Somatic Symptom Disorders

Transcription

1 Somatic Symptom Disorders What to Family Physician needs to know Dalhousie Refresher Course Allan Abbass 1

2 Faculty/Presenter Disclosure Faculty: Allan Abbass Relationships with commercial interests: None

3 Objectives to understand that Emotions are somatic events Somatic symptoms form in part when emotions are not consciously experienced Emotional factors causing somatic symptoms can be directly detected in the family practice interview Brief emotion focused interventions can treat somatic symptom disorders 3

4 Terminology Somatic Symptom and related Disorders DSM5 Includes Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder Somatization: process by which emotions translate to somatic symptoms Medically Unexplained Symptoms: MUS Psychophysiological Disorders: brain-body processes DATE, ADDITIONAL DETAILS (set this text using Header & Footer) 4

5 The burden of emotion-linked somatic conditions 20-30% of Family Doctor visits 50% of med-surg consultations 1/6 of Emerg visits QE2HSC: ¾ chest pain, 9/10 abdo pain 1/12 of admissions QE2HSC Disability Costs: massive Doctor burnout linked to work with MUS and other traumatized populations Doctors can have similar problems: difficulty to recognize and manage emotions 5

6 What causes Somatic Symptom Disorders Lack of understanding of body Fear and Avoidance cycles RX Educate Reassure Encourage activity Self directed treatments Adverse Events in Childhood Attachment Trauma Autonomic Nervous System effects Alexithymia: Inability to identify emotions Blocked off feelings About the trauma MUS and spectrum of functional disorders + psychiatric disorders

7 Education: few points The symptoms are in the body (not imagined) Learned brain pathways keep symptoms rolling The symptoms are not dangerous: there is no structural damage Talk to yourself and challenge yourself to overcome fearful thoughts (cognitive) and Resume full function (behavioral) asap 7

8 Understanding and detecting unconscious emotional factors Intensive Short-term Dynamic Psychotherapy (ISTDP) 8

9 ISTDP Evidence in MUS 15 published outcome studies Urethral Syndrome/ Pelvic Pain, Back Pain, Functional Movement Disorders, Chronic Headache, Pseudoseizures, Chronic Pain (3 RCTs) Irritable Bowel Syndrome, Mixed MUS (2 studies), Atopic Dermatitis, Bruxism, Functional Neurological disorders Effects are medium to large and sustained in follow-up (Town and Driessen 2013) Outperformed Mindfulness-based Stress Reduction for Chronic Pain Outperformed CBT in recent study of Chronic Pain Good evidence for cost reduction and health service reduction after this brief treatment DATE, ADDITIONAL DETAILS (set this text using Header & Footer) 9

10 KEY POINTS Attachment trauma causes a range of complex feelings to be produced and buried These complex feelings are mobilized in current relationships including the patient doctor relationship Unconscious anxiety and corresponding defenses are markers of unprocessed feelings Healthy emotional experiencing has a specific physiology which is distinct from unconscious anxiety Hidden from View: a Clinician s Guide to Psychophysiological Disorders Abbass and Schubiner, in press 10

11 BOND With Parents PAIN Rage, Guilt about the Rage Symptoms Self-destruct Fear closeness 11

12 Current Person Doctor, Boss, Spouse Past Person Example: Father, Mother, Sibling, Abuser 12 = Transference

13 Unconscious Defense Unconscious Anxiety Unconscious Feelings

14 Unconscious Defences 4. Conversion Unconscious Anxiety 1. Striated Muscle 2. Smooth Muscle 3. Cognitive- perceptual disruption Unconscious Feelings

15 Psychodiagnosis: observe, take history and focus on emotions during symptom incidents Unconscious defense 3. Monitor anxiety & defense responses Unconscious anxiety 2. Feelings and Anxiety rise 1. Focus on Feelings Unconscious impulses and feelings DATE, ADDITIONAL DETAILS (set this text using Header & Footer) 15

