Assessing and Managing Emotion-Linked Conditions in Family Medicine

1. Hidden from View No Longer: Assessing and Managing Emotion-linked Conditions in Family Medicine Dalhousie Refresher Course March 2019 Allan Abbass Ange Cooper Thanks to Dr H. Schubiner for some slides Dal Refresher Course March 2019

2. Faculty/Presenter Disclosure • Faculty: • Allan Abbass • Ange Cooper • Relationships 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

3. Objectives • Name 4 ways that unprocessed emotions can trigger physical bodily symptoms • Describe how to assess a patient's bodily responses to emotions and anxiety • Describe the burden of emotion-linked conditions • Differentiate between the physiological pathways of emotions e.g. anger versus anxiety Dal Refresher Course March 2019

4. ‘Sorrow that finds no vent in tears may make other organs weep’ Sir Henry Maudsley 1835-1918 Dal Refresher Course March 2019

5. The Burden of Emotion-linked Conditions • Labels: MUS, Somatic/Psychophysiologic/Functional Disorder • Vast array of medical conditions and presentations are linked to unprocessed emotions and a dysregulated nervous system • 40-49% of Family Doctor visits • 50% of med-surg consultations • 1/6 of Emerg visits (Halifax): 75% of chest pain, 89% of abdominal pain • 8% of admissions QE2HSC • Disability Costs: massive • Doctor burnout linked to work with this and other traumatized populations • 1/3 of all primary patients will present symptoms and have significant adverse childhood events and be vulnerable to these conditions Dal Refresher Course March 2019

6. Emotion-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? Dal Refresher Course March 2019

7. “Adverse Childhood Experiences are the single greatest unaddressed public health threat facing our nation today”~ Dr Robert BlockFormer president of American Academy of Pediatrics Dal Refresher Course March 2019

8. Dal Refresher Course March 2019

9. SIGNALS not just SYMPTOMS • Often 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 Dal Refresher Course March 2019

10. Assessment Framework Defenses e.g. Somatization Anxiety (non-conscious yet observable!) (1.2 milliseconds after) Symptoms Symptoms Unconscious Feelings (Anger, guilt, grief, love, pain) Emotional EVENT Dal Refresher Course March 2019

11. In room with Patients/ Transference Current Life Past Dal Refresher Course March 2019

12. Experiential Exercise… Dal Refresher Course March 2019

13. Anxiety Pathways & Symptoms • Rheumatology • Orthopedics • General Surgery S E VERITY • GI • Respiratory • CV • Urology • Neurology • Psychiatry Somatic NS Hand 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 Dal Refresher Course March 2019

14. Overlapping Presentations Headache Confusion Irritable Bowel Dyspepsia Abdominal pain Dysregulated Nervous System Bladder dysfunction Pelvic Pain Chemical Sensitivity Fibromyalgia Fatigue Hypertension Chest pain Psoriasis Dermatitis Conversion Pseudoneurological Phenomena Depression Anxiety Panic Dal Refresher Course March 2019

15. What causes Emotion-Linked Conditions Fear of injury or death Avoidance Family member anxiety Random Symptom Learned Pain Pathways: Brain process Autonomic Nervous System tendencies and effects Threat of gain or loss of people (includes Doctor) Feelings about Attachment Trauma Alexithymia: Inability to identify emotions Dal Refresher Course March 2019

16. Fear of injury or death Avoidance Family member anxiety Random Symptom Learned Pain Pathways: Brain process Autonomic Nervous System tendencies and effects Threat of gain or loss of people Feelings about Attachment Trauma Alexithymia: Inability to identify emotions Dal Refresher Course March 2019

17. How deep do you need to go? Rule out Medical Causes Thorough History Education about PPD Guided or self directed cognitive and behavioral approaches Psychodiagnostic Interview and ISTDP-based Brief Sessions ISTDP Treatment or Referral Dal Refresher Course March 2019

18. Emotion-Linked Presentation An Approach for Family Doctors Rule out Medical Causes Thorough History Education Symptoms persist or recur Symptoms remit Guided or self directed cognitive and behavioral approaches Symptoms persist or recur Symptoms remit Psychodiagnostic Interview and ISTDP-based Brief Sessions Symptoms remit Symptoms persist or recur ISTDP Treatment Dal Refresher Course March 2019 Hidden from View, 2018

19. 1. Medical Evaluation of the Patient with new symptom: e.g. shoulder pain • Build Trust with patient • If 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 weeks • Having few questions about stress and the body, childhood adveristy on intake forms helps have these conversations later Dal Refresher Course March 2019

20. Clues to the diagnosis of PPD • History 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 Dal Refresher Course March 2019 From H Schubiner, Hidden from View 2018, Appendices

21. Clues to the diagnosis of PPD 2 Symptoms which: • persist after normal healing would have occurred • shift locations • are bilateral • occur due to social contagion • vary with time of day, place, or activity in discernible patterns • correlate with stressful situations From H Schubiner Dal Refresher Course March 2019

