Stress and the Body-Working with Symptoms unexplained by disease

Dr Venetia Young

Lakes Medical Practice,

Penrith, Cumbria

A professional Magpie?

Hypnotherapy Family/systemic therapy Family Constellations Solution Focussed Brief Therapy EFT NLP Narrative Native American approaches Body Psychotherapy (psychodynamic) Guided visualisations Mindfulness 2 years training Frequent attenders audit A lot of reading! GP training x2!

Aims of today Understand how the body produces symptoms when a person is

distressed and be able to explain it Lots of tips to deal with these symptoms in short consultations Learn about the stress cycle Learn about the molecules of emotion Learn about breathing Heart rate variability How these relate to CHD, COPD, DM, Bipolar Disorder, Chronic

pain… From Health Anxiety to Fabricating and Inducing Illness Case discussions Leave feeling relaxed and curious to learn more!

Symptom

Perceptible changes in the body or its function indicating disease (Oxford English Dictionary)

In groups of two to four chat about all the bodily symptoms you have noted in the last week or two: headache, back ache, migraine, asthma, joint pain, sore throat…..

Experience of Symptoms

80 - 90 % population have at least one symptom a week. (Anderson et al 1968, Hannay 1978.)

Women aged 20 - 44 have on average 10 symptom days out of 28 days. (Banks et al 1975)

Medical consultation 1/37 symptom episodes (Banks et al 1975)

Going to the doctor/nurse

What would have made you go to the doctor with a symptom you had last week?

How do patients decide?

0

2

4

6

8

10

12

Three year incidence of 10 common symptoms and the proportion with organic disease

Kroenke & Mangelsdorff 1989

Frequent Attending

Gill (1996) Prevalence of Frequent attending (FA) (FA = >12 visits per year. 1990 FAs = 37 ( 0.6%) 1995 168 ( 2.7%)

1990 consultations by FA’s were 5% of all attendance's - 1995 13% of all.

Stress and the body - sayings

It breaks your heart Her (s)mothering suffocates me It sticks in your throat He gets on my nerves I’m shit scared ……………

The stress cycle

Makes the link as to how stress gets into the body

Lists the symptoms Explains all of the symptoms Explains the consequences of the symptoms Enables patients to make choices Varied menu of helpful options

Explaining the stress cycle

Charles: 72, recently had stent put in after short episode of new angina. Op technically a great success

Comes into the surgery with feeling that he is going to have a heart attack, cold, sweaty, hands tense, head feels like exploding.

Explain the stress cycle: always a worrier, likes to be in charge, never been in hospital, felt very vulnerable, not enough time to adjust to idea of operation

Adrenaline

The flight or fight hormone Raises pulse Raises BP Increases breathing rate Causes muscles to tense Causes frontal lobe arteries to constrict Causes negative ‘catastrophic thinking’ Feels awful -avoids situations - more stress

CHD and stress/anxiety/panic Panic disorder is present in…. 15-20% of people with palpitations 33% of people with chest pain and no CHD 34% of people with proven CHD Panic disorder alters cardiovascular responsiveness 55% of patients with known CHD hyperventilate 66% experience their typical angina pain when they

hyperventilate higher BP and cholesterol men with high score for anxiety have 6 times increase in sudden

cardiac death

Continued…. Investigations 75% of people with a negative angiogram who have panic

disorder continue on multiple treatments more follow up, more testing, more investigations. 50% remain disabled or unemployed Reference Jeejeebhoy, Dorian and Newman - Panic disorder and the

heart: a cardiology perspective. Journal of psychosomatic research (2000) 48 393-403

Dean Ornish

Reversing heart disease 1996 Love and Survival 1998 Heart coherence – heart rate variability Institute of HeartMath HRV exercise

HeartMath Tip Take five minutes several times a day, whether or

not you’re feeling especially stressed, to try these simple steps adapted from the HeartMath Attitude Breathing® tool.

Focus on your heart as you breathe in. Concentrate on a positive feeling or attitude as you

breathe out. Lock in this new feeling as you continue to breathe it

in and out through your heart. As you become adept at using this HeartMath tool,

select new feelings and to help you "de-stress" as needed.

Breathing

How does breathing affect how you feel? Exercise: cross, relaxed, sad, cross but trying

to hide it, frustrated, relieved

Breathing too much Neuro: parasthesia, dizzy, headaches, Loss of

concentration, visual disturbances CV: cold hands/feet, palpitations, chest pains, light

headedness, tachycardia MS: muscle aches, cramps, general weakness and

fatigue GI:heartburn, bloated feeling, abdominal distension,

dry mouth, belching and flatulence Resp: sigh, yawn, air hunger, inability to take deep

breath, irritable cough, apical breathing, breathless Other: speech, vocabulary,

7/11 breathing

Abdominal breathing In through nose - out through mouth 7 in and 11 out with 1 sec in between 6-8 breaths per minute. Stimulates the vagus nerve major part of the

automonic nervous system: ‘rest and digest’ nerve. Facial expression, and voice control

Alters blood flow through abdominal cavity General muscle relaxation

COPD/asthma - breathing

55 year old woman. Thought she was done for with mild COPD. Life more limited, not going out much with husband, children all left home, blamed herself. Came to COPD afternoon

Breathing Relaxation Remembering what she liked doing ‘This has saved my life’

Severe COPD

65 year old woman – couldn’t breathe, chest muscles all tight, frightened/panicky

O2 sats 91% RR 20 upper chest and shoulders high

O2 sats 96% RR 10 shoulders low Gobsmacked! Belief had been that she simply had to

breathe more because of her COPD not less!

