Adrian hemmings 011110


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presentation Adrian Hemmings at Primhe Masterclass Croydon 01/11/2010

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  • The anterior cingulate cortex can be divided anatomically based on cognitive (dorsal), and emotional (ventral) components.[4] The dorsal part of the ACC is connected with the prefrontal cortex and parietal cortex as well as the motor system and the frontal eye fields[5] making it a central station for processing top-down and bottom-up stimuli and assigning appropriate control to other areas in the brain. By contrast, the ventral part of the ACC is connected with amygdala, nucleus accumbens, hypothalamus, and anterior insula, and is involved in assessing the salience of emotion and motivational information. The ACC seems to be especially involved when effort is needed to carry out a task such as in early learning and problem-solving.[6] Many studies attribute functions such as error detection, anticipation of tasks, motivation, and modulation of emotional responses to the ACC.[4][5][7]
  • The parietal lobe integrates sensory information from different modalities, particularly determining spatial sense and navigation. For example, it comprises somatosensory cortex and the dorsal stream of the visual system. This enables regions of the parietal cortex to map objects perceived visually into body coordinate positions.
    It is an integral part of the limbic system, which is involved with emotion formation and processing, learning, and memory, and is also important for executive function and respiratory control.
    The parahippocampal gyrus (Syn. hippocampal gyrus)[1] is a grey matter cortical region of the brain that surrounds the hippocampus. This region plays an important role in memory encoding and retrievaL
    DL-PFC serves as the highest cortical area responsible for motor planning, organization, and regulation. It plays an important role in the integration of sensory and mnemonic information and the regulation of intellectual function and action. It is also involved in working memory. However, DL-PFC is not exclusively responsible for the executive functions. All complex mental activity requires the additional cortical and subcortical circuits that DL-PFC is connected with
    The locus of control returns to them.
  • Adrian hemmings 011110

    1. 1. Dr Adrian Hemmings Working with Medically Unexplained Physical Symptoms (MUPS)
    2. 2. During this presentation we will examine:  The outline of a psychoeducuative group  Different classifications of MUPS  An overview of theories of aetiology  What do Neuro-imaging studies have to offer?  An overall theory of MUPs  So what ? How might this be relevant to 10 minute consultation?
    3. 3. Initial letter to patient from GP I am writing to let you know about a new course that we are about to start that will be held here at the surgery. It is called ‘Coping with Health Problems’. I know that you have had a series of health problems and I thought that this programme might be helpful to you It will be run by … who has a special interest in working with people with health problems in order to help them cope with their illness. The course consists of an initial assessment when a comprehensive history will be taken along with few simple and harmless tests. You will be told more about the course and, if you both agree that it might be useful, you will be invited to eight one-and-a-half-hour weekly group meetings. If you would like to attend simply contact….
    4. 4. Assessment  Client’s attitude to the referral and the problem  Details of the illness  Present symptoms: Type of pain, Occurrence  What makes it worse and what makes it better  Thoughts accompanying pain
    5. 5. Assessment  Coping Strategies  Consequences on life  Others response  History including previous treatments  General beliefs about the nature and meaning of the symptoms
    6. 6. Assessment  Biofeedback:EMG,GSR,Peripheral Temp  Medication Other treatments  Goals of treatment What would you like to change?  Rationale for psychological treatment (contribution of stress as a cause or effect. Test out hypothesis of psychological element)  Description of course:
    7. 7. Follow-up letter from group leader to patient Following our meeting on ….. concerning the effects of your (symptom description), enclosed is the course outline that I promised. The course will start on (date) at the … (directions) . It will start at ... in … room. Each meeting will last for one and a half hours. As I explained when we met the course is a mixture of education and self help. This means that in between each meeting an exercise will be set which will help you to monitor your progress. Before we meet I'd be grateful if you would have a think about what you would like to gain from the course - try imagining yourself in eight weeks time and think of what you would like to have changed by then. You'll be able to discuss this in more detail at our first meeting.
