Evidence Based Practices for Health Anxiety and Somatic Symptom Disorders

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Hey there everybody and welcome to this video  on practices for addressing health anxiety and   somatic symptoms i’m your host dr 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  
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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  
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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  
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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  
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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  
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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 a miss in the body factory you just  didn’t know what to look for before um and it’s  
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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
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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  
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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  
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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   gaiting difficulties for example that experience  things very differently what you may experience  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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  
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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 vander kulk said it  best that a lot of times trauma is remembered as  
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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  
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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 hyper vigilant to   any sort of cardiac symptoms or any sort of  related symptoms so emdr can be really helpful at  
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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  
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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  
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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  
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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
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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 back egg therefore it must be   catastrophic all right let’s look at the facts and  same thing for emotion-based reasoning looking at  
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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 heartiness are also  interventions that can be very helpful recognizing  
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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  
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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  
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heartiness 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  
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slice of a pie however you want to think about  it recognizing that 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  
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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  
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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
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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 health care providers even from  
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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  
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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 lenahan  
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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 dysregular dysregulation  helping them identify what is causing this symptom  
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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  
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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 end how can   i have my highest quality of life possible and  also have this condition this symptom this fear
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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and research again can be a little  bit 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
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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  
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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  
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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  
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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  
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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  
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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  
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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  
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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 and that  can really help allay some of your anxiety  
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and recognize click bait click bait is there  and this is true for the media too they’ll put   out these little teasers but click bait 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  
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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  
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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  
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um so do recognize click bait for what it is a  organization’s desire to increase their views and relational interventions  limit exposure to people who   dwell on their symptoms or people’s disorders
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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  
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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  
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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 one the people   who want to focus on the sky falling that is a  healthy boundary to set find a trusted provider  
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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  
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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  
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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  
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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  
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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  
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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 your cold   by the fact that you’re wearing a sweater i’m  not going to be critical you do what you need  
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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  
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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  
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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  
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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  
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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 a additional reason why somebody may  be really wanting a diagnosis just  
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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  
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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  
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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