Transcription
Hey there, everybody, and welcome to this video on practices for addressing health anxiety and somatic symptoms. I'm your host, Dr. Don Donnelly Snipes.
Now, obviously, the title of this is "Evidence-Based Practices." However, doing the research on PubMed, unfortunately, there was a devastating lack of research on evidence-based practices for treating these issues. So, we'll talk about what I did find, and we'll talk about what I have learned over 20-some odd years of clinical practice.
Unfortunately, much of the literature still refers to somatic symptom disorders as symptoms which have no physical cause, and that is not true anymore. And I mean, this was even after the DSM-5 was released, that the research, especially from in medical journals, was focused on symptoms that have no identifiable medical cause. The DSM-5 defines somatic symptom disorders, though, as one or more physical symptoms that result in clinically significant distress. It says nothing about whether there is or is not a physiological cause, and we need to really underscore that doctors must get away from assuming that something is all in people's heads when they cannot identify a cause. Fibromyalgia, for the longest time, POTS, hyperparathyroid, and chronic fatigue syndrome have all fallen into that category where for years, decades, people were told that, "Hey, there's no underlying physiological cause for your complaints. Therefore, nothing must be wrong, and it must be all in your head." And now we know that, hey, there actually is physiological, um, markers. There actually are physiological markers, and something is actually amiss in the body factory. You just didn't know what to look for before.
And it's important for us as behavioral health clinicians and social workers to also really guard against invalidating people's experiences. We want to help them improve their quality of life. We don't live in their skin, so invalidating their experiences is not helpful. One of the analogies I make sometimes, if you've ever worked with somebody who has a psychotic disorder, when they are in a psychotic episode, no amount of telling them that their perception of what's going on is wrong is going to do any good. It's actually going to break the relationship. It's important to join them in their reality, their perceptions. Now, I am by no means saying that people with somatic symptoms are psychotic. No, I am not. I'm saying their symptoms, their perceptions, their feelings, the way they are experiencing life is very real. And just because we don't experience it that way doesn't mean it's not real to them. We've learned over the years that there are a lot of people with sensory integration and sensory gating difficulties, for example, that experience things very differently. What you may experience as lukewarm, they may experience as scalding. The temperature objectively is the exact same, but their nervous system, their sensory response is very, very different. And by ignoring that, we are causing trauma. We are causing them to feel invalidated, hopeless, and helpless, and we're promoting emotional dysregulation.
Think about people who, well, let me go on with this before I, before I make another analogy. Physical interventions for somatic symptom disorders. This person is having physical symptoms. It's going to be difficult to address anything cognitively until we have the facts. So, they've probably already had a physical and blood work in order to provide evidence of what is or is not going on that we can measure at this point in time. So, let's get that data. This can help people rule out, for example, catastrophic physical concerns. If they're concerned that they've got cancer, for example, you know, let's get the information that says we don't see any evidence of that right now. Doesn't mean you're not having symptoms, but let's rule out anything that we can, um, relatively easily. I'm not talking about sending people to, you know, 16 different specialists, but that can help us when we get to the cognitive interventions because it gives us some foundation to evaluate.
So, for example, if somebody is having pain in their back, and I will use my example, my mother died of kidney cancer. For months, she thought that she had pulled a muscle in her back at the gym. Turns out it was kidney cancer, and that freaked me out. Um, so then when I started having pain in my back, I got concerned. And then I got some blood work that was a little bit off, I got even more concerned. But then I looked at the blood work and I looked at all of the other tests of kidney function and white blood cells and everything else, and they were all within normal parameters. So, what was the take-home? And we're going to talk more about Occam's Razor in a minute. The take-home, or the most, um, logical explanation, the simplest explanation was, "Hey, it's probably your scoliosis," or "You probably pulled a muscle in your back," which I do a lot, you know, working out on the farm, moving bales of hay and those sorts of things.
Cognitive interventions. Now, if somebody is having somatic symptoms, we are not necessarily going to be able to address those very much. What we are going to need to look for is how can we improve your quality of life? EMDR, I have on the top of the list. Why is that? A lot of people, not everybody, but a lot of people with somatic symptoms have a history of trauma. And Van der Kolk said it best, that a lot of times trauma is remembered as a sensation or a feeling as opposed to a thought or a memory. And EMDR may be able to help untangle or identify a connection between a traumatic experience and a somatic symptom. So, EMDR can be very helpful. People can also develop health anxiety and after a traumatic experience where a loved one dies of an illness, or after they have a particular physical health problem like a heart attack, then they may become hypervigilant to any sort of cardiac symptoms or any sort of related symptoms. So, EMDR can be really helpful at helping people integrate these memories in a way that it doesn't always trigger their fight-or-flight response. It doesn't trigger their anxiety, at least not to the same extent.
