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hi David
alas I don’t have any experience with benign fasciculation syndrome. Thanks for posting. KarinTHank you Howard and Alicia. THis is very helpful information because there are so many presenting needs in some people. It’s nice to know what works for you all and I”m now getting some skills in co-creating goals with the client about what’s most important to them to address. I listened to the Ezra Klein interview of Rachel ZOfness and heard her quote that trauma is a co-morbidity for chronic pain 80% of the time. I would like to know more about that – it seemed important. Do either of you or any of my esteemed colleagues know more about this? Thank you! Karin
hello! I am Karin Lee Hughes MD. I trained in family medicine, and palliative/hospice medicine in Salt Lake City Utah. I practiced primarily hospice for about 20 years , primarily doing home visits/working with comprehensive symptom management/whole person care in the setting of a team. I loved the work because I could use a full spectrum of tools (not just medications). I experienced trauma in my personal life early in my career which led to postpartum depression and other complications. I have been on a journey of healing and growth. The journey has involved a lot of exploration and training in yoga, Reiki, relaxation response/meditation and psychotherapy. I started to train specifically in mindfulness based somatic therapy and post traumatic growth somatic therapy the last 4-5 years and opened my own practice on a limited basis in 2019. The last year has been a bigger transition away from hospice and solely working with clients with anxiety/depression/trauma/mind body disorders such as chronic pain. My current setting is in a behavioral health clinic with psychologists and therapists; I also teach resiliency for professional caregivers in our community. I have attempted to work with physicians in our community on resilience too but have not gotten much traction. I have experienced some neural circuit pain issues (tendinitis) in the past that have resolved with psychotherapy/health boundary setting and limiting the amount of vicarious trauma/job related stresses. I have been interested in this field for many years but only recently found the PPD/TMS group in the last year. I had done some training several years ago through the Harvard mind body group and shadowed a lovely physician who has since retired in Salt Lake City when I lived there. I currently live in Western Colorado. I’m enjoying the community and the training!
That’s a wonderful idea! I am looking for something similar but haven’t come across anything yet…nor have I been able to design anything>.. 🙂 Karin
hi Lilia
YOu are providing such comprehensive wrap around care of your patient and family! Just your attention/care to all those details I’m sure is making a big difference. I think managing our own expectations is important and reassessing their goals of the “therapy/treatment” in this population particularly.-
The only other things i can think of would be: 1- the more we can support the family to feel calm/regulated around their loved one, that seems to be very therapeutic for these individuals and the family unit. Sometimes I/we end up working primarily with the family members to be more regulated and that can make all the difference for the patient. 2- Helping to teach the patient the skill of “savoring”(5 senses or a view, awe, etc), “Taking in the good” and staying with neutral or positive sensations in the body for 10-15 seconds at a time also has been very effective for one of my patient’s with cognitive decline. (RIck Hanson, PhD’s work primarily but also from Post Traumatic Growth Somatic therapy/mindfulness based somatic therapy). If they can learn to stay with positive sensations/experiences or if the family can direct them to stay with experiences longer, I find the nervous system gets more regulated/more safety is felt in the body/mind and the danger alarm is turned down. If you want to discuss more please email me karinleehughes@me.com. happy to explore more thanks KarinHI Lilia
I often work with a similar population (hospice/palliative medicine). Not sure if you’ve already tried this, but some families like to use guided practices/recordings that they turn on for the patient to help them refocus /feel more safe/calm/relaxed when their symptoms are worse. (i tailor the practices to what has been helpful in sessions or what they have access to.- for some, self compassion practices such as Dr. Kristin Neff’s recordings on selfcompassion.org can be helpful- i don’t know if the recordings are available in Spanish language. For others, I recommend Insight Timer or other apps (usually the younger generation has to help with setting this up)-So I too teach many “bottom up” techniques to increase safety in the body and turn off the danger signal. Thank you for clarifying that the method you are teaching in primarily “top down”. Given the bidrectional nature of our nervous system, it has made sense to me to work with both types of skils/techniques.
Case study: (I got permission from this client to submit her information and have changed identifiers).
