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In fact, I think some patients aren’t really ready to hear there is even HOPE ! After all they have been through, how could there be? and if there were any hope at all, wouldn’t that mean that they had needlessly suffered? And, if they had needlessly suffered, that could, of course, be ENRAGING and too much to bare.
HI Everyone !!
Just getting the conversation started for Workshop 3…we talked about providing the patient with Validation, Hope and Understanding early in the process of evaluation and how this is the first step and a critical step in recovery. In fact, if we skip this, we will likely have a resistant patient who feels judged, misunderstood or that we are on the fringe of medicine and don’t know what we are talking about.
I made this mistake just last week !!……a man came to me with decades of whole body pain….all the doctors, tests, treatments, etc. that one has. His ultimate diagnosis was chronic back pain from failed back syndrome and fibromyalgia. I thought he knew what I did and had come to see me to try a new path. In the first hour, I jumped in with this new approach to chronic pain and maybe it could help him – thinking he would be so relieved and excited. However, I had skipped the validation piece. I had read all of his medical records prior to his appointment, but from his perspective, I didn’t listen to his stories. He said I had not listened to him, that I had judged him, that I didn’t know the details of his pain and his experiences and how this had destroyed his life. I went too fast and didn’t listen enough. I had miscalculated how quickly I could go from Validation and Hope to Understanding…I felt really bad. He left my care, so I didn’t get a redo on that one. In hindsight, I should have seen how much pain he was in and been more sensitive to where he was in the first visit – I should have put more testers out there to explore how ready he was to hear the good news and developed the relationship more before diving into it.Beatrice,
The most sensitive and “influential”, if you will, part of our brain is our DANGER SIGNAL. It is the part of our brain that keeps us alive 24/7. Without it, we would not know it is safe to cross the street and we would quickly miscalculate or ignore our environments and be killed or die. “Our environments” include both our external environments (e.g. “Is it still lightening outside?” or “That car is driving too fast”) and our internal environments (e.g.”why is my heart racing right now?” or “what is that sensation in my knee?” or “Ouch! Am I sitting on a pin?”Then, combine that with our fear mind – our memories, experiences (cognitive, physical and emotional memories), interpretations – all of that combining into our brain’s processing mechanism of PREDICTIVE CODING. Based our our past learned experiences, current new information is reinterpreted and then updated to the database to create new experiences.
The problem is, like a computer, our fear brain/danger signal is only as “smart” as the information we put into it. The conclusion that we are in danger or are not in danger is simply AN OPINION, and, like so many opinions, when based on inaccurate or limited information, the opinion can be wrong.
So, we have a danger signal (the engine light, if you will) being controlled by predictive coding (the car’s computer) which is in turn only as good as the wiring of the electrical board in the car (the opinion).
So, the danger signal senses a sensation. Based on our past experiences, our brain’s predictive coding determines it MIGHT by dangerous. Then, our personal opinions begin to add information, “My doctor said I would never heal; I would just have to manage my pain”, “I read online that cauliflower is toxic and can give you stomachaches if you eat too much of it. Mom always made us eat raw cauliflower. Mom stresses me out. Mom is dangerous. Cauliflower is dangerous. Cauliflower gives me stomaches. I have a stomach ache.”
Then, FEAR BRAIN chimes in…..”What other foods are toxic to me?” or “What other symptoms is cauliflower causing me? Maybe that sensation in my head right now is the beginning of a headache? Am I getting a headache? I have a headache now!!! Cauliflower causes me headaches too!! I have environmental sensitivities to cauliflower.”
Another piece of the dynamic is that all of our SENSES MAGNIFY when we are in DANGER. We have all watched all of the nature shows and seen how animals have such amazing vision, hearing, smell perceptions. We, humans, do also. When we are in danger, all of our senses become more acute. Combine that with overly sensitive fear interpretations and everyone sound becomes a burglar, every smell becomes a fire, every movement becomes a falling tree and every internal sensation becomes a sign of disease or injury.
Lastly, once we sense a danger, our BRAINS ARE COMPELLED to keep checking back!! Is the lion about to pounce yet? What about now? Is the lion closer than it was? Which direction is it going in?” or conversely, “What is my arm pain doing now? Will it get worse? Why did I just get that sharp sensation? Does that mean I have damaged nerves? Should I stop typing?”
