1. Talk therapies and the body in working with the elderly somatosensory methods and balance training as adjuvants in treating elderly with anxiety and depressions Münsterlingen 11.5.2006 Pirjo Juhela

2. Why balance training? Are these specifically problems with geropsychiatric patients? Why the interest in the body?

3. Not really, our main problems are of course: different psychiatric symptoms and problems Depression Anxiety Paranoid symptoms Personality disorders etc.

4. - often the problem is social isolation and avoidant behavior. But....... - often our patients have somatic complaints (with or without somatic conditions) Regardless of the diagnosis.

5. Patients complain: ”Oh, I would love to do all kinds of things if I were healthy again. But since I am not feeling well I can't. ” ”I can’t do anything you understand, when I feel so misarable, shaky and dizzy. If I just could get the right medication I would be able to go shopping and visit friends.” ”Yes I feel lonely, and it would be nice to have someone visit me. But my daughter is so tired of hearing me complain. And I don’t care for strangers, I don’t want to participate in any groups or activities.”

6. Our physiotherapist and I searched for a physical training method in addition to psychotherapeutic approach and relaxation methods which would be: - Easy to apply - Could be done in a group - ”normal” and acceptable by our clients (over the age of 65) And which would help break the vicious circle of social isolation and avoidant behavior

7. This same type of patients are also found in general practice: - complaining of somatic symptoms - extensive testing, imaging is done - usually results are minimal - patient is left unsatisfied or - patient has been diagnosed with a somatic condition, but is unable to cope with the situation

8. Hypochondriasis Somatization syndrome Somatoform disorders Panic attacks Anxiety Depression ”Health phobias” ”Somatic distress syndrome” ””Health distress””

9. Typical problems with ’health distress” patients are: Worry / preoccupation = distress (fear?) over bodily sensations / somatic symptoms heightened vigilance for bodily sensations Catastrophizing Frequent but unsatisfactory visits to health services And the cardinal symptom often is social isolation and avoidant behavior

10. What is the common denominator? Is it fear ?

11. reactions of the autonomic nervuos system emotionally oriented behaviour stress hormones amygdala thalamus cortex memory centers (hippocampus, rhinal cortex) Juhela 2002

12. Development of THREAT Vigilance Arousal - action tendency sympathetic reaction: fight or flight Juhela/Siivola 2002 parasympathetic reaction (dorsal vagal): freeze or

13. What is experienced in hyperarousal? - focusing on the threat, selective perception - bodily reactions (hyperventilation, choking, racing and pounding heart, throbbing, pulsating sensation in the ears, sweating, dizzyness etc) - need to act out - run, seek help - feeling of fear, terror - cognitions of catastrophe

14. Balance training 1. instability training which challenges balance 2. stability training which corrects balance Movements that are common everyday movements. And failures in balance which are common in falls.

15.  Balance training - daring to do something  Psychotherapeutic approach - verbalization and conceptualization, reflection  Body awareness, relaxation – getting to know your body * Learning to trust one’s body Our treatment repertoire

16. The goals of our treatment in general are:  Autonomy – maximizing and maintaining  Loneliness – minimizing negative ideation about alternative social contacts  Subjective well-being – increasing possibilities

17. Does balance training add important elements into our repertoire??  Improves physical mobility, improves physical fitness  Increases ’discretely’ social contacts: - it is activity in a group, but performance individually - it is fun and playful  Enhances daring, encourages to try more and diminishes avoidant behaviour  Strong sensorimotor experience combined with emotion of succeeding  Repetive, can become a custom, pattern, organize the day * Improves mood

18. With special thanks to Pirkko Makkonen and Kirsti Udd