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JOURNAL OF THE ACADEMY OF MEDICAL PSYCHOLOGY
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VOLUME 1, ISSUE 2
November 1, 2010
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November 2010 • Volume 1, Issue 2
Archives of Medical Psychology
Table of Contents Issue II
Table of Contents .............................................................................................................iii
The Contribution of Case Studies to Medical Psychology Research ......................28
Mark Muse
Cost Savings of Treatment of Medically Unexplained Symptoms ............................34
Using Intensive Short-term Dynamic Psychotherapy (ISTDP)
by a Hospital Emergency Department
Allan Abbass, Samuel Campbell, S. Gerald Hann
Irmingard Lenzer, Robert Tarzwell, and David Maxwell
Implementing an Emotion-Focused Consultation Service to Examine ....................44
Medically Unexplained Symptoms in the Emergency Department
Allan Abbass, Robert Tarzwell, S Gerald Hann
Irmingard Lenzer, Samuel Campbell, and David Maxwell
Principles of Alcohol Detoxification for Collaboration Among ...................................52
Psychologists and Other Medical Professionals
Jerry Morris
Archives Author and Reader Information
Author and reader information about the Archives of Medical Psychology, the Academy of
Medical Psychology (AMP) and the American Board of Medical Psychology (ABMP) appear
at the beginning of Issue I of Volume I. The Masthead, Table of Contents of Issue I, Editorial
Statement, Definition of Medical Psychology, Introduction to the Archives of Medical and
Editorial Policy are listed in the section on pages with roman numerals.
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The Contribution of Case Studies to Medical Psychology Research
Mark Muse
Muse Psychological Associates
Abstract
Case studies are oftentimes conceded a minor place in scientific research as preliminary
investigations, to be followed up with controlled, randomized studies. The present paper argues that case study observations not only provide the initial data base upon which eventual inductive processes lead to theories which are subsequently tested through the
deductive-experimentation method but, within the field of medical psychology, case studies
are the preferred procedure for continuing to identify specific effects of pharmacologic
agents after their initial approval in Phase III of the FDA protocol. In this respect, case studies are the gold standard for in-depth clinical studies in real-life circumstances and, as
such, they are in need of greater promotion than what is received in current psychopharmacology research literature.
Introduction
The value of case studies in the scientific study of human behavior would not appear to
need justification were it not for the current emphasis on randomized clinical trials in the
drug industry. While the value of reputable clinical trials is indisputable, their strength lies
in indicating how a group of persons reacts to a particular treatment; but, they tell us little
about how a particular individual responds. It is, on the other hand, the individual who is
being treated in clinical medical psychology. This fact has been largely respected within the
field of psychopathology, where the accumulation of empirical observations through case
studies has formed the backbone of diagnostic/nosologic systems, augmented, to be sure,
by secondary epidemiological studies. Within pharmacotherapy, however, the relative neglect of case studies in favor of clinical trials threatens to skew results and conclusions
drawn from such findings, steering clinical practice more toward formula application of predetermined protocol as a reflection of formatted research designs yielding formalized group
conceptualizations of conditions which fail to sufficiently recognize that group reactions are
only statistical descriptions. A more relevant clinical reality is anchored in the individual experience of each person. Indeed, front-line psychology providers appear to derive more
usefulness from research reports that include case studies along with statistically derived
conclusions on the effectiveness of psychotherapy and pharmacotherapy (1).
Within the broader field of clinical psychology, the value of the case study as a means to
empirical investigation--by compiling data through meticulous, systematic observations-has fluctuated over the years. In the 1970’s and 1980’s the push in psychology in general
Correspondence address: Mark Muse, Muse Psychological Associates, 604 Crocus Drive,
Rockville, MD 20850. Email: [email protected].
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was to establish the “science” side of the discipline through conducting controlled experiments, thus relegating the case study to an historical past. The emphasis in the 80s to
demonstrate one school of psychotherapy to be more effective than another led to endless
studies comparing different approaches within experimental designs. Decades later it is
no surprise that the result of those experiments was equivocal, ambiguous and unreliable (2).
Why? Were not the most sophisticated experimental designs applied and had not the results been analyzed with the most advanced statistical methods? The studies conducted
were serious and as rigorous as the topic allowed for but the effort to discover the superiority of one therapy over another was destined to fail because the great attraction of “doing
science” in the field of mental health blinded the researchers to the limitations, and ultimately inadequacy, of their approach. Before a theory can be tested with the experimental
method, the question must be adequately understood and properly posed; otherwise, the
answer is garble. It is not enough to define an operational question if that definition is inherently ambiguous. What good does it do to operationally define “recovery from depression” as a reduction on the Hamilton scale when the very meaning of depression has
escaped us? What are we, indeed, measuring when comparing one psychotherapy procedure to another if we cannot agree upon what the essence of psychotherapy is?
