Allan Abbass Ange Cooper Thanks to Dr H Schubiner for some slides 1 Hidden from View No Longer Assessing and Managing Emotionlinked Conditions in Family Medicine Dal Refresher Course March 2019 ID: 932946
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Dalhousie Refresher Course March 2019Allan AbbassAnge CooperThanks to Dr H. Schubiner for some slides
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Hidden from View No Longer: Assessing and Managing Emotion-linked Conditions in Family Medicine
Dal Refresher Course March 2019
Slide2Faculty/Presenter DisclosureFaculty: Allan AbbassAnge CooperRelationships with commercial interests: Ange Cooper: ‘Emotihealth’ educational organisation developing experiential courses for Family Doctors and other HCPs.
HANDOUT is on www.allanabbass.com under Publications
Dal Refresher Course March 2019
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Slide3ObjectivesName 4 ways that unprocessed emotions can trigger physical bodily symptomsDescribe how to assess a patient's bodily responses to emotions and anxietyDescribe the burden of emotion-linked conditions
Differentiate between the physiological pathways of emotions e.g. anger versus anxiety
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Slide4‘Sorrow that finds no vent in tears may make other organs weep’
Sir Henry
Maudsley 1835-1918
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Slide5The Burden of Emotion-linked ConditionsLabels: MUS, Somatic/Psychophysiologic/Functional DisorderVast array of medical conditions and presentations are linked to unprocessed emotions and a dysregulated nervous system40-49% of Family Doctor visits
50% of med-surg consultations1/6 of Emerg
visits (Halifax): 75% of chest pain, 89% of abdominal pain8% of admissions QE2HSC Disability Costs: massiveDoctor burnout linked to work with this and other traumatized populations1/3 of all primary patients will present symptoms and have significant adverse childhood events and be vulnerable to these conditions
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Slide6Emotion-linked Conditions Overview Persistent bodily complaints for which medical examination and investigation does not provide sufficient explanation These conditions can co-exist with structural conditions, like cancer or MS, and psychiatric symptoms, like depression/anxiety and produce a worse outcome or exacerbate underlying pathology.
This group of syndromes are highly responsive to emotionally focused treatment – why?
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Slide7“Adverse Childhood Experiences are the single greatest unaddressed public health threat facing our nation today”
~
Dr
Robert Block
Former president of American Academy of Pediatrics
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Slide8In-built
Emotional Network
In-built Fear Network
Stimulus
Emotion
Stimulus Fear
Adaptive Action: cry, reach out, connect, assert boundaries.
Adaptive Action: Fight/Flight/Freeze
ACEs/Trauma/Unmet Attachment Needs
Threat remains
Emotion + Fear
Dysregulation/Anxiety
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Slide9SIGNALS not just SYMPTOMSOften when anxiety or unexplained physical conditions emerge, unresolved emotions from the past have been triggered
Physiologically, the emotions trigger anxiety to deal with the perceived threat
Therefore, the events prior to the onset of anxiety, depressive or somatic processes are important as they may indicate strong feelings which are now being automatically/unconsciously shunted back into the body
This moment can be utilised to help the patient discover what strong emotions may have been triggered and link to the onset of symptoms
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Slide10Assessment FrameworkDal Refresher Course March 201910
Symptoms
Unconscious
Feelings
(Anger, guilt, grief, love, pain)
Anxiety (non-conscious yet observable!)
