Recently, a patient in my medical psychology practice started our first meeting saying, "Hey Doc, I don't know why I'm here, I'm not crazy!" This is not unusual, and although most medical patients are unwilling to state their concern about being asked to see a psychologist this boldly, that's what many of them are thinking. Another patient told me that she was actually insulted when her dermatologist recommended that she come see me.
Now it’s quite understandable why many medical patients would be put off by the idea of seeing a psychologist. Historically, patients were referred to clinical psychologists (and psychiatrists) because of emotional/mental health issues. This is still true for the majority of those who are being treated by these specialists. Increasingly however, in the era of integrated care and behavioral health, this is changing.
Earlier in my career, well before these new models began to evolve, I, as a member of the Division of Internal Medicine at Scripps Clinic, in La Jolla, California, began seeing patients in consultation when their very significant physical symptoms were not supported by the medical evidence. My physician colleagues learned how to refer these patients without their feeling abandoned or diminished, and I learned to work with them in a way that they felt respected and understood.
In this blog post, I'm going to be talking about the relationship between emotional factors and certain types of medical problems/physical symptoms ("Managing Anxiety in the Medically Ill" — http://www.psychiatrictimes.com/special-reports/managing-anxiety-medical...)
Let me be clear: I am not a physician, and when I work with medical patients, they continue seeing the physician who referred them. In those instances, where a patient I'm seeing wants to address medical problems or physical symptoms, I refer that patient to a physician for a thorough medical evaluation before embarking on any type of behavioral health program. In my next two blogs, I will be discussing the interaction between the physical and psychological, and the mind-body relationship, with a specific focus on the following medical problems:
In this blog:
Subsequently, I’ll focus on:
One of my earliest experiences was with a gentleman who had been referred to me after his stomach pains had been thoroughly investigated, and his physicians could not find any medical problems that would explain his distress. He came into my office, sat down, looked at me somewhat quizzically and said, “Why am I talking to a psychologist? It’s my stomach that hurts." I talked about the relationship between emotions and physical symptoms, and then said, "Look, you're going to get charged for this visit anyway, so why don’t we spend a few minutes talking about what's going on — and, by the way, while we’re talking, would you raise your shoulders and clench your fists?" He looked at me curiously, but went along with my request.
I took a brief history and reviewed his medical records but every time his shoulders dropped, I reminded him to raise his shoulders and clench his fists. A few minutes later, I asked how he was feeling, and he said that his shoulders hurt, and so did his back.
I told him that many people tense their shoulders without being aware of it, and often develop shoulder and back pains. When seen by rheumatologists or orthopedists, they were told there was no medical evidence to explain their pain. At that moment he looked at me and asked, "Can that happen to your stomach as well?" After I nodded affirmatively, he sat up, and began to discuss his work problems, the pressures he was under at home, and the circumstances that led to him experiencing gastric distress. A combination of visits with me, a consultation with a dietician who guided him on avoiding foods that trigger gastric reflux, and teaching him some relaxation techniques, led to a significant decrease in his symptomatology.
What are some of the medical conditions that might lead to a referral to a medical psychologist?
Diabetes/Type 1 or Type 2 — as many of you know, diabetes is a medical condition that results in elevated blood glucose levels and is treated by a combination of medications and lifestyle changes.
Type 1 diabetes is an autoimmune disease which destroys the pancreas, which then cannot produce insulin, requiring patients to go on a regimen of monitoring their glucose levels, taking insulin 1, and lifestyle changes. Type 2 diabetes, which is multi-factorial, much more prevalent, and is associated with genetic factors, obesity, aging, poor dietary habits, and decreased physical activity. Type 2 diabetes is often treated by oral medications, or insulin and lifestyle changes.
What role do medical psychologists have in the treatment of diabetes? A lot. In type 2 diabetes, weight reduction, increased exercise, and dietary changes can significantly affect, and in some cases reverse, type 2 diabetes. In type 1 diabetes, in addition to monitoring blood glucose levels and the use of insulin, dietary changes and increased activity are needed to achieve control and a lower A1C, an important measure of long-term blood glucose level. A referral to a dietitian is always part of the treatment protocol, since they can tell the patient what to eat. Referral to a medical psychologist is equally as important in order to learn how to make the changes that are necessary to keep blood glucose levels under control.