Improving health literacy is very, very helpful. And there was a little research on this. The more people feel educated about a particular illness or condition, the more empowered they feel to either protect themselves from getting it or to deal with it if it happens. The key is, where do you, how do you improve health literacy? And it's really difficult in today's day and age of the internet where not everything is a hundred percent accurate, and a lot of things are written so generally that it can actually promote more anxiety. Improving health literacy, especially in people who already have health anxiety or somatic symptoms, in my opinion, can best be done through guidance from a case manager, a social worker, a counselor, or a medical professional who can gather the information that is appropriate and accurate for that person without providing them information that might trigger unnecessary anxiety. And we'll talk about that a little bit more in a minute.
Cognitive processing. And this is where that physical comes in. Cognitive processing encourages people to get away from emotional reasoning, emotion-based reasoning. "I feel scared, therefore something must be wrong." And look at the facts. What are the facts for and against my belief that I'm in danger of getting this condition or that I have this condition? Now, cognitive processing doesn't work as well with somatic symptoms because the facts are the facts. If the person is experiencing a symptom, that's what they're experiencing. And even if there's no medical cause or if there is, it doesn't matter for our purposes as behavioral health clinicians. If they're experiencing a reduction in their quality of life as a result of a physiological symptom, then it is. So, what facts might we look at? Well, we're going to talk about backward chaining in a minute, but we might look at facts such as, what makes it worse and what makes it better? Control. What aspects of this situation can you control? Once you've identified what makes it worse and what makes it better, then you can identify ways to try to reduce the intensity of the symptoms. Once you've identified the risk factors for getting an illness, then what aspects can you control? What can you do to keep from getting it? Or if you have it, what can you do to help yourself recover from it or live a high quality of life with it? And P stands for probability. And we need to recognize it. And again, it's really important not to invalidate people's perceptions, but we also need to recognize if, based on the facts that I have, and if I do the things that are within my control, what is the probability I can have a high quality of life?
Cognitive behavioral interventions. Those come up a lot. I think it's probably because it's one of the easiest things to do a study on, quite honestly. But addressing distortions can be very helpful. All-or-none thinking. "I'm either sick or I'm not sick." "I can either have a horrible quality of life or a good quality of life." Jumping to conclusions, like I said, "I have a backache, therefore it must be catastrophic." All right, let's look at the facts. And same thing for emotion-based reasoning. Looking at the facts and thinking, "You know what are three other explanations for why my back might hurt or why I might feel like, you know, my chest is a little tight, besides something catastrophic?"
Living in the "and" and hardiness are also interventions that can be very helpful. Recognizing again that sometimes people have symptoms, somatic physical symptoms, that met current medical knowledge can't fully explain or can't explain the intensity of the symptom. However, they're having it. So, how can they have their highest quality of life and be experiencing this symptom? People with chronic illnesses face this all the time. "How can I have a rich and meaningful life and cope with the symptoms of my particular condition?" Similar to living in the "and" is hardiness. And we've talked about this in other videos. Hardiness is comprised of commitment, control, and challenge. Commitment means helping people recognize all of the things in their life to which they are committed, all of the things in their life that bring it meaning and richness. And each one of those things is like a bean in a jar or a slice of a pie, however you want to think about it. Recognizing that at any one point in time, all of the pieces of your pie may not be going perfect, but focusing, or at least acknowledging, those things that are going right, that you're committed to, can be helpful. Control. What can you do to continue to experience good things and the things that are going right? And what things can you do to maybe improve the things that are going crappy right now? And challenge. You know, sometimes life just keeps throwing us curveballs or lemons or whatever your life throws at you. And yes, it sucks. We can view these things as barriers that keep us from having the life we want and just kind of sit down and go, "I give up." Or we can view them as obstacles, things that we need to either get over, around, under, or through in order to get to that quality of life that we want.