    8. 8. Programme Outline Week 1: General introduction , goal setting and models of health  Introduction to the notion of coping  Hot cross bun  Goals on a flip chart  Introduction to self monitoring
    9. 9. Programme Outline Week 2: What happens when we are stressed by health problems  Self monitoring review  Stress what is it?  Individual stress reactions to symptoms  Early experiences of illness
    10. 10. Programme Outline Week 3: Physical reactions to stress  Self monitoring review  Cave person exercise  Active progressive relaxation
    11. 11. Programme Outline Week 4: How do individual views of illness effect health?  Review of self monitoring  How thinking and beliefs effect feelings  NATS and BATS
    12. 12. Programme Outline  Week 5 : How does behaviour affect health: in introduction to TA  Self monitoring review  How behaviour can maintain behaviour  How we interact with other people  TA overview – Ego states, transactions and games
    13. 13. Programme Outline  Week 6: Pain and Pain management  Review of self monitoring exercises  The relative nature of pain – the gateway theory  Autogenic training
    14. 14. Programme Outline  Week 7: Putting together the pieces  Open ended group for participants to bring own agenda  So what?
    15. 15. Programme outline Week 8: Evaluation of goals and the future
    16. 16. Exercise  Thinking of your childhood how was illness managed in your family?  How did your parents respond to you/your siblings when you were ill?  How did you respond to your parents/siblings?  How has this effected your current relationship with illness?
    17. 17. The Organic Genesis of Patient Presentations (Kroenke and Manglesdorf 1993)
    18. 18. Types of MUPS Functional Symptoms Somatic presentation among patients with depression or anxiety and somatisation Hypochondriacal Worry/ Health Anxiety
    19. 19. Functional somatic syndromes Gastroenterology Irritable Bowel Syndrome, Functional dyspepsia Cardiology Atypical chest pain Neurology Common Headache, CFS Rheumatology Fibromyalgia Complex regional pain syndromes Gynaecology Chronic pelvic pain Allergology Multiple chemical sensitivity Orthopaedics Chronic back pain Dentistry Temporomandibular joint dysfunction
    20. 20. Somatisation  A transient or persistent tendency to experience and communicate psychological distress in the form of somatic symptoms and to seek medical help for them. It occupies a continuum from a simple misinterpretation of a subjective bodily sensation to an unwavering belief that a physical disease is present
    21. 21. Health Anxiety  Health anxiety OCD spectrum of ‘disorders’.  Obsessional preoccupation with the idea or the thought of currently (or will be) experiencing a physical illness.  Common health anxieties tend to centre on conditions such as cancer, HIV, AIDs etc,  May fixate on any type of illness.  Also called illness phobia/ illness anxiety or hypochondriasis.
    22. 22. The Spectrum of MUPS Duration: transient persistent No. of Sx: one multiple Insight: good none Disability: none severe
    23. 23. Theories of Aetiology  Psychobiological  High levels of physiological arousal  Alexithymia  Cognitive/Behavioural  Somatisation is rewarded  Secondary gains reinforce symptoms
    24. 24. Theories of Aetiology  Psychoanalytical  Real conflicts denied, suppressed or repressed  Anxiety displaced into physical symptoms  Sociocultural  Emotions expressed through physical symptoms  Specific “culture bound” syndromes (Koro, taijin kyofusho)
    25. 25. • EP posits a theoretical framework to understand false illness signaling • An EP approach to somatisation asks whether false illness signaling represents an innate psychological mechanism triggered by situational exigencies • Somatisation may represent a behavioural strategy that bestows survival value Theories of Aetiology Evolutionary psychology (EP)
    26. 26. Theories of Aetiology Early Trauma  High correlation with early trauma and MUPs (Roelofs and Spinhoven 2006) (Salmon et al 2003)
    27. 27. Theories of Aetiology Attachment styles  Secure – reliable care giving as children, positive view of self and comfortable depending on others  Dismissing – unresponsive caregiving, self reliant others not to be relied on  Preoccupied – inconsistent caregiving, negative view of self seen as unlovable and expecting others to view negatively preoccupied vigilant  Fearful – needs not met when young negative view of self and others approach and avoidant  High correlation with MUPS and preoccupied and fearful AS
    28. 28. Continuum of Attachment B Secure A Avoidant C Resistant/Ambivalent Up regulateDown regulate Flexible
    29. 29. Theories of Aetiology Dissociation  Higher levels of dissociative amnesia in somatising patients (Brown et al 2005)  Linked to pseudo-seizures (Prueter et al 2002)
    30. 30. Theories of Aetiology Immune system  Activation of the immune system seems to induce behaviour patterns that are similar to the illness behaviour seen in depression and somatisation (Rief and Barsky 2005).
