Integrative MedicineMind – Body Connections

PLC OR RNNovember 26, 2010

Jeffrey P Schaefer MSc MD FRCPC FACP

website

dr.schaeferville.com

Conflicts of Interest

• none

Objectives

• Session participants will learn that:– the current paradigm is insufficient– a psychobiological framework is useful– there is more to stress than stress– we can reduce the effects of stress

And above all...

Relax Responsibly

Case

• 46 year old educator

total body pain and fatigue x 5 years

assessed by GIM, Neurology, Gastroenterology

investigations normal

Problem List

– daily occipitofrontal headache

– chest pain, episodic, at work

– abdominal pain

– fatigue

– poor concentration & dizziness

– work issues

What’s your diagnosis?

Diagnosis: ______________________

Hopefully, uptodate.comhas something…

Diagnosis Menu

• What’s your diagnosis / diagnoses?– Chronic Fatigue Syndrome / Idiopathic Chronic Fatigue– Fibromyalgia– Tension Headache– Irritable Bowel Syndrome– Multiple Chemical Sensitivity Syndrome– Interstitial Cystitis– Hematuria Loin-pain Syndrome– Depression and Anxiety– Conversion Disorder– Somatization

This is a problem!

One condition or many?

Chronic Fatigue SyndromeFibromyalgia

Irritable Bowel SyndromeMultiple Chem Sensitivity Syndrome

Sick Building SyndromeHypoglycemia

Gulf War Syndrome

Undocumented LabelsHeadache Syndromes

AsthmaPainful Conditions

Various

Bodily Distress Disorder

• Do functional symptoms cluster in a way that support multiple conditions?– Cross sectional survey of patients with

functional symptoms– Screened 2,300 patients 978 were judged

functional

Median Number of SymptomsMen & Women 5

“Bodily Distress Disorder”Fink et al. Psychosom Med

2007

Chest Pain GroupGI Symptoms Group

Musculoskeletal Group

< 3% of patients had symptomsconfined to their predominant group

3 group model explained 36% of the variance

• associated with anxiety • preoccupied with symptoms• preoccupied with illness• low threshold to request consultation• difficult / impossible to reassure

Multiplicity of diagnostic labels is an artifact of

medical specialization.

Psychobiology‘the mind-body connection’

Psychobiological Framework

NO MATTER WHAT ELSE

IS GOING ON!

Talk about Stress...

Acute Stress Response

Fight, Fright, Flight, Frolic Response

Hans Selye (1907-1982)

General Adaptation Response

– Alarm– Failure to adapt– Exhaustion

Recipe for Stress• Novelty

• Unpredictability

• Threat to ego

• Loss of control

Absolute Stress

Relative Stress

Interpretation of the world

stress4 parts

Stress Stimuli

Experience the stimuli

Physiological Response(Body Chemistry Response)

• Hormones

• Neurochemistry

• Immunochemistry

• Energy Metabolism

Experience of thePhysiological Response

Stress Hormones

• Corticosteroids– Cortisol

• Catecholamines– Adrenaline (Epinephrine)– Nor-adrenaline (Nor-epinephrine)

Cortisol

Cortisol Regulation

• Brain– emotion, pain,

memory

• Hypothalamus– autonomic function

• Pituitary– stimulating hormone

• Adrenal Gland– cortex

Left: Areas of the brain that ‘light-up’ during strong emotion.(happy, sad, disgust)

These correlate to Vagus Nerve mediated Heart Rate Variability.

Mind Body Connection: neural and hormonal

Immediate Effects of Cortisol

• Response to Absolute Stress– increase vigilance– respond to emotion don’t think– raise blood sugar– increase psychomotor activity– obtain food

Prolonged Effects of Cortisol• increase appetite• increase blood sugar• increase fat stores• redistribute fat• salt retention BP +• reduce acid barrier• menstrual cycle problems• male impotence

• bone calcium loss• muscle wasting• insomnia• irritability• depressed mood• memory loss*• immune dysfunction

Pituitary Tumor & Cushing’s Disease

Disease States

• Moon facies

Catecholamines• Adrenaline (Epinephrine)

• Nor-adrenaline (Nor-epinephrine)

Effects of Catecholamines

• increase heart rate• increase cardiac force of contraction• narrows blood vessels• increase blood pressure• dilates pupils• dilates airways• reduces flow of blood to GI tract• reduces saliva production• increases platelet adherence ‘stickiness’• increases sweat production

Acute Stress and MI• Mortality in Widowers

– 40% increase within 6 mo of spouses death

• Myocardial Infarction Onset Study– incidence of AMI 14X among recent widows /

widowers

Self-report AMI Trigger412 reports from 849 AMI

Chronic Stress & Immune Dysfunction

• Influenza Vaccination

• Difference between stressed and non-stressed group.

– Lancet 1999

Punch Biopsies• 13 Care Givers vs 13 Controls• Complete wound healing

– Caregivers 48.7 vs 39.3 days (9 day diff)– Age and income did not effect outcome

So now what?

www.calgaryhealthregion.ca/cmbm/

CMBM Approach

• symptoms are psychobiological – real & explainable & diagnosable

• management– cognitive reassurance is insufficient– uncovering a psychological trauma is insufficient– psychotropic medications are counterproductive– success lays in self-regulation

Self-regulation• Somatic Awareness

– experiential– link emotional state with body symptoms– effortless breathing

• Medication Reduction / Elimination

– group therapy– education– heartmath– guided imagery

Don’t forget to breathe…

Breathing... by any other name...

• ‘naked’ woman

• Living with COPD – diaphragmatic breathing

• Living with COPD – relaxing w diaphrag btng

Humor....

• Laughter Therapy

Dr. Sonia Lupien

• Work on yourself– improve problem solving– learn to appreciate others– learn to appreciate yourself– practice goodwill

• Work on your Body– breathe– move– power of laughter and smiles

Goodwill

• Mother Theresa Effect

– improved self-esteem

• 290 patients 2004 - 2009

Objectives

• Session participants will learn that:– the current paradigm is insufficient– a psychobiological framework fits observations– there is more to stress than stress– we can reduce the effects of stress