22. 2. More interviewing and education • If symptoms persist. • Then take more detailed history • Look for patterns: separation and rejection • Educate about how pain can be learned effect from fear responses and brain expectations and avoidance patterns • Encourage physical activity to break fear - avoidance cycles and modify ANS responses • Avoid meds Dal Refresher Course March 2019

23. One construction worker: role of expectation and interpretation Dal Refresher Course March 2019

24. Another construction worker Dal Refresher Course March 2019

25. Dal Refresher Course March 2019

26. 3. Cognitive – Behavioral - Education Interventions • Help recognize triggers • Think about what feelings are activating symptoms • Encourage activity and explain everything again • Teach how to relax while doing things • Inexpensive 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 mins • Avoid meds Dal Refresher Course March 2019

27. How deep do you need to go? Rule out Medical Causes Thorough History Education about PPD Guided or self directed cognitive and behavioral approaches Psychodiagnostic Interview and ISTDP-based Brief Sessions ISTDP Treatment or Referral Dal Refresher Course March 2019

28. 4. Psychodiagnosis: Understanding and detecting unconscious emotional factorsIntensive Short-term Dynamic Psychotherapy (ISTDP) Dal Refresher Course March 2019

29. ISTDP Evidence in MUS/ PPD/SSD • 17 published somatic outcome studies • Urethral 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 Disorders • Effects are sustained or increase in follow-up (Town and Driessen 2013) • Outperformed Mindfulness-based Stress Reduction for Chronic Pain • Outperforms CBT in recent meta-analysis • Good evidence for cost reduction and health service reduction Dal Refresher Course March 2019

30. BOND With Parents Trauma FEAR PAIN Symptoms Self-destruct Fear closeness Rage, Guilt about the Rage Dal Refresher Course March 2019

31. Current Person Doctor, Boss, Spouse = Transference. Normal process we all do Past Person Example: Father, Mother, Sibling, Abuser Dal Refresher Course March 2019

32. Psychodiagnosis: observe, take history and focus on emotions during symptom incidents. Summarize findings with patient Dal Refresher Course March 2019

33. Striated muscle: Voluntary muscle: Hand clench and Sigh. Use intellectual and character defenses • Smooth 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. Dal Refresher Course March 2019

34. Striated Muscle Pathway • Hands Clench • Arms • Shoulders, Neck • Intercostal: 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 Dal Refresher Course March 2019

35. Smooth Muscle • Gastrointestinal • Vascular: eg migraine • Coronary Arteries • Bronchi • Bladder (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 Dal Refresher Course March 2019

36. Cognitive-perceptual Disruption • Losing track of thoughts, • poor memory, • Visual blurring, tunnel vision, blindness • Ears ringing, Loss of hearing • Hallucination in all 5 senses • Anesthesia, paresthesia • Depersonalization, Derealization, Dissociation • Pseudoseizures and fainting • Severe personality dysfunction • Cant intellectualize abut feelings Dal Refresher Course March 2019

37. Reduce anxiety to remove symptoms • Ask about body cues • Notice hands feet etc. • Let the patient talk more • Summarize findings: intellectualize • Ask about when it gets worse or better Dal Refresher Course March 2019

38. Motor Conversion • Functional weakness in the body in one or more areas. • When conversion is active, there is no unconscious anxiety in the striated muscles Dal Refresher Course March 2019

39. Experiencing the feelings: overrides the symptoms • Rage: Upward heat or energy sensation. From feet up to neck then down arms • Urge to grab and do some form of violence • Guilt: 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 Dal Refresher Course March 2019

40. Inhibitory Forces go Down Somatic Pathway of rage goes Up same system AMA Atlas online Dal Refresher Course March 2019

41. 4. 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 inward • Help see the body difference between anger and anxiety • Help them see that there is always guilt about any anger • Ask where they learned the patterns from • Recap and review everything at the end. • 45 minutes x up to 5 meetings Dal Refresher Course March 2019

42. Experiencing the feelings: overrides the symptoms • Rage: Upward heat or energy sensation. From feet up to neck then down arms • Urge to grab and do some form of violence • Guilt: 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 Dal Refresher Course March 2019

43. 5. Family Doctor Brief Therapy 2: Build anxiety tolerance • For 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 Dal Refresher Course March 2019

44. Conscious Feelings Threshold to Repression 3 2 1 3 Striated Muscle Anxiety Isolation of Affect 2 Unconscious Anxiety 1 Focus on Feelings Rise in complex feelings and anxiety 3. Intellectual Recap Dal Refresher Course March 2019

45. When to Refer • Significant dissociation: major memory lapses • Violent behaviors • Substance dependence • Major depression and/or Suicidal ideation • Serious physical effects: paralysis, weight loss, intractable vomiting • Psychotic phenomena • Non response or worsening in your first few efforts • Keep in regular contact even with referral Dal Refresher Course March 2019

46. Reference Materials • Reaching through Resistance. • Detailed manual on ISTDP psychodiagnosis and treatment with case examples • www.reachingthroughresistance.com • Available on Amazon: http://a.co/3UGMWx0 https://emotihealth.com/ • 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