To jump to double-blind randomized studies when we have yet to understand the material
being studied is to misspend effort that might be best directed toward clarifying the basis
of our assumptions, before putting them to the test. In effect, we have precipitated ourselves into applying the experimental model in a field where we are not sure what we are
looking for because we have not taken the time in our observations to obtain the most
basic element in science, which is the observation of facts, as close as possible to the environment in which they naturally occur, and the accumulation and categorization of such
observations. If we, as psychologists, go off half-cocked, determined to identify the effectiveness of one medication against another in the treatment of X condition, we will do no
better than the biomedical establishment has done with their woefully inadequate conceptualization of what a condition is and what constitutes a treatment. A new paradigm (3) can
only be formed by deconstructing the traditional conceptualization of psychopharmacology
within the reductionistic orientation of the medical model. Such a paradigm, perhaps based
more upon an anthropological model rather than the medical model, is best discovered by
suspending judgment, and by getting as close to the observable fact as possible through
delving into hands-on case studies.
The past futility of applying experimental design to the study of the efficacy of various psychotherapeutic approaches should guide us when determining where the initial emphasis
of medical psychology should be placed in its scientific investigation. In the case of psychotherapy, psychology embarked, obstinately, upon the discovery of which “school” of
psychotherapy was more effective, without realizing that such schools were actually a constellation of theories, ideologies and philosophies. Only in retrospect can we say that we
lacked the meticulous observations and accumulation of data to construct inductive
hypotheses that might eventually be tested through controlled experimentation. In fact, the
entire subject was approached with a reverse logic: First you decide what truth is, and then
you expect it to be ratified by running an experiment.
When has science been served by the deduction method, which falls more faithfully in the
field of logic and philosophy? It took psychology until the Twenty-First Century to realize
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that the experimental method is designed to confirm the veracity of observable facts by
determining their probability, but it is of little or no use in crowning one “school” of thought
over another (or one pharmaceutical brand over another, for that matter). A side-note here
is the admission that, without the affirmation of one school of psychotherapy’s superiority
over another, the experimental results that incessantly and indefatigable denied all sides
final triumph over other schools, we would have spent a great deal longer in tiring of
carrying the banner of our favorite school (4). [Here, it must be said that the cognitive-behavioral approach has, most probably for reasons of fashion rather than substantiated effect,
appeared to have captured the attention of most “learned” publications. The lack of systematic testing of other psychotherapeutic approaches leaves the continued preference for CBT
open for debate, just as one might dispute the staying power of the plunging neckline once
the mode has changed.]
Making detailed observations and documenting those observations is the first step in accumulating a substantial database which allows a young science to speculate into the nature of things. Psychopharmacology is a young science, and only once sufficient data
accumulates can we begin to see relationships emerge between data points and, little by
little, generate tentative and timid theories about observed patterns. To date, in this slowly
maturing process, clinical psychopharmacology has accumulated sufficient data to make,
at best, limited and preliminary speculations, but certainly not enough to warrant more extensive theories. If the experimental method is most effective in testing theories, then we
have little to test by that method at this time. On the other hand, if we limit ourselves to pose
questions of a more humble nature, we might strive to elucidate certain trends before eventually applying the experimental method. Instead of testing the hypothesis that one antidepressant is better than another, usually by conducted a very flawed “clinical trial,” one might
better spend the time collecting data on how a particular antidepressant affects different
populations (age, sex, race, etc.), with different types of depression (major, bipolar, adjustment, dysthymia, NOS), under different conditions (divorce, job loss, stable family, etc.). Before formulating any particular theory, a great deal of single case observations, performed
as close to natural environment as possible, need to be accumulated before preliminary hypotheses might be generated that might, eventually, lead to a theory which might be broken
down into testable operational definitions. Clinical psychopharmacology, and even more so
in the broader, more robust case of medical psychology, is in need of far more data, and
far less poorly formed hypotheses, weakly tested by ineffectual experimental studies. The
case study is just such a search for primary data.