(1.2 milliseconds after)
Defenses
e.g. Somatization
Symptoms
Emotional EVENT
Slide11Past
In room with
Patients/
Transference
Current Life
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Slide12Experiential Exercise…
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Slide13Somatic NSHand clenching
Tension in arms, neck, shoulders, head
Sighing respiration
Fidgeting, tension in legs, feet and abdomen
Para/Sympathetic NS
Bladder urgency
IBS and diarrhoea
Migraines
Asthma
Pain
Cognitive-Perceptual NS
Drifting, dissociation, confusion
Visual blurring or narrowing of visual field
Fainting, freezing, fugue state
Hallucinations
Anxiety Pathways & Symptoms
S
E
VERITY
Rheumatology
Orthopedics
General Surgery
GI
Respiratory
CV
Urology
Neurology
Psychiatry
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Slide14Dysregulated
Nervous
System
Overlapping Presentations
Irritable Bowel
Dyspepsia
Abdominal pain
Fibromyalgia
Fatigue
Depression
Anxiety
Panic
Hypertension
Chest pain
Conversion
Pseudoneurological
Phenomena
Chemical
Sensitivity
Headache
Confusion
Bladder dysfunction
Pelvic Pain
Psoriasis
Dermatitis
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Slide15What causes Emotion-Linked ConditionsAlexithymia: Inability to identify emotions
Fear of injury or death
Autonomic Nervous System tendencies and effects
Random Symptom
Learned Pain Pathways:
Brain process
Threat of gain or loss
of people (includes Doctor)
Avoidance
Family member anxiety
Feelings about
Attachment Trauma
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Slide1616
Threat of gain or loss
of people
Alexithymia: Inability
to identify emotions
Fear of injury or death
Autonomic Nervous
System tendencies and effects
Random Symptom
Learned Pain Pathways:
Brain process
Avoidance
Family member anxiety
Feelings about
Attachment Trauma
Dal Refresher Course March 2019
Slide17How deep do you need to go?Dal Refresher Course March 2019
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Rule out Medical Causes
Thorough History
Education about PPD
Psychodiagnostic
Interview
and ISTDP-based Brief Sessions
ISTDP Treatment or Referral
Guided or self directed cognitive and behavioral approaches
Slide18Emotion-Linked Presentation
Rule out Medical Causes
Thorough History
Education
Psychodiagnostic
Interview
and ISTDP-based Brief Sessions
Guided or self directed cognitive and behavioral approaches
Symptoms persist or recur
Symptoms remit
Symptoms remit
Symptoms persist or recur
Symptoms remit
Symptoms persist or recur
ISTDP Treatment
An Approach
for Family Doctors
Hidden from View, 2018
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Slide191. Medical Evaluation of the Patient with new symptom: e.g. shoulder painBuild Trust with patientIf no findings then reassure patient and encourage return to function
Try not to prescribe Don’t set follow-up At least 1/3 of patients respond over days to weeksHaving few questions about stress and the body, childhood
adveristy on intake forms helps have these conversations later
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Slide20Clues to the diagnosis of PPDHistory of PPDs (Review of Symptoms lifetime checklist)History of adverse childhood events (ACE scale)Self-criticism, self-sacrificing, perfectionism, need to please, and others (personality traits checklist)
Onset of symptoms coincide with significant stressful life events Symptom distribution
From H
Schubiner
, Hidden from View 2018, Appendices
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Slide21Clues to the diagnosis of PPD 2Symptoms which:persist after normal healing would have occurred
shift locationsare bilateraloccur due to social contagion
vary with time of day, place, or activity in discernible patternscorrelate with stressful situations
From H
Schubiner
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Slide222. More interviewing and educationIf symptoms persist.Then take more detailed historyLook for patterns: separation and rejection
Educate about how pain can be learned effect from fear responses and brain expectations and avoidance patternsEncourage physical activity to break fear - avoidance cycles and modify ANS responsesAvoid meds
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Slide23One construction worker: role of expectation and interpretation
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Slide24Another construction worker
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Slide25Dal Refresher Course March 201925
Slide263. Cognitive – Behavioral - Education InterventionsHelp recognize triggersThink about what feelings are activating symptomsEncourage activity and explain everything again
Teach how to relax while doing thingsInexpensive Manuals and websites like “Unlearn Your Pain” have these ingredients www.unlearnyourpain.com
Set follow-up: plan to meet few times weekly for 20-30 minsAvoid meds
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Slide27How deep do you need to go?Dal Refresher Course March 2019
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Rule out Medical Causes
Thorough History
Education about PPD
Psychodiagnostic
Interview
and ISTDP-based Brief Sessions
ISTDP Treatment or Referral
Guided or self directed cognitive and behavioral approaches
Slide284. Psychodiagnosis: Understanding and detecting unconscious emotional factorsIntensive Short-term Dynamic Psychotherapy (ISTDP)
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Slide29ISTDP Evidence in MUS/ PPD/SSD17 published somatic outcome studiesUrethral Syndrome/ Pelvic Pain, Back Pain, Functional Movement Disorders, Chronic Headache, Pseudoseizures, Chronic Pain (5 RCTs) Irritable Bowel Syndrome,
Mixed MUS (2 studies), Atopic Dermatitis, Bruxism, Functional Neurological DisordersEffects are sustained or increase in follow-up (Town and Driessen 2013)
Outperformed Mindfulness-based Stress Reduction for Chronic PainOutperforms CBT in recent meta-analysisGood evidence for cost reduction and health service reduction
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Dal Refresher Course March 2019
Slide30BONDWithParents
Trauma
FEAR
PAIN
Rage, Guilt
about the Rage
Symptoms
Self-destruct
Fear closeness
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Dal Refresher Course March 2019
Slide31Current Person
Doctor, Boss, Spouse
Past Person
Example: Father, Mother,
Sibling, Abuser
= Transference.