There are many psychological problems that co-occur with diabetes, including depression, anxiety, eating disorders and diabetes distress (http://www.apa.org/monitor/2017/06/cover-diabetes.aspx). A quarter of people with diabetes experience depression at some point in their lifetimes (American Psychologist, 2016) and adults with diabetes are 20 percent more likely to have anxiety disorder. Psychological interventions can treat those conditions, improve behaviors such as medical adherence, delay the disease’s onset and even prevent diabetes from developing in the first place (http://www.apa.org/monitor/2017/06/cover-diabetes.aspx).
As everyone knows, long-term management of food intake and increased exercise are difficult to sustain. Psychologists are often a critical part of the intervention strategy for diabetic patients to help them implement lifestyle changes.
Irritable Bowel Syndrome/Crohn's Disease — the aforementioned problems are both serious and distressing to those who are suffering from them. Patients are most often cared for by gastroenterologists. A combination of diagnostic tests, dietary changes, and medications are part of the treatment regimen. In a recent review article entitled “Psychological Issues in Inflammatory Bowel Disease,” the authors described how stressful experiences adversely affect the course of IBS (https://www.hindawi.com/journals/grp/2012/106502/).
In addition, the fact that symptoms are often unpredictable, chronic, and often affect the patient in all aspects of their life, suggest that one of the consequences of these diseases is the development of associated psychological problems. For example, those patients will often experience both anxiety and depression that significantly affect their quality of life. In this case, the psychologist’s role may be twofold: helping the patient manage stress which affects their gastrointestinal problems; and helping patients manage the anxiety and depression that often develop as a result of these medical problems.
At this point the research evidence suggests that stress management, relaxation training, and certain forms of cognitive behavioral therapy may help patients both deal effectively with their underlying disease, and the consequences of having this type of medical problem.
Allergic Diseases — Patients may have allergic diseases including asthma to reactions to foods, odors, smoke, and insect stings. Untreated, reactions to a specific allergen can lead to anaphylactic shock and even death. So you might ask, why would any of these patients be referred to a psychologist? Because stress can significantly contribute to the intensity of an allergic reaction. Sometimes a patient's false beliefs about their allergies lead them to have a restricted quality of life, and a fearful response to an allergic reaction exacerbates the intensity of their symptoms. According to an article in Immunology and Allergy Clinics of North America, “Stress and Allergic Diseases,” excessive psychological stress and allergic disorders are linked with many allergic conditions being considered psychosomatic disorders which have worsened outcomes for patients with high levels of stress.
Allergies are real, and the medications to treat them are many and varied. However, the fear of an allergic reaction can dramatically increase how the body responds, and patients may generalize to other non-allergic agents. A physician colleague conducts blinded challenges with patients who believe that they are allergic to certain substances. In a controlled environment, the patient is exposed to an array of odors, including those that the patient believes he or she is allergic to. In many instances, the patient's belief about their sensitivity to a certain type of allergen is not supported by actually being exposed to it. Let me give you three brief examples of what I'm talking about.
A patient with an allergic reaction to cigarette smoke became so fearful that he began to limit the number of social and professional activities in which he was willing to participate. With the help of an expert in teaching him swallowing techniques, and my helping him reduce his panic reactions, he made significant progress and is now living a full and active life. He still has a cigarette smoke allergy but it does not limit his range of activities.
Another time, I was referred a woman who believed that she was asthmatic for more than 10 years. Not only was she taking high doses of medication, but she was also fearful of walking more than 20 or 30 feet away from her car. Any shortness of breath panicked her, and she would use an inhaler. After some discussion and testing her capacity to walk without becoming fatigued, she was reevaluated by her allergist, found to not have asthma, and over a period of time, discontinued all use of medication and returned to a normal life.
One final patient was a man who believed he had allergies to a number of foods and odors leading to multiple visits to numerous physicians. He was evaluated and found to have only a mild allergic reaction to two food items. He subsequently learned a series of cognitive behavioral techniques and has been able to return to having a full social life and career path.
So what are the take aways for the readers of this blog? First, there is often an interplay between medical illness, physical symptoms, and psychological issues. Helping patients understand this often leads to a better quality of life, fewer physician visits, and overall increased satisfaction.