2. Functional Symptoms and Mindfulness Dr Gina Johnson Kingfisher Practice, Luton 25 November 2014 gina.johnson@nhs.net

3. Sorrow which finds no vent in tears may make other organs weep Sir Henry Maudsley (c.1907)

4. Definitions Medically unexplained symptoms (MUS) are ‘persistent bodily complaints for which adequate examination does not reveal sufficient explanatory structural or other specified pathology’. RCPsych 2011

5. Somatic symptom disorder Somatic symptoms lasting at least six months that are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings and behaviours regarding those symptoms American Psychiatric Association 2013

6. Functional somatic syndromes irritable bowel syndrome (gastroenterology) chronic pelvic pain (gynaecology) fibromyalgia (rheumatology) non-cardiac chest pain (cardiology) tension headache (neurology) hyperventilation syndrome (respiratory medicine) Chronic regional pain syndrome (neurology) Wessely 1999, Fukushima 2014

7. Burton 2003

8. Prevalence MUS: 20 -50% of all consultations in primary care Previously “fat notes”, now “slow loaders” Up to 50% of all general hospital out-patients MUS + Functional Somatic Syndromes: Up to 70% of all general hospital out-patients RCPsych 2011

9. Cost to Health Services 10% of total NHS expenditure in 2010 £14 billion in cost of sickness absence The cost of hospital investigation was twice as high as those whose symptoms were explained by organic disease MUS rarely converted to a pathological diagnosis. Severe somatisation: 4 -10% end with an organic explanation for their symptoms Bermingham 2010 RCPsych 2011

10. Conventional medical model History Examination Tests Diagnosis Treatment

11. 1. Patient seeks help to relieve symptoms 2. Patient has no understanding of causes after biomedical consultation - no pathology 3. Patient increasingly anxious with escalating symptoms 4. Increased bodily sensations with body to mind cascade 5. Increasing focus on symptoms with pressure to re- investigate or refer to secondary care

13. Pointers to functional symptoms Multiple symptoms, often in different organ systems Chronic symptoms that are vague or that exceed objective findings History of extensive diagnostic testing Rejection of previous doctors Your own emotional response to the patient: – A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person – A sense of being overwhelmed by a patient who has had numerous evaluations by other doctors

14. Warning signs Localising/focal neurological signs Signs of inflammatory arthritis or connective tissue disease Signs of cardiorespiratory disease Significant weight loss Sleep apnoea Significant lymphadenopathy

15. Investigations to consider FBC LFTs RFTs Serum ferritin (in children only) ESR or CRP Random blood glucose TFTs Anti-TTG Anti-nuclear antibodies and rheumatoid factor Creatine kinase Urinalysis for protein and blood

16. Alternative model Symptoms are a manifestation of distress which the patient may not recognise or be able to verbalise. Concern about unexplained symptoms causes escalation

17. Performance Hyper Arousal Healthy tension 20% reserve Breakdown Fatigue Exhaustion Intended Ill health Actual P A performance-arousal curve P represents the catastrophic cliff-edge of breakdown

18. Useful explanatory models Body distress Physiological hyperarousal - > burnout. The body becomes “stuck” in an inappropriate state Hyperventilation Muscle tension

19. Over-Pressured? Predicament: Negative automatic thinking Reactive emotions Damaging behaviours Physiological symptoms Unhelpful lifestyle responses Limbic System stuck in Fight, Flight, Freeze or Fold reducing connection to Wise Observer Negative Impact : Autonomic nervous system Hormonal imbalance Molecules of emotion Immune system

20. Autonomic nervous system Regulates most of the body’s involuntary functions Influenced by: Balance between the sympathetic and parasympathetic system Hormones through the HPA axis Immune system, influencing TH1/TH2 balance Neuropeptides – molecules of emotion specific for emotional states – hostility – sadness – joy etc

21. Physiological Arousal/Overbreathing Musculoskeletal: Cramps/stiffness; fatigue; reduced anaerobic threshold; muscle twitches; painful joints; jaw clenching Mental: Anxiety/Panic/Defence Neurological: Dizziness; feelings of unreality; visual disturbance; headaches; ‘pins and needles’ in face or extremities; increased sensitivity to stimulation (e.g. light, noise and pressure) Cardiovascular: Palpitations; missed beats; angina like pains. Gastrointestinal: Nausea; bloating; ‘shaking inside’; dry throat; sensations of restricted swallowing Respiratory: Irritable cough; tight chest; sighing or yawning; breathlessness/lack of air

22. The Nijmegen questionnaire Shortness of breath Accelerated or deepened breathing Unable to breathe deeply Palpitations Tightness around the mouth Feeling tense Stiffness of fingers or arms Chest pain Constricted chest Bloated abdomen sensation Tingling fingers Cold hands or feet Blurred vision Dizzy spells Confusion or feelings of losing touch with environment Score: 0 Never 1 Rarely 2 Sometimes 3 Often 4 Very often Scores of more than 23 are consistent with hyperventilation Sensitivity 91% Specificity 95%