Thanks for the question. The good news is that once we understand how all of this works, we can get it to WORK FOR US AND NOT AGAINST US !!
Alicia BatsonHope this helps!!
As an adult psychiatrist in practice with a demographic of high-functioning young to middle-aged adults, I often prescribe “anti-depressants”, mostly SSRI’s, bupsirone, SNRI’s or NDRI (bupropion). While it is true that science has not shown us the biochemical milieu behind mood states, nor how these medicines work, I can only say that I see benefit daily in my patients. I presume a large part of the benefit is placebo – they are suffering, they finally receive help and get started in therapy. However, therapy often takes a couple of month, or more, to get started, and I don’t believe I am that powerful of a placebo response. I get response rates >90% and quickly. I suppose it could all be placebo, but people don’t necessarily respond to the first agent they try. I think the article is confusing – a lot of overlapping and changing topics and discussions – over focusing on “sedating” meds like opioids (not used by psychiatrists), TCA’s (hardly ever used anymore) and benzodiazepines (hopefully, rarely used as a last or short-term result). To the degree, that a BZD is “sedating” vs. treating an underlying disorder directly, biochemically – I’m not sure that matters. If you have ever had severe anxiety and panic, I’m sure the patient does not care what the mechanism is – it works! However, my patients on BZD’s are not zombies; they are alert and can think clearly. Too high of a BZD dose will definitely sedate. If these medications cause side effects, we find one that doesn’t. There is no evidence that antipsychotics cause sedation as a treatment mechanism – the goal is not to sedate the patient – it is to stop the voices and paranoia and they do do this. Only in an agitated, violent patient, would you try to sedate them – so they don’t harm themselves or others. There is a mental state called mania and lithium and neuroleptics actually resolve it, stop it, so if you believe you are God and you are going to harm someone who gets in your way, lithium can bring you back to reality. So, it is a much more complicated story. I only know that these medications do safe lives and help people function so that they can work and have families and enjoy their life. It is always great when a patient feels confident to pursue their affective mood states and trauma through therapy, and I recommend this to every patient. However, I can’t jump on the bad wagon that all mental health meds are bad. I don’t know why they work, but patients are better and are grateful. More relevant to TMS/PDD however is that if you are highly anxious and BELIEVE these meds will give you side effects, they will !! It is not uncommon for people with chronic pain to also be very sensitive to medication side effects – nocebo affect.
I don’t work with children, however, when I have worked with young adults, I do agree that meeting with them alone is essential, though I do like how you were able to observe the interaction with the parent in the beginning. I feel like young adults often have more stress from personality traits driving symptoms and from social media making them feel afraid, uncertain, lacking confidence and threatened – especially for girls. Bullying can be more of a factor with children also, and they may have experienced sexual assault or experiences that frightened them, pregnancy, etc. or even, been perpetrators and now, racked with guilt. You would be less likely to get to the bottom of it with a parent there.
I feel like for a patient who has a lot of symptoms and/or a lot of anxiety, I start out with every 2 week visits. I find that one week intervals are too soon – they don’t have time to experiment with the ideas, practice the tools and to notice pain shifting over time. With too frequent of visits, frequent visits than every few weeks or months, maybe every 2 weeks. They will need more consistent guidance in self-soothing, learning to calm the sympathetic nervous system, regular reassurance that they aren’t broken, regular reminders of the tools and techniques – the more a person’s SNS is turned on, the less they remember !! If they have less anxiety and more capacity to remember and practice, then visits can be more spaced out. I communicate ththey will tend to over-rely on you and over-focus on their pain, expecting it to be gone with each visit. For a very anxious patient, they need moreat the extra time gives them time to practice the tools. So, in brief, I usually start out every 2 weeks for a few sessions, then as they improve, I go to monthly, then do that awhile and go to every other month. You are helping them build confidence that they can do this on their own. It’s like a child learning to walk and to separate from the parent – they will keep returning to you and looking back at you, as they learn and begin to develop the independence to explore and take risks on their own. Sometimes, they need to be nudged and allowed to figure it our on their own, but not too early or they will give up and relapse. I don’t think they benefit from direct learning, either 1:1 or in a didactic class, before entering a mutually supportive, interactive group class. A group class can be frustrating if the participants are not all at the same level of learning. I don’t think that answers the question about how many patients at a time, but I think that really depends on many factors. I’ve always had a mixed patient population of chronic pain patients and other mental health concerns, so I don’t really think about it like that.