No one has found more value in the single case study than B. F. Skinner (5), who later attributed his “single subject research method” to Ivan Pavlov (6). Skinner applied the techniques of operant conditioning to subjects and measured the outcomes at various points
in time. As an extenuation of the case study, single subject designs were considered by
Skinner to be the design of choice when measuring behavioral change as they systematically measure the degree of impact of the independent variable over time, while reducing
the number of extraneous variables by limiting the number of subjects. Skinner was well
aware of the danger of “testing theories,” and preferred the inductive method, where the
investigator follows a series of observations to a conclusion or principle. For Skinner, psychology would do well to acknowledge its relative lack of basic facts, and to limit itself to
the recollections of data before prematurely speculating with theories and, much less, before applying sophisticated experiments to poorly defined terms (7). His interest in the case
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study and relative disinterest in statistical studies based on poorly controlled group experimentation aligned him closely to the clinical psychologist who works daily with the single
case in the form of individual patients.
By closely observing enough subjects individually and following the data trail that such observations leave, one might better answer the question of which type of patient, under
which conditions, and with which constellations of symptoms responds better to a particular
treatment. Notice here that we are not simply testing an ill-defined group of “schizophrenics”
or “major depressives,” but are observing a particular individual, of a given age, sex and
race, with symptoms that may or may not fit into a single nosology, under real life conditions, as that person responds to a given intervention. Such an approach requires considerable patience, and would require extensive replication with many more individual subjects
before principles for generalization might be extracted. In comparison to “controlled clinical
studies,” it could be inferred that the inductive method requires far more investment and,
thus, is less likely to turn a quick profit. Still, it is less likely to produce false positives. What
is more, it is likely to be far more relevant to patients whom the medical psychologist is
treating on a daily basis. The single subject analysis of behavior is exactly what the clinician
does with each patient; it is an ongoing, fluid interplay between clinician and patient; it does
not begin and end with a predetermined protocol.
FDA’s Phase Four drug approval/monitoring protocol calls for continued studies of drugs
once they are released to the market. While open label studies, post hoc retro-analyses, and
limited double blind group studies are undertaken after FDA approval, most post marketing
monitoring/reporting is done on a case-by-case basis, and represents ipso facto case studies. While there is a great deal of merit in such reporting, it is an uncontrolled, hit or miss
venture. What might be of greater value would be for the professional journals to reserve
greater space for case studies that might confirm routine or average responses to certain
treatments while highlighting minority reactions and describing unusual reactions. Such reports might point the way to further research or discover an artifact of treatment that would
otherwise go unnoticed in group designs. Case studies would ideally go beyond the reporting of side effects and adverse events, and would present observations linking treatment interventions to outcome according to such subject variables as race, gender, age, education,
civil status, major life events, diagnosed conditions and constellation of symptoms.
Apart from the possibility of capturing post-approval phenomena, which may point the way
to trends which lay latent in group designs, an additional potential of the case study is its
potential for pointing out outliers. “Outlier” is a mathematical (statistical) term meaning an
observation which lies outside the overall pattern of a distribution (8). An outlier can point
out problems with the established way of seeing things in that a theory usually attempts to
incorporate the most data in the most parsimonious fashion, but in doing so may leave out
essential variants that prove the theory wrong, or at least lacking to some degree. The
classic case study presents outliers which might otherwise be absorbed into the statistical
mean of group studies. Case studies are made up of the unusual cases that impressed a
clinician and challenged normal assumptions to the extent that the observer is required to
generate new explanations to account for the observed phenomena. This is medical psychology at its best: The individual person as the subject of the scientist-practitioner’s inquiries, with the objective of understanding that person within the broader background of
the discipline’s accumulated knowledge without losing sight of the patient before us. In
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doing so, we stretch the very discipline to fit the person of interest. Such intense observation will reap special subject variables in each case that we treat, and will also provide from
time to time outliers which are worthy of sharing with our colleagues because they have
heuristic value and can spur the discipline towards greater permeability.
Eventually, such a case study method will generate hypotheses, which may lend themselves to experimentation. Yet, there is so much of value to be derived from the observations themselves that our discipline need not be in a hurry to prematurely generate clinical
trials that render largely spurious conclusions, as has been the practice of clinical medicine
in the recent past.
Examples of the Heuristic Value of Case Studies
The following are a sampling of case studies from my own files, anyone of which would be
worth further exploration for possible leads to future epidemiological investigation or eventual experimental analysis.
1. An adolescent alcohol and drug abuser who, after treated with Adderall for ADHD, suddenly stopped all further substance abuse. Was he self-medicating for ADHD-induced
akathisia? How many other ADHD/substance abusers would find their abuse reduced
by analeptics?