23. Reduction of blood carbon dioxide by hyperventilation causes cerebral vasoconstriction and limits oxygen transfer to the brain, causing “brain fog” and dizziness Overbreathing -> brain hypoxia Ito 2000

25. Panic attacks that seem to strike out-of-the-blue are not without warning after all, says psychologist Alicia Meuret, Southern Methodist University, Dallas. A new study found significant physiological breath instability one hour before patients reported feeling a panic attack, Meuret says. The findings suggest potentially new treatments for panic, and re-examination of other "unexpected" medical problems, including seizures, strokes and manic episodes Meuret 2009 Panic attacks are not without warning

26. Muscular pain Slumped or chin-jutting posture makes muscles strain against gravity Sympathetic overdrive keeps muscles tense Minor strains create myofascial trigger points Protective spasm may make pain worse

27. Research Investigations End tidal CO 2 Cortisol Respiratory sinus arrhythmia (heart rate variability) – like a CTG for adults

28. Heart rate variability Responds to the respiratory cycle High variability indicates decreased vagal tone and high resilience Predicts mortality after myocardial infarction and in heart failure, hypertension, and diabetes Biofeedback devices (emwave or stresseraser) See www.heartmath.comwww.heartmath.com Lombardi, 2000

29. How can we help these people? The “easy” option – more investigations, symptomatic treatment, review appointments ? OR…….

30. Suggested strategies Give them time Stop trying to fix them! Acknowledge their suffering Reflect their emotional response Broaden the agenda Explain your expectation about tests or referrals BEFORE making them Reframe the problem

31. Give a plausible physiological explanation, not just “stress”. Refer to neurosymptoms.org Clarify any disagreements Involve the family Negotiate a way forward, helping them to manage symptoms and improve function Provide continuity and follow up Treatment strategies – mindfulness, increased vagal tone, breathwork, CBT, motivational interviewing… Edwards 2010, Rosendal 2005, Aiarzaguena 2007

33. The “new” sciences Neuroplasticity Epigenetics

34. Re-Wiring the brain Stress response Stress hormones released

35. Re-wiring the brain New response Endorphins released

36. Quietening the stress response In the face of sudden threats and challenges we have six mindful seconds to create a quietening response using our breath. Recognise mind/body signals of threat Step back; change body posture/position Slow the out breath while being feeling anchored to the ground and your core strength Bring into the body/mind a sense of self appreciation with the in breath Let go of negative responses with the out breath

37. How to increase your vagal tone Eat Suck your thumb or a dummy Touch your lips (comfort blanket?) Play the flute Slow down your respiration Prolong your outbreath Progressive muscular relaxation

39. Motivational Interviewing Helping people who are “stuck” e.g. addiction Recognising ambivalence and pros/cons of change Respect the patient’s experience Reflect their feelings in statements (which may be over-exaggerated for effect) “it seems that part of you feels that….”

40. Motivational Interviewing Look for the “change talk” People believe arguments much more if they came out of their own mouths Try to change how they feel, not what they know Summarise with the more helpful option last Miller WR and Rollnick S. Motivational Interviewing – Helping People Change

41. https://www.youtube.com/watch?v=- 4EDhdAHrOg

43. Mindfulness Mindfulness is the buzz-word of the moment with good reason. It works! It is used in business by the likes of Google, Virgin, Price-Waterhouse Coopers, London Transport and it is increasingly used within the NHS to assist individuals with a wide range of illnesses and conditions.

44. Mindfulness based CBT An invitation to be aware, curious and non- judgemental Examining how people run patterns which can result in the continuation of symptoms Becoming aware of these patterns Showing people how to change them

45. Mindfulness Being conscious or aware of something; a state achieved by focusing one's awareness on the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations.

46. Brains on wheels

47. Curious observers When we do things in a mindful way, we are aware of what we are doing. We become observers: we notice how we feel; how we are acting and reacting; the things around us; how we engage with them. We spend time in the moment, rather than in our racing minds; we don’t judge – we simply become aware. When we do this we experience life more fully and more calmly.

48. The ABCs of mindfulness: A A stands for Awareness and Acceptance We become more and more aware of what we are doing and how we are feeling, behaving, acting and reacting, and we acknowledge and accept it.

49. B B stands for Being Present Being in the moment, not in our heads and our thoughts, not analysing the past and imagining the future, not planning, rushing, striving…just being. From here we can observe what is happening for us moment to moment, we can be aware and accepting.

50. Cs C stands for Compassion and Curiosity We are kind, compassionate and curious towards ourselves and what we notice. We are not judging ourselves, we are just observing, being aware, and accepting what we find. We treat ourselves as we would treat others, with kindness and compassion.

51. Feelings, those that feel good, and those that feel less than good, are all OK. This is not about battling and fighting with ourselves, it is simply about recognising what is going on for us and accepting what is, right now, in this moment…

52. http://www.ted.com/talks/andy_puddicombe _all_it_takes_is_10_mindful_minutes?languag e=en

53. Routes to Mindfulness Being in the moment T’ai Chi Yoga Meditation Some forms of prayer Raisin awareness

54. www.headspace.com