Now, take drawing from Dialectical Behavior Therapy, we have backward chaining, radical acceptance, and distress tolerance. Many people who have somatic symptoms or who have health anxiety have experienced invalidation from significant others, from healthcare providers, even from mental health providers. And therefore, they may feel very hopeless, helpless, demoralized. It's important to give them a place where they can say, "This is what I'm experiencing," and be heard and believed. We're not saying you're making it up. We recognize we may not be able to explain why you're feeling it, but we recognize you're feeling it. So, let's backward chain and see what was it or what things may have added together to trigger this flare-up, to trigger this particular, um, symptom episode that you're having. And this is something that Linehan really promotes with people who have borderline personality disorder and emotional dysregulation. However, it's very, very helpful for people who also experience what I'll call somatic dysregulation, dysregulation, helping them identify what is causing this symptom for them at this point in time. It provides an immense amount of personal control to be able to say, "Okay, I can see a couple of things that I might be able to do to prevent this in the future."
Radical acceptance is recognizing that, "Hey, I have this symptom. Maybe there is no medical explanation, or maybe there is, and I can't get rid of it for some reason, like POTS or chronic fatigue syndrome." Radically accepting, "I've got this." So, back up to living in the "and." "How can I have my highest quality of life possible and also have this condition, this symptom, this fear?" Distress tolerance is another skill that can be helpful when people start feeling a symptom. Not saying that it doesn't exist, okay? I'm not saying that it doesn't exist. What I'm saying is when they start feeling the symptom, just like we do with anxiety, sort of developing a relationship with it and saying, "All right, you're back again. Well, crap on a cracker." Once a person is able to tolerate the distress, they don't have to like it, but being able to tolerate it can prevent rushes of anxiety, floods of adrenaline that can potentially exacerbate or make, make their symptoms worse. So, distress tolerance can be helpful when they're having a flare-up. Being distress tolerant for most symptoms that people present with can be helpful because when we get stressed, it triggers that stress response system, and it can increase inflammation, it can impair sleep, it can impair GI functioning, it can cause all kinds of symptoms that can make the original symptom even worse. So, distress tolerance can be a helpful tool. Again, and I know I've said this like 16 times already, I'm going to say it again. This is not to say the person is not experiencing XYZ symptom. It's just help them recognize, "Okay, I'm experiencing this symptom. It is what it is. What can I do next?" Instead of getting angry and starting to fight with it and try to get rid of it, even though they know they can't.
Another technique that can be helpful for people, especially with health anxiety, is to schedule in worry. What I call worry checking or research time, depending on their particular diagnosis. If they have health anxiety, tabling their worry, tabling their focus on doing research to try to figure out what's going on, to a prescribed 30-minute period during the day can feel somewhat liberating because then they don't have to think about it the rest of the day. When they start worrying about it, they can jot it down in their journal or on a little piece of paper and say, "Okay, I will worry about this this evening. Right now, I'm going to focus on these other things." Checking during this time, if they are concerned about particular issues, instead of spending a whole lot of time checking things, scheduling time to do it or research. And research again can be a little dicey because people can find out not so good or not so hopeful information. I am not encouraging people to ignore acute, intense symptoms if they're having them. It is important to find that happy medium.
Environmental interventions. Turn off the TV. Turn it off. If you are hearing stuff on the TV that is triggering your health anxiety, triggering your somatic symptoms, then turn it off. This was super true during the pandemic. I almost didn't watch TV during the pandemic. And even like, um, prime time TV, especially when they started integrating the pandemic into the storyline, I quit watching it. I'm like, "When I am watching TV, I am trying to escape. I don't want this continually thrown in my face." I'll do the same thing when I'm watching a show and they insist on weaving in this theme of some character in the store, and in the show, having cancer. There was a period there, it seemed like every single show I was watching, somebody had cancer. I'm like, "This is not what I want to have to think about right now." Now, obviously, that was shortly after my mother had passed from cancer, and I'm like, "No, I don't want to have to think about that. I don't want to worry about that." So, turn off the TV or find something that, you know, is safe to watch, a comedy, a, you know, some other show where that's not going to be woven in.