59-year-old married female professional was referred to me at the behavioral health clinic by a LMFT therapist who has been seeing her for several years for Anxiety, depression, panic disorder, and ADHD with chronic low back pain. She has been told that she can rewire her brain and is interested in learning more about this and finding more ways to treat the pain without medications. She has undergone multiple back surgeries, injections of her shoulder’s and is in ongoing physical therapy. Her most severe area of pain over the last few years is her low back. She reports that she knows that she has overused her back and has done a lot of high intensity extreme athletic events such as cycling. The reason that she exercises so much is to treat her anxiety, depression and pain. She had some injuries as a gymnast and was told to push through the pain- that is an old pattern for her. Her pain correlates well with stress in her life and she is aware of this link. Most recently she had a spinal fusion done in a large metropolitan area in July 2022. She reports discomfort with prolonged sitting or prolonged cycling with some radicular symptoms down the posterior right buttocks into the posterior thigh. Given the amount of injuries that she has had, I asked her to contact the surgeon from July and clarify what the parameters are for her in terms of safe amount of exercise.Past Medical Hx also includes Hashimoto’s thyroid disease, A/V nodal reentrant tachycardia status post ablation, dyslexia, history of multiple vertebral and facet fractures from injuries, GERD and glaucoma.
Spinal fusion of L4 -S1OVIDDX handouts completed with client- body map reveals: Multiple areas of pain including left elbow bilateral knees bilateral ankles right hip low-back, both shoulders and neck. Lifetime stressors include: in utero severe stress of her mother, Emotional neglect, mental illness in her household; adult stressors include multiple accidents, two previous divorces, change in sexual functioning, multiple deaths in her family from COVID 19, work stress, financial stress, ongoing stress as a parent of a trans-young adult and a lesbian young adult (the father of these children has rigid religious beliefs which have been very stressful on these young adult children).
Lifetime Review of Symptoms: Is positive for TMJ, neck pain, back pain, piriformis syndrome, shoulder pain, knee pain conquered, frequent urination, menopause dysfunction, numbness, anxiety
Personality traits include perfectionism, high expectations, conscientious self, overly responsible, rule following, low self-esteem, putting others needs first, hypervigilance, and worrying although this is improvingMedications include: Escitalopram Oxalate 20 mg po qd
Vyvanse (Oral) 20 mg po qd
Montelukast Sodium 10 mg po qd
Levothyroxine Sodium 25 mcg po qd
Estradiol (Oral) 0.5 mg po qd
Cyclobenzaprine HCl 5 mg 1-2 po QHS Prn
Progesterone Micronized 100 mg po QHS
traZODone HCl 50 mg po QHS
Diclofenac 75 mg po BID prnPE: thorough musculoskeletal and neurologic exam which was essentially normal except for Mildly tender posterior cervical muscles and mild-moderate anxiety.
Labs/data: 6/2022 basic labs are normal including TSH. 8/2022 lumbar xrays: Frontal lateral views lumbar spine are obtained. s/p posterior fusion and decompression from L3 to L4. Disc spacers from L3-L4, L4-5, and L5-S1. mild shift scoliosis noted centered to the right at L1 to the left at L4. Vertebral body heights are preserved. There is mild DDD at L2-L3..
2018 CT lumbar spine: Age-indeterminate right L3 transverse process fracture, likely subacute/chronic. L4-S1 posterior fusion without evidence of hardware complication. Minimal early partial osseous bridging across the intervertebral discs. MRI lumbar spine 2016 1. Moderate multilevel degenerative disc disease with mild central stenosis at L4-5 and borderline to mild central stenosis at L3-4 and moderate central disc protrusion at L5-S1. 2. Marrow edema in the left pedicle/pars at L5 likely DJD or stress related.Questions: Clearly a lot of her symptoms seem to be related to a mind-body syndrome but she also has injuries/hardware in her back. Like to discuss working with her to turn off the danger signal. So far I’ve been working with her on psychoeducation, psychotherapy to help calm down the hypervigilance, increase mindful awareness, reduce her night time alcohol use, teaching more autonomic regulatory practices to help her calm the nervous system down (primarily in flight). She is responding well and appears much less anxious. Next steps will be to do more somatic tracking exercises..
thank youTHank you ALicia! Very helpful to get this information. I am definitely curious about the “instances where the persistent state of symptoms can create physiologic changes in the body” as well. I will submit a case soon.
hi Howard
I’m excited to report that I just for the first time was able to logon to this forum today. Two questions that I have are about timing. Wondering if there is any research or if not then clinical experience to know how long it takes for a neural circuit disorder/mind body syndrome to develop? And wondering if you could discuss how likely and over what time frame are these conditions are reversible?
thank you
Karin