16 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 16

17 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 17

18 Cognitive-perceptual Disruption Losing track of thoughts, poor memory, fainting Visual blurring, tunnel vision, blindness Hallucination in all 5 senses Anesthesia, paresthesia Depersonalization, Derealization, Dissociation 18

19 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 à the person is quite relaxed though cant lift arms etc. 19

20 Interpretation of Test Results 1) No change in active symptoms: Look for organic or other factors. 2) Symptoms fluctuate with anxiety: Possible role of anxiety in worsening/causing symptoms 3) Symptoms removed by emotional experience: Likely somatization or conversion of emotions 4) No unconscious anxiety is mobilized: No underlying feelings are present, or test not done correctly.

21 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. Distinct waves Grief: pain with thoughts of loss, tears, longing for the lost person. Love: warm sensation expansion in chest, urge to embrace 21

22 Inhibitory Forces go Down Somatic Pathway of rage goes Up same system AMA Atlas online 22

23 Process of Sessions 1 Orient Pa*ent Find Focus Mobilize Feelings 2 Pa*ent tenses, detaches and defends 3 Pa*ent goes flat with conversion, smooth muscle anxiety or cogni*ve perceptual disrup*on Clarify the defenses and the effect of defenses. Verify the pa*ent s will to examine emo*onal process. Use Graded Format to build capacity over few sessions Pa*ent feels complex feelings Examine feelings, follow lead of the pa*ent to past linked feelings. Recap and summarize. Hidden from View: A clinician s Guide to Psychophysiological Disorders. Abbass and Schubiner, in press 23

24 Family Doctor Brief Therapy 2: Sessions Focus the session on incidents of symptoms (includes in office anxiety) Watch for patient going flat Anger turning inward Going flat and weak: smooth muscle, conversion or mental confusion Developing depression Help see the difference between anger and anxiety Help them see that there is always guilt about any anger that is experienced Ask where they got the patterns from Recap everything at the end. 45 minutes x up to 5 meetings

25 Family Doctor Brief Therapy 3: Process feelings After some complex feelings are identified, help the patient notice how the feelings are felt in the body Distinguish these from anxiety and other mechanisms or behaviors Ask what aggression they are afraid the anger would do Any anger will be followed by guilt about the anger Summarize the findings See if they can identify where the feelings come from Recap and summarize together 25

26 Family Doctor Brief Therapy 4: Build anxiety tolerance 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

27 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 DATE, ADDITIONAL DETAILS (set this text using Header & Footer) 27

28 Monitor Countertransference BOND PAIN RAGE, GUILT about the Rage Symptoms Self destruct Harm patients

29 Past feelings of attachment trauma are stirred with patients Current (Dying Patient) Past (Father abandoned family at age 3: Grief, rage and guilt)

30 Unconscious Defense: Substance Use Depression: burnout Abuse patient Neglect patient Medical Error Past Feelings Unconscious Anxiety: Striated muscle Smooth muscle Cognitive-perceptual

31 Over and Under doing Medical Error Crosskerry, et al, 2008, 2010 Under doing: Omission bias Detached from patient Ignoring the patient Dismissing severity of Symptoms Neglecting to manage Not giving needed direction Avoid tests and examinations Avoid procedures Overdoing: Commission Bias Over-involved with patient Sexual or paternal roles Rescuing Criticizing, belittling, battling patient Rough examination Too many procedures/investigations more invasive: more adverse events Alternation between extremes 31

32 Reference Materials Reaching through Resistance. Detailed manual on ISTDP psychodiagnosis and treatment with case examples e.com Available on Amazon: Somatization article in JFP: Graded Format article: Hidden from View: A clinician s guide to Psychophysiological Disorders Written with a Mind-body expert internist and written for family doctors How to educate, provide first and second line treatments and basic ISTDP methods. Coming out early 2018 Psychophysiologic Press 32