Konstantin Buteyko 30 yrs agoClaims to ↓ symptoms in Asthma, sinusitis,

emphysema, snoringCore aspects: Raise awareness of breathing( self

assessment)Retrain nasal breathingRelaxation techniqueBreathing home programmeIntegrating breathing for daily activitySessions between 5(one week)-10(staggered) depending

on severity (90min/session.

CDSR :Holloway and Laserson 2004 ( Breathing for asthma)

Outcomes measured 1.Severity of symptoms

2. Number of acute exacerbations 3. In-patient hospitalisation episodes 4. Physiological measures - lung function (e.g. PEFR, FEV1, FVC, MV etc) 5. Reduction in medication usage (e.g. inhaled or oral steroids or rescue bronchodilator) 6. Reduction in GP and hospital out-patient appointments 7. Evidence of symptomatic improvement 8. Patient's subjective evaluation of the intervention

Diabetes

Joan – 65 with Type 2 DM, Anxiety and Barratt’s oesophagus

Poor control HbA1c 8.8 Doctor appts every 2 days phoning nurse in

between – health anxiety CBT Work with family Breathing

1 year on

Routine appts every 4-6 weeks – occasional attendances in between

Diabetic control good HbA1c 6.6 – reduced oral meds

Coping strategies – breathing and managing her family relationships

Bipolar Disorder

45 year old with nearly obstructed umbilical hernia and a panic attack

Solution focussed consulting

Pre appointment change Problem description Goals Scaling Exceptions Miracle question Feedback, homework and compliment

Margaret 63

Hypertension, neck pain, IBS, back pain, irritable bladder, fatigue, asthma, codeine addiction

Her life

Elderly mother frail Sister with MS with 2 children Brother in care home cerebral palsy Divorced 4 children Adult son living at home with his 8 year old. 2 bedroom house Compulsive carer

Solutions

Eden carers – aromatherapy Help for her mother and sister Making sense of it all with a genogram Understanding she hadn’t got cancer Getting her friendships back Exercise Problem solving Setting boundaries with son and grandson Women who love too much by Robin Norwood

Sliding scale for thinking about illness behaviour- Eminson and Postlethwaite 1992 1 Classical neglect – ignore symptoms 2 Jeopardise health through non-compliance 3 Marked non-compliance 4 Lackadaisical in response to symptoms 5 Normal response to symptoms 6 Anxious about symptoms 7 Exaggerate symptoms 8 Invent symptoms - talking 9 Fabricate illness - doing

Health Anxiety Inventory

Clare – 7 months pregnant

Presents in Emergency Department on Saturday evening on her own. Says she is diabetic on Insulin and because she has just moved area and has a new GP. She has run out of insulin. She is worried because her blood sugar is high. She thinks she has got a urine infection which has caused this. She has bladder problems and self catheterises because of a past history of transverse myelitis.

She uses a stick and walks with a limp. She seems very pleasant.

Investigations

Urine: blood 2+ trace protein, nitrite negative, no leucs, no ketones, sugar ++++

Skin prick: glucose 25 HbA1C – all normal MSUs x 20 in past 3 years – mainly no

growth

Observations

Staff nurse notes that her limp is variable depending on who is looking

She also notes that the catheter left in the toilet looks mangled.

Notes show frequent attendances at ED over many years for UTIs and requests for antibiotics and pain killers

Midwife

Says there is a strategy meeting for FII the next week owing to child protection concerns – not to tell patient of this.

Recommends admission for observation Patient agrees and says that’s kind as she

could do with looking after.

Getting everyone on board

Supposing the midwife had said: oh just give her antibiotics and the insulin she needs?

Supposing your line manager had said the same but you were still worried?

Supposing the social worker had said, I leave all these medical things to the doctors to sort out

What might the new GP say having summarised the records?

What does the strategy meeting do?

Outcome Child registered under child in need Genogram ? CSA in mother ? Who father LSCS – no-one had told the paediatrician GP/HV/SW/midwife/CPN - close knit team around family with

good communication and challenging. Two doctor approach in practice

All insulin removed Referral to MUS clinic in edinburgh Mother and child doing well though Mum still anxious

Resources Positive mental training CDs Mentor and Northumbria leaflets –

anxiety/stress/relaxation Respiratory physiotherapist – First Steps - Primary Care MH Team– anxiety

management (including health anxiety) Long term conditions pilot - through First steps Yoga Tai Chi Meditation/mindfulness – Buddhist group Relaxation group - MIND

Referencesand websites Dean Ornish – Love and survival Dean Ornish - Reversing heart disease Susan McDaniel - Family Oriented Primary Care – good chapter on

psycho-bio-social approach to MUS www.heartmath.org Thich Nat Hanh – the Miracle of Mindfulness ‘Overcoming Anxiety’ and ‘Feel the Fear’. Self help leaflets Health Anxiety Inventory - HAI www.primhe.org.uk presentations and David McDaid on the economics of

MUS www.neurosymptoms.org Dr Jon Stone www.positiverewards.co.uk Dr Alastair Dobbin – self-hypnosis ‘10 minutes for the family’ Routledge 2004 Asen Tomson Tomson and

Young ABC MUS Chris Burton RCGP MUS guidance

What will your menu of skills be be?

Three simple things you would like to try Which new area of skill acquisition might

inspire you to go on a course?

Five finger relaxation exercise

Exercise and good exhaustion feeling Feeling loved Compliment Beautiful Place