point 3: The Manager Stepping Aside (Month 6)

When “The One Who Keeps Going” softened enough to allow the Bereaved Mother exile to be witnessed by Hoa’s Self, the internal system reorganized. The Manager did not disappear — it remained available when Hoa needed to function, to work, to parent. But it was no longer running the entire system from a position of emergency. The body could relax because the psyche had found another way to hold the pain.

Turning Point 4: The Pivotal Letter (Month 7)

“I have been in pain for seven years because I would not let myself miss you.” This sentence was the integration point — the moment when the physical and emotional realities merged into a single, coherent understanding. It was not “the pain is imaginary” or “the pain is purely physical.” It was: “My body held my grief because I would not, and now I am ready to carry it myself.” This is Hummingbird work at its most transformative.

Turning Point 5: The Altar in the Living Room (Month 7)

Moving Ly’s photographs from the closet to a visible altar was a behavioral enactment of a psychic shift: grief moved from hidden to held, from shameful to sacred. The daughter’s response — “I’m glad we can see her now” — revealed that the family had been affected by the hidden grief too. Bringing Ly into the family’s shared space allowed the entire system to begin mourning together.

Where Single-Direction Treatment Failed

If only the Serpent had been addressed: Twelve physicians had already tried this approach. Nutrient repletion, sleep improvement, and pain medication would have produced some reduction in pain but would have left the central sensitization’s emotional driver untouched. The pain would have plateaued at 4-5/10 — better than 8/10 but still disabling — because the neuroinflammatory signals from unprocessed grief would have continued to activate glial cells and maintain the sensitized state.

If only the Jaguar had been addressed: Grief therapy alone, in a body sleeping 4 hours a night, depleted of magnesium and vitamin D, with an exhausted HPA axis and active neuroinflammation, would have been asking Hoa to do the hardest emotional work of her life without the biological resources to do it. The SE breakthrough in month 4 was possible because by that point, sleep had improved, pain had reduced, and her nervous system had enough resilience to hold the grief without shattering.

If only the Hummingbird had been addressed: Narrative therapy and meaning-making without the physical stabilization and emotional processing would have produced insights that the body could not enact. A beautiful letter to Ly, written from a body in 8/10 pain with no emotional processing, would have been a literary exercise, not a healing event.

If only the Eagle had been addressed: Meditation in a body wracked with pain is not contemplative practice — it is endurance. The Eagle work became possible and meaningful only after the pain had reduced, the grief had been accessed, and the narrative had been rewritten. Then, sitting with Quan Am’s name on her breath, Hoa could practice being present to her entire experience — including pain, including grief — without being consumed by it.

Lessons & Principles

Pain is real AND has emotional roots — both/and, never either/or. The most harmful false dichotomy in medicine is the distinction between “real” (physical, measurable) and “psychosomatic” (imaginary, psychological). Fibromyalgia involves measurable neuroinflammation, quantifiable changes in pain neurotransmitters, visible alterations on functional MRI. It is also, in many cases, inseparable from emotional history. Telling a patient “it’s in your head” is both scientifically inaccurate and therapeutically destructive. The correct framing: “Your pain is real, it has biological mechanisms, AND those mechanisms are influenced by your emotional life. We need to address both.”
Grief that is not expressed goes into the body. This is not a metaphor. Unresolved grief elevates inflammatory cytokines, dysregulates the HPA axis, disrupts sleep architecture, and — over years — can drive central sensitization. The body does not distinguish between physical injury and emotional injury; both produce inflammation, and both require processing for the inflammation to resolve. Vietnamese cultural norms around emotional restraint (“Vietnamese people don’t do that”) can make grief expression especially difficult, creating a higher risk of somatic grief.
Sleep is the foundation of pain treatment. No other intervention — pharmaceutical, nutritional, or emotional — will produce lasting pain reduction if the patient is not sleeping. Deep sleep is when the glymphatic system clears neuroinflammatory metabolites, when the brain downregulates pain sensitivity, when cortisol and melatonin rhythms reset. The first priority in fibromyalgia treatment must be restoring sleep.
Chronic NSAIDs can perpetuate chronic pain. The paradox of ibuprofen in fibromyalgia: it provides short-term relief while driving intestinal permeability, systemic inflammation, and potentially worsening the neuroinflammatory cycle it is meant to address. Weaning off chronic NSAIDs — with appropriate alternative anti-inflammatory support — is often a necessary and counterintuitive step.
Low-dose naltrexone (LDN) is an underutilized tool for central sensitization. By modulating microglial activation and reducing neuroinflammation, LDN addresses the actual mechanism of fibromyalgia rather than simply blocking pain signals. It is inexpensive, well-tolerated, and has a growing evidence base (Younger et al., 2014).
Cultural grief practices can be therapeutic when performed with intention. Hoa’s temple visits, Ly’s altar, the annual death anniversary — these Vietnamese mourning rituals contain genuine therapeutic wisdom: they maintain relationship with the dead, they provide structured containers for grief expression, and they affirm that love does not end with physical death. The therapeutic error is not in performing cultural rituals — it is in performing them mechanically, without the internal emotional process that gives them meaning.
The treatment sequence matters. Body first (sleep, nutrients, pain reduction), then emotional processing (grief, trauma), then meaning-making (narrative, purpose), then contemplative practice (meditation, witness consciousness). This sequence respects the body’s capacity and ensures that each phase has the foundation it needs. You do not ask a person in 8/10 pain with 4 hours of sleep to do deep grief work. You build the floor before you ask them to dance.

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