I feel like for a patient who has a lot of symptoms and/or a lot of anxiety, I start out with every 2 week visits. I find that one week intervals are too soon – they don’t have time to experiment with the ideas, practice the tools and to notice pain shifting over time. With too frequent of visits, they will tend to over-rely on you and over-focus on their pain, expecting it to be gone with each visit. For a very anxious patient, they need more frequent visits than every few weeks or months, maybe every 2 weeks. They will need more consistent guidance in self-soothing, learning to calm the sympathetic nervous system, regular reassurance that they aren’t broken, regular reminders of the tools and techniques – the more a person’s SNS is turned on, the less they remember !! If they have less anxiety and more capacity to remember and practice, then visits can be more spaced out. I communicate that the extra time gives them time to practice the tools. So, in brief, I usually start out every 2 weeks for a few sessions, then as they improve, I go to monthly, then do that awhile and go to every other month. You are helping them build confidence that they can do this on their own. It’s like a child learning to walk and to separate from the parent – they will keep returning to you and looking back at you, as they learn and begin to develop the independence to explore and take risks on their own. Sometimes, they need to be nudged and allowed to figure it our on their own, but not too early or they will give up and relapse. I don’t think they benefit from direct learning, either 1:1 or in a didactic class, before entering a mutually supportive, interactive group class. A group class can be frustrating if the participants are not all at the same level of learning. I don’t think that answers the question about how many patients at a time, but I think that really depends on many factors. I’ve always had a mixed patient population of chronic pain patients and other mental health concerns, so I don’t really think about it like that.
Hi Becca,
I have found that it is best to not address the psychiatric or pain medications during treatment. What I find is that as patients do the work, their danger signal begins to turn off and their pain, other physical symptoms, anxiety and depression begin to get better. This improvement and “evidence” that they are on the right track gives them hope and more motivation to continue doing the work. As their symptoms improve, they notice they are needed the “as needed” or rescue medications less. Over time, they can develop confidence to work with their doctor to gradually begin to taper off of the scheduled medications. If they are doing the work and aren’t have symptoms, they should not need the medication.
However, I have found that if this process is started too early in recovery, i.e. before they have learned to keep their danger signal turned off and developed the confidence that it will stay turned off, then the process of getting of meds will only serve to scare them, thus keeping the danger signal on and the pain going. They risk misinterpreting the slightest symptom as a return of the pain or depression and a sign that they can’t do without it.
Most of the time, I don’t find that these medications are causing a problem though I do encourage people to try reaching for the “pro’s” less often as time goes on , so that they can instead use the onset/worsening of pain as “an opportunity” to learn how to intervene on their own behalf with practices of self-compassion, self-soothing and somatic tracking. The pain is the material you need to practice your recovery. I tell them, “begin to view your symptoms as an opportunity for you to learn how to better take care of yourself in the face of life’s stressors”. “To the degree that you are still having pain or other symptoms, that is information for you that you still have not fully learned how to take care of yourself”. So again, the brain is helping you to understand this.
If the patient feels like the medication is causing emotional numbing and they don’t want to feel like that, then it is reasonable to taper off of the medication – I would consider this a side effect. However, if there is some benefit for them (and sometimes they don’t realize there is benefit until they are off of it!), then it might be best to wait until they have recovered more fully.
I hope this helps. Thanks for the question.Hi Everyone!
Grace will soon be posting the requested recovery program checklist that I use for each patient to help me remember which aspects/tools/techniques of recovery we have already gone over in session. It definitely doesn’t mean you won’t need to or want to go over them several times because when a patient’s brain is under threat, they will have difficulty remembering the concepts – they must be repeated over and over. I use the form to help remind me what the important tools to recovery are and as patients get better, it reinforces and keeps a record of which tools were most helpful for them as individuals. Also, if you have already gone over one tool of recovery 5 times and they aren’t better, maybe that means I’m on the wrong track and need to look under the rocks/drivers of their danger signal.