Normal process
we all do
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Slide32Psychodiagnosis: observe, take history and focus on emotions during symptom incidents. Summarize findings with patient Dal Refresher Course March 2019
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Slide33Striated muscle: Voluntary muscle: Hand clench and Sigh. Use intellectual and character defensesSmooth muscle anxiety: Gut, vascular, bladder, airways. Repression. No tone in striated muscles.Cognitive perceptual disruption: confusion, sensory symptoms and primitive defenses. No tone in striated muscles.Motor Conversion: Due to repression. Low tone in striated muscle.
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Slide34Striated Muscle PathwayHands Clench
Arms
Shoulders, NeckIntercostal: Sighs
Legs and Feet
Fibromyalgia, Headache, chest pain,
Tremor, spasm, Tics, TMJ pain
Shortness of breath, hyperventilation, panic
Can Intellectualize about feelings but don’t feel the feelings
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Dal Refresher Course March 2019
Slide35Smooth MuscleGastrointestinal
Vascular: eg migraine
Coronary ArteriesBronchiBladder (transitional muscle) -> Acute or chronic spasm and pain plus end organ effects
Patient looks “relaxed” = Not Tense in Striated Muscle
Cant intellectualize about feelings: they disappear into the body
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Slide36Cognitive-perceptual DisruptionLosing track of thoughts,
poor memory, Visual blurring, tunnel vision, blindnessEars ringing, Loss of hearing
Hallucination in all 5 sensesAnesthesia, paresthesiaDepersonalization, Derealization
, Dissociation
Pseudoseizures
and fainting
Severe personality dysfunction
Cant intellectualize abut feelings
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Slide37Reduce anxiety to remove symptomsAsk about body cuesNotice hands feet etc.Let the patient talk more
Summarize findings: intellectualizeAsk about when it gets worse or better
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Slide38Motor ConversionFunctional weakness in the body in one or more areas.When conversion is active, there is no unconscious anxiety in the striated muscles
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Dal Refresher Course March 2019
Slide39Rage: Upward heat or energy sensation. From feet up to neck then down armsUrge to grab and do some form of violenceGuilt: Chest constriction and pain with thoughts of remorse. Grief: pain with thoughts of loss, tears, longing for the lost person.Love: warm sensation expansion in chest, urge to embrace
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Experiencing the feelings: overrides the symptoms
Dal Refresher Course March 2019
Slide40Inhibitory
Forces
go Down
Somatic Pathway of
rage goes Up
same system
AMA Atlas online
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Dal Refresher Course March 2019
Slide414. Family Doctor Brief Therapy 1: Sessions“Can we get to understand together how emotions like anger work in the body”Focus on incidents of symptoms (includes in office anxiety)Watch for anger turning inwardHelp see the body difference between anger and anxietyHelp them see that there is always guilt about any anger
Ask where they learned the patterns fromRecap and review everything at the end.45 minutes x up to 5 meetings
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Slide42Rage: Upward heat or energy sensation. From feet up to neck then down armsUrge to grab and do some form of violenceGuilt: Chest constriction and pain with thoughts of remorse. Grief: pain with thoughts of loss, tears, longing for the lost person.Love: warm sensation expansion in chest, urge to embrace
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Experiencing the feelings: overrides the symptoms
Dal Refresher Course March 2019
Slide435. Family Doctor Brief Therapy 2: Build anxiety toleranceFor patients with smooth muscle anxiety and conversion
Cycles of emotional focus and intellectual recap
When patients can self-reflect on emotions, the anxiety shifts from other pathways into striated muscle.
This makes emotional experiencing possible and safe while overcoming symptoms
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Slide44Unconscious
Anxiety
Striated Muscle Anxiety
Isolation of Affect
Threshold to Repression
Conscious
Feelings
Focus on Feelings
Rise in complex feelings and anxiety
3. Intellectual Recap
1
3
2
3
2
1
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Slide45When to ReferSignificant dissociation: major memory lapsesViolent behaviorsSubstance dependenceMajor depression and/or Suicidal ideation Serious physical effects: paralysis, weight loss, intractable vomitingPsychotic phenomena Non response or worsening in your first few efforts
Keep in regular contact even with referral
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Dal Refresher Course March 2019
Slide46Reference MaterialsReaching through Resistance. Detailed manual on ISTDP psychodiagnosis and treatment with case exampleswww.reachingthroughresistance.comAvailable on Amazon:
http://a.co/3UGMWx0
https://emotihealth.com/
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Hidden from View: A clinician’s guide to Psychophysiological Disorders
Written with a Mind-body expert internist for family doctors
How to educate, provide first and second line treatments and basic ISTDP methods.
https://www.unlearnyourpain.com/hidden_from_view_book
Unlearn you Pain: H
Schubiner
www.unlearnyourpain.com
Dal Refresher Course March 2019