Live Workshop 2

[Grace Batts]

[Jessy Glaub]

Here is a link to one of the videos I like to use to demonstrate predictive coding in person. https://youtube.com/shorts/65p1sA-Cb1E?feature=share

[aolden]

I really enjoyed our discussion yesterday. Howard and Alicia, I wonder if you could provide us with a syllabus or an outline for the year’s lectures? It would help me to have a big picture of the program.

[Lilia Graue, MD]

Hi all, here are the two papers I mentioned today re predictive processing, POTS, and fear/threat conditioning.

Norcliffe-Kaufmann, 2022, Fear conditioning as a pathogenic mechanism in the postural tachycardia syndrome https://drive.google.com/file/d/17cPkE0P8CNK3dRBWZSYektvAQ0JPJAtX/view?usp=sharing

LeDoux 2014, Coming to terms with fear https://drive.google.com/file/d/1P6F5QDUz3DryFYTrEEthNC9NPk8-VIjR/view?usp=sharing

[hschubiner]

Thanks for being in the class with us!!

Grace will email you the intake forms that I use.

Here’s the youtube channel from my patient on mast cell activation syndrome:
https://www.youtube.com/@thehistaminedeception5378

The video on trauma and healing vision from Mark Wolynn, which is excellent:
youtube.com/watch?v=YqBhAgqZGSU

Here’s the reference on the article we published on racism and pain:
Racism as a Source of Pain https://doi.org/10.1007/s11606-022-08015-0

Thanks again!!
Howard

[Lilia Graue, MD]

Hi all, here’s the link to the papers I mentioned today re predictive processing, POTS and threat conditioning.

https://drive.google.com/file/d/17cPkE0P8CNK3dRBWZSYektvAQ0JPJAtX/view?usp=sharing (Norcliffe-Kaufmann et al, 2022, Fear conditioning as a pathogenic mechanism in the postural tachycardia syndrome)

https://drive.google.com/file/d/1P6F5QDUz3DryFYTrEEthNC9NPk8-VIjR/view?usp=sharing (LeDoux, 2014, Coming to terms with fear)

[abatson]

Sure! Grace will be posting the 2023 syllabus very soon.
Alicia

[Grace Batts]

Here is the link to the syllabus:

https://oviddx.com/wp-content/uploads/2023/01/OvidDx-Certification-Course-Syllabus-2023.pdf

[Lilia Graue, MD]

Alicia and Howard, and everyone else who’d like to chime in, I have a question and a case related to the question.

Question:
Have you worked with elderly patients with cognitive decline? If so, are there specific suggestions you’d offer for working with this population?

Case:
I’ve been working with an 82 yo F with Parkinson’s, depression, cognitive decline, vasculitis, hypertension and hyponatremia, who was referred to me for post-herpetic neuralgia, and it’s been really challenging.

The greatest success so far has been with her children, who were very open to psychoeducation about primary pain and to working through the fear/avoidance cycle. They have stopped organizing around the pain, and have made significant shifts in how they relate to her, in addition to organizing more family gatherings and more frequent visits with her children and grandchildren, which brings her joy. They are making the best of her good days and keeping her company on not-so-good days, and she recently went on a short trip to the beach with one of her daughters and her family.

She and I have established a good rapport, and during the time we’ve been working together she has grown in willingness to engage socially, with ups and downs. Her children have shared that she seems more engaged and in general her mood has had a positive trend.

In terms of the pain, we haven’t had much success with the neural repatterning toolkit – psychoeducation has been incredibly difficult; she will sometimes agree to have me guide her through somatic tracking, mindfulness and compassion practices, and sometimes she won’t; she refuses to practice in-between sessions; any and every time we come near difficult events/emotions she gets intense pain but denies any connection between her emotions and pain (other than that the pain seems to come at random times, and is not triggered by movement); she refuses to engage in physical movement beyond two days a week during her PT sessions (her mobility is quite limited – her muscle mass is very very low, she can walk with the help of a walker with the tiniest steps, and for most of the day she sits on a recliner), and won’t leave her room unless her children are visiting (and even then it’s a struggle unless it’s a large family gathering downstairs). She’s had several episodes of severe hyponatremia and UTIs during the time we’ve been working together, with associated lethargy. She has a history of poor health in childhood, lost her father to suicide in her teens, and her husband has had an extramarital relationship for decades – they keep separate lives though they live in the same house and will both be present for family gatherings and celebrations. During the pandemic several of her friends and elderly relatives died, and the remaining ones are not meeting anymore like they used to. She has live-in nurses and both they and her children have tried everything to encourage her to be more active and/or do guided practices, but she gets combative. There have been episodes during which she refuses to bathe or to get up to urinate for a few days, which usually ends with a UTI.

My role in her medical team is in the psychosocial domain. She has a neurologist, a geriatrician, and a rheumatologist seeing to the medical aspects, and her daughter is also a physician.

Any insights or suggestions would be much appreciated, thank you!

• This reply was modified 1 year, 2 months ago by Lilia Graue, MD.
• This reply was modified 1 year, 2 months ago by Lilia Graue, MD.

[Grace Batts]

Here is the link to the recorded session:
Live Workshop 2

Please note the passcode: 4!?FLdqM

[makse]

Hi,

I really enjoy the course so far as it opens my view to the complexity of pain and other symptoms that I often see in my daily practice.