AliciaJesse Glaub,
Regarding your patients who are unable to except the diagnosis…
I would help them to build an evidence sheet (we will talk more about this).
Teach them that DOUBT (in the mind-body diagnosis) = FEAR (because the opposite belief is you are broken) = PAIN (because fear is the fuel for the pain).
DOUBT = FEAR = PAIN
Suggest to them that in trying this new approach, they “have nothing to lose but you pain” – no side effects, no risks (like meds and surgery). What do they have to lose by trying it? They don’t have to believe fully right away, but if you can get them to invest enough to begin to see a little improvement, it can give them confidence, then that gives hope, which begins to turn off the danger signal, which improves the pain and pretty soon, you have an uphill snowball rolling !
Alicia Batson MDHi Jessi Glaub !!
Regarding your 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…”…..
Emotions are repressed for a reason – patients have learned that they are very painful to feel or very dangerous to feel. They are repressing in order to survive – this is what they learned either in childhood or adulthood. But as adults, we have to start acknowledging, accepting and feeling these difficult emotions, if we are to heal. When my patients are exhibiting discomfort with anger/rage/sadness, I often explain to them that it is ok to feel both anger/rage/sadness and love/support/compassion at the same time !!! It is not either/or – it is both/and. They need to hear that it does not make them a bad person, a bad mother, a bad sister, a bad daughter, etc. to have these feelings. They will feel guilt and shame for having negative emotions towards people they believe they are only supposed to love !!! It is the guilt and shame that is suppressing the anger and causing the pain – not the anger itself. The anger is the normal emotion that is just trying to be felt and then, released from the body. Help them to let go of the guilt and shame for feeling these other emotions and they will be able to feel the anger, then it passes and then the pain goes with it.
Alicia Batson MD
Unfortunately, most studies to date are lumping all “long-haulers” into one category, as if they are all the same demographic/population, thus the results are confounded.
When we talk about “long-COVID”, it is important to distinguish those who had severe initial illness (hospitalized, ICU stays, intubation, etc) vs. those who has mild initial illness (never hospitalized, only tested positive).
For those with “Long-COVID with mild initial illness” – shall we refer to them as “LONG COVID-MII”? – there is no biologic evidence for end organ damage, they have normal 02 saturations despite subjective reports of shortness of breath, studies are showing they are mostly white, middle to upper income, and younger than 40 years of age. Of course, studies showed those with COVID who got the sickest were people of color, poor and older/elderly. They have many symptoms consistent with an overly activated sympathetic nervous system and many are also diagnosed with POTS, chronic fatigue syndrome and fibromyalgia – other psychophysiologic conditions. They also often have PTSD, anxiety disorders and depression.Dr. Graue,
Those are great papers on POTS and fear conditioning. Thank you for sharing. I was not previously aware of them.
AliciaDr. Graue,
Regarding your question about the care of your patient…an “82 yo F with Parkinson’s, depression, cognitive decline, vasculitis, hypertension and hyponatremia, who was referred to me for post-herpetic neuralgia”…
First of all, I think you deserve kudos for so patiently sticking with it and with her. I would think that even though you may not feel you are making progress, her time with you improves her quality of life. It sounds like she has had some great sadnesses and disappointments in life. You are giving her some reprieve from that and reminding her brain and soul that she is worthy of kindness and compassion.
I have found it to be a challenge working with elderly when there is cognitive decline already present. They may tend to forget the information and recovery methods you imparted and even what it felt like to experience compassion or love.
Late stage aging can be so terrifying – the failing body, the humiliations and vulnerabilities, the constant reminders of what you can no longer do or shouldn’t do…and then there is death looming which for some can be the most terrifying.
I think that sometimes while our goals for our chronic pain patients may be no more pain, it may be wiser (and even more compassionate) to just meet them where they are, be with them in the way they want to be and just listen and support. Humor is always a good tool when all else fails.
When my patients are exhibiting a lot of resistance, I interpret that to mean they just aren’t ready for the work and need more time to learn to relax in their bodies, feel calmness and safety, decrease general anxiety.
Hope something in this message helps.
Alicia