Avoid. And yes, there's a term for it now, cyberchondria. Many very benign, as well as not so benign, conditions share similar symptoms like fatigue. People may go on and and start searching for what would be causing my persistent ongoing fatigue. And there is literally everything in the alphabet that can cause fatigue. But a person with health anxiety is often going to hone in on the, uh, most catastrophic explanation. "Oh my gosh, it could be this." Well, okay, how likely? Let's go back to facts, control, and probability. What is the probability out of the 37 things it could be? What is the probability it's the one catastrophic thing? There's a, a theory, I don't know what to call it, called Occam's Razor, which says basically, often the simplest explanation is the most accurate explanation. So, think, you know, if you have a backache, if you have a neck ache, if you have, um, an itch, what is the most likely cause of it? And then explore, explore that. And that can really help allay some of your anxiety. And recognize clickbait. Clickbait is there. And this is true for the media too. They'll put out these little teasers, but clickbait and television teasers are there to motivate you to go to their site to hear what they have to say so they can get advertising revenue. And it's important to recognize that. So, they are going to probably put some very generic, benign stuff out there that everybody has or everybody can relate to because they're trying to trigger your anxiety. People are more motivated when they feel like there's a problem. If they're saying, "Oh, watch this video of this, this happy dog running around," they're not going to get as many people to click on it as if they say, "Watch this video that may, um, help you identify five early warning signs of this catastrophic something something." Um, so do recognize clickbait for what it is, an organization's desire to increase their views.
And relational interventions. Limit exposure to people who dwell on their symptoms or people's disorders. Many of us know people who are very, very focused on these things, and they want to talk about these things constantly. Their friend's XYZ disorder or their XYZ symptom or the possibility of getting XYZ condition. And when you are immersed in that, when it's constantly bombarding you, just like every time you turn on the TV, it can feel inescapable, and you can feel, uh, powerless and unsafe because you're constantly being presented with the worst-case scenario. And rarely are you hearing, "Okay, well, here are all the other factors. Here are all the ways to prevent it. Here's the probability that it's going to be an issue for you." So, if you need to limit exposure to what I call "Chicken Littles," the ones, the people who want to focus on the sky falling, that is a healthy boundary to set.
Find a trusted provider, mental health, social work, medical, ideally medical, that can help you get your, get answers to your questions. Somebody who can point you in the direction of accurate, understandable health literacy information. Communicate with your significant others how they can best help you with your distress. And this goes back to some degree to those secure attachments, being responsive to you when you're in distress, reminding you of distress tolerance skills, maybe helping you by turning off that TV. "You know what? This seems to be triggering your anxiety. So, let's turn this off and go do something else." And not perseverating. Sometimes it's important to remind people in your life that, "Hey, that's too much for me to hear. I don't want to hear about whatever it is."
Validation of your perception. It's important for people to understand that your reality is your reality. They don't have to agree with it. They don't have to be experiencing it themselves, but your reality is your reality. When, um, we're at my house, my, my body temperature runs very different than everybody else in my household. And I can be like sweating to death, and they're all walking around in sweaters. Does it mean that I'm not actually hot? No, clearly I am. I'm sweating. But their perception is very different. They're like, "I don't know how you can be hot or walking around in shorts in this weather." I am. It just is the way I am is how I'm experiencing the world right now. So, validating your perception. And in our household, I validate that, "Hey, you know, I can see you're cold by the fact that you're wearing a sweater. I'm not going to be critical. You do what you need to do. I do what I need to do." And empathy. Empathy can be really helpful. Now, that doesn't mean, um, encouraging perseverating on the symptoms, but empathy about how frustrating and disempowering it must feel sometimes not to have answers. And I was just having a discussion with one of my friends the other day about how liberating it can be, even if you are diagnosed with a chronic illness, how liberating it can be to finally have a diagnosis that says, "This is what you've got." And even if there's not a treatment for it, at least you know. At least you have something to call it. At least you have, you know, an avenue that you can look for clinical trials or something if you feel like you need to do that. But it's very liberating as well because a lot of times, unfortunately, I know I've gone through this entire presentation and harped on the fact that your reality is your reality, but a lot of our loved ones and providers and other people don't understand. And if they don't have a diagnosis, it's hard for them to be willing to empathize. And the same thing is true in terms of getting reasonable accommodations at work. Unless you have a diagnosis of some sort, a lot of times it's really difficult to get reasonable accommodations. So, there can be an additional reason why somebody may be really wanting a diagnosis. "Just tell me what's wrong or tell me what I've got. That way I can get what I need to get in order to have my highest quality of life."
There is a disturbing lack of research into the interventions to help improve the quality of life of people with somatic symptom disorders and health anxiety. The majority of interventions discussed in this presentation are those that I have used in clinical practice and or used personally. One of the most important factors in addressing somatic symptom disorders and health anxiety, in my opinion, is to balance awareness of the current facts with the reality of the presenting symptoms for that person and focus on helping them do what they can to improve their quality of life.