Although this approach really resonate with me, I have some questions regarding your scientific work.
– From the RCT study for EAET (Emotion Awareness and Expression Therapy) for fibromyalgia, it it highlighted that 34.8% achived above 50% improvement at six months follow up. But when I reviewed the result section, I saw that the mean scores on the outcomes measures did not differ tremendously from the control groups. My question is: Does these results mirror the improvements you see in fibromyalgia patients in your treatment outside the clinical trials? And do you have comments regarding why there is similarity between most of the outcome measures, but substantial difference in the amount who achived more than 50% improvement?

– In the low back pain study from 2021, were the results from the intervention group astonishing regarding pain and disability. I understand that the PRT (pain reprocessing therapy) intervention may differ from EAET. But do you see higher improvement rates in MBS patients where the pain manifests in one body region compered to more widespread (like fibromyalgia)?

(Please excuse my typos and grammatical errors. I have a condition called being Norwegian)

[makse]

Hi,

I really enjoy the course so far as it opens my view to the complexity of pain and other symptoms that I often see in my daily practice.

Although this approach really resonate with me, I have some questions regarding your scientific work.
– From the RCT study for EAET (Emotion Awareness and Expression Therapy) for fibromyalgia, it it highlighted that 34.8% achived above 50% improvement at six months follow up. But when I reviewed the result section, I saw that the mean scores on the outcomes measures did not differ tremendously from the control groups. My question is: Does these results mirror the improvements you see in fibromyalgia patients in your treatment outside the clinical trials? And do you have comments regarding why there is similarity between most of the outcome measures, but substantial difference in the amount who achived more than 50% improvement?

– In the low back pain study from 2021, were the results from the intervention group astonishing regarding pain and disability. I understand that the PRT (pain reprocessing therapy) intervention may differ from EAET. But do you see higher improvement rates in MBS patients where the pain manifests in one body region compered to more widespread (like fibromyalgia)?

(Please excuse my typos and grammatical errors. I have a condition called being Norwegian)

[Jessy Glaub]

I have gone through the App modules probably 3-4 times and have something new to take away each time, especially with the communication pearls. I was wondering if anyone has some good communication pearls for the following patient scenarios.

1. I have a subset of patients who tend to express some emotions about their pain experience and life stressors related to the onset of those symptoms, but immediately follow it up with a justification for why they shouldn’t feel that way or will same something along the lines of “but I am blessed for…”. This seems to cause a barrier to the healing process. If it helps here is an example, I have a patient whose driver of symptoms seems to be mostly related to repressed anger she has towards her children. As we dive into that she will start to talk about how rough the pregnancy and birthing experiences were and say something along the lines of “they really destroyed me” and talk about how she can’t do the things she wanted to achieve, but immediately back peddle from that and talk about how blessed she is to have them, etc… Throughout the rest of the PRT process she is all in on and has had modest improvement in symptoms but I think this wall we are facing is inhibiting further progress. The lesson discussing the need for autonomy and how internal conflict can trigger danger alarms seemed to fit perfectly for this. Any recommendations on angles to approach these discussions from or insights from similar experiences?

2. This doesn’t happen often but on occasion, I will have a new patient who is very attached to the diagnosis or self-diagnosis that they have like fibro or EDS. I am always very cognisant of making sure my patients feel heard and validated, but when these scenarios arise it seems that my explanations of how pain works (just like how the PRT process explains it) and what the potential to get better is, I would say this information gets refuted would be the best way to put it (i.e., that can’t work for me, there is no cure for fibro, everyone with EDS lives in chronic pain, etc…). I totally understand why those perceptions are there and I explain that obviously, which has helped a few times create some buy-in on the process and allowed for the continuation of care, other times it seems no amount of evidence would be sufficient. In those times I chalk it up as they are not ready for treatment, still in the pre-contemplation phase essentially. Does anyone have good insights from their experiences on this? I am also a chiropractor so a lot of times people come to see me with different expectations than what I actually do so it can be a bit of a curveball, so this might be a unique source of this friction.

I look forward to the feedback and insights from some of you more experienced clinicians/therapists!

[hschubiner]

Hi Lilia.
It’s so good of you to post such a simple and straightforward case!! 🙂

Clearly, this will be very challenging, but you are absolutely doing the right thing by engaging her family and helping her to have more social activities and happiness in her life. I think you can also engage her family to help you and her to see that her pain will be less when she’s engaged and busy and happy; and her pain will be worse at other times.

When you talk about difficult issues and the pain recurs, that is about a good an educational process as you can have. And, I would continue to help her see that. But if that doesn’t help her to see this, then she is probably not going to see it, at age 82 and with some cognitive decline. You are helping her, but you may not help her deal with the pain. Have you done any EAET work with her at all?

Best, Howard

[hschubiner]

Thanks for your questions, Makse.
By the way, I will be in Norway in the fall and will hopefully be doing some lectures or workshops there.

You’re right the that mean scores in the EAET fibromyalgia study were not that different and not even statistically different at 6 months than the CBT group. However, the proportion who rated their improvement was much greater. It is very difficult to show that one psychological intervention for pain is actually superior to another. There are virtually no studies that show that. Our fibromyalgia study was possibly the first to do that; and yes, the results do not “knock you over.” In practice, we combine assessment, predictive processing education, PRT and EAET on an individual basis; and we couldn’t do much of that in that group setting of the fibromyalgia study.

The Boulder back pain PRT study did show better results, but there was no active comparison group. That study (PRT versus CBT for back pain) is now being planned and will be conducted by Yoni Ashar in Denver, so we’ll see how that goes (in a few years). 🙂

The likelihood that someone gets better doesn’t really depend on where their pain is or what symptoms they have. It’s more dependent on if they can accept the model, do the exercises, let go of fear, deal with stress and trauma, etc.

Does that help?
Best, Howard

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