    31. 31. Neuro-imaging studies: Irritable Bowel Syndrome  Anterior Cingulate Cortex (ACC) as having a role in the regulation of pain in IBS (Ringel et al 1999)  Uprated in chronic and downrated in acute (Peyron et al 2000)  Association with CSA and dissociation (Salmon et al 2003)
    32. 32. Neuro-imaging studies: Chronic Fatigue Syndrome  Significant positive relationships were found for cerebellar, temporal, cingulate and frontal regions and a significant negative relationship was found for the left posterior parietal cortex in CFS patients v controls (Cook et al. 2007).  Increased activation in the occipito-parietal cortex, posterior cingulate gyrus and parahippocampal gyrus, and decreased activation in dorsolateral and dorsomedial prefrontal cortices (Caseras et al. 2008).
    33. 33. Neuro-imaging studies: Fybromyalgia  Low stimulus pressure associated with 13 regions of brain activated compared with only one in controls. (Gracely et al. 2002).  Greater activation in contralateral insular cortex in both non painful warm and pain stimulus (Cook et al. 2004).
    34. 34. Neuro-imaging studies: Expectation (Nocebo effect) (Rief & Broadbent 2007)  Expectation of symptoms leads to the activation of brain areas corresponding to symptom perception  Distraction from symptoms reduces brain activity in perception areas
    35. 35. The perception-filter model of somatisation (modified from Rief and Barsky 2005 in Rief and Broadbent 2007)
    36. 36. The Triune Brain
    37. 37. The role of emotion  Emotion associated with profound physiological changes  Often unconscious as bypasses frontal cortex  Often clients have limited language for emotions  Affect avoidance (having feelings, expressing feelings and confusion about feelings)
    38. 38. Common Safety Behaviours  Checking pulse  Hypervigilence of ‘symptoms’  Reducing activity  Symptom browsing on internet  Seeking reassurance from GP  Palpating parts of the body  Reducing food intake  Slowing down/speeding up
    39. 39. Potential interventions: Behavioural  Reducing “boom and bust” mode  Reducing symptom-focusing behaviours  Anxiety management skills  Re-education re somatising precipitators and perpetuators and treatment programme  Graded exposure (using exposure hierachy)  Identifying and reducing safety behaviours
    40. 40. Potential interventions: physiological  Relaxation exercises (diaphragmatic breathing, APR autogenics)  Graded exercise  Moving specific symptom focused parts of body  Diet  Substance use
    41. 41. Potential interventions: Emotional  Identifying feelings  Developing language for feeling  Reducing feeling avoidance  Having conversation with symptom
    42. 42. Development of ‘illness behaviour’  Often related to attachment styles  When GP and patient are together – two attachment styles and illness behaviours are interacting
    43. 43. Attunement enables affect-regulation Like the securely attached mother, the empathic psychobiologically attuned clinician’s regulation of the patient’s affective-arousal states is critical to transforming the patient’s insecure nonconscious internal working model that encodes strategies of affect regulation Schore 2007 12
    44. 44. • B.. Background -What is happening in your life at the moment? • A.. Affect- How do you feel about that? • T.. Trouble -What is the most troubling part of.. • H..Handling - How are you managing to deal with that? • E..Empathy - That must be difficult for you. The BATHE technique (Stuart and Leiberman 2002)
    45. 45. Dos and Don’ts: DO  Talk about coping  Use one designated GP  Schedule frequent, brief, regular visits not contingent on new complaints.  Allow "sick role;" focus on function rather than symptoms.  Explore psychosocial issues.  Prescribe benign treatments and enjoyment time.
    46. 46. Dos and Don’ts: DON’T  Suggest "It's all in your head.“  Pursue invasive diagnostic tests, medications or surgical interventions without good indications.  Refer excessively to specialists.  Focus on the symptoms themselves
    47. 47. MUPS Further Reading Bass, C Ed (1990). Somatisation: physical symptoms and psychological illness. Blackwell Oxford. Donohugue, P. & Seigel ,M. (1997). Sick and Tired of Feeling Sick and Tired, Living with invisible chronic illness and Sage Mayou, R., Bass,C. & Sharpe, M. (1995). Treatment of functional somatic symptoms. Oxford University Press. Oxford. Gill, D. (2007). Hughes’ Outline of Modern Psychiatry. Wiley & Sons (see Chapter 9 on Physical Symptoms and Psychiatric Disorders) Sanders, D., (1996) ofor Psychosomatic Problems. London: Sage Publicationst Woolfolk, R. & Allen, L. (2007).Treating Somatization. A Cognitive Behavioral Approach Guildford Press Johnson,S. (2008). Medically Unexplained Illness. Gender and Biopsychosocial Implications. APA Journals: Journal of Psychosomatic Research, Psychosomatics