2. A retiree medicated for anxiety during 10 years, only to find that when all anxiolytics
were temporarily suspended for pheochromocytoma testing he had no greater anxiety
without the medications than with them. How many years beyond his clinical need was
he medicated? How many other chronically anxious individuals are placed on continuous medication schedules without periodic assessment of need?
3. A middle-aged patient with chronic, life-long OCD and panic, and decades of medication with the psychiatric prognosis that he would need medication for life, went on a two
week vacation to a tropical island and experienced for the first time a “complete cure,”
in which all of his anxiety symptoms, OCD and panic included, were absent. If an instant
clinical change accompanies a change of venue, how much of his condition was “hardwired,” as he had been told by treating professionals because of the life-long manifest
symptoms?
4. A man in his 50s who struggled with voyeurism and exhibitionism most of his life and
had been treated with behavioral approaches without success until Prozac was added
and he discovered a reduction in his libido that gave him the distance from his urges
that he needed to make decisions about his actions without the overall sex drive overriding his intentions. Cognitive behavioral therapy subsequently became effective. How
much more effective could psychotherapy be in impulse-related disorders if it were routinely integrated with the judicious use of adjunctive pharmacotherapy?
5. A patient with OCD symptom of needing to sleep on his back to avoid the thought that
Satan would sodomize him, was treated with ECT and subsequently experienced his
obsession as a psychotic symptom in which he now believed the sodomy had occurred.
Is there a fine line between severe OCD and delusional disorder?
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References
M E D I C A L
P S Y C H O L O G Y
1. Stewart R & Chambless D. Interesting practitioners in training in empirically supported treatments: Research reviews versus case studies. J of Cl Psychol, 2010, 66,
73–95.
2. McGrath R & Muse M. Room for a new standard? Response to comments by Heiby.
J of Cl Psychol, 2010, 66, 112-115.
3. Echeburúa E. Modificación de Conducta y Psicología Clínica. 1993. Bilbao, Spain.
Servicio Editorial de la Universidad del País Vasco.
4. Muse M. Combining therapies in medical Psychology: When to medicate and when
not. Arch of Med Psychol, 2010, 1, 19–27.
5. Skinner BF. A case history in scientific method. Am Psychol 1956,11, 221–233.
6. Catania A & Laties V. Pavlov and Skinner: Two lives in science. J Exp Anal of Beh.
1999, 72, 455–461.
7. Sidman M. Tactics of Scientific Research. 1960. Oxford, England: Basic Books.
8. Moore DS & McCabe GP Introduction to the Practice of Statistics, 3rd edit. 1991.
New York: W. H. Freeman.
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Cost Savings of Treatment of Medically Unexplained Symptoms
Using Intensive Short-term Dynamic Psychotherapy (ISTDP)
by a Hospital Emergency Department
Allan Abbass
Samuel Campbell
S. Gerald Hann
Irmingard Lenzer
Robert Tarzwell
David Maxwell
Queen Elizabeth II Health Sciences Centre Emergency Department
And
Centre for Emotions and Health Dalhousie University
Abstract
Somatization of emotions accounts for excess use of Emergency Department (ED) physician services for patients with medically unexplained symptoms (MUS). Intensive Shortterm Dynamic Psychotherapy (ISTDP) was introduced into the Emergency Department
(ED) of a general hospital to diagnose and manage 50 sequential patients with MUS. In this
study we analyzed the cost effects of that study. In the year following treatment, there was
a 69% reduction in ED visits by these patients at an average cost reduction of $910 per patient. ISTDP interventions averaged 3.8 sessions averaging $406 per patient. A description
of the ISTDP methods used is provided along with a case vignette. The Brief Symptom Inventory (BSI) was used to measure the effects of the ISTDP intervention with “pre and
post” testing. Averaged pre-test scores on the Somatization subscale improved from 1.21
to 0.86 at post-test. The hospital judged this demonstration project a success and allocated
funds for an ISTDP-trained psychologist to treat MUS patients in the ED. While further research is warranted, this service and hybrids of it should be implemented to assist in cost
savings and service use reduction in Emergency Departments.
Background
Somatization, as used herein, is defined as the translation of emotions into the development or worsening of somatic problems or complaints. This process accounts for a large
proportion of physician visits including emergency department (ED) visits (1, 2). Patients frequently present to the ED with medically unexplained physical symptoms (MUS) (1) many
of which are driven by psychological factors. Anxiety and somatization may account for a
significant portion of these cases, although Emergency Physicians (EPs) may be reluctant,
for a variety of reasons, to make these diagnoses (2). Between 1998 and 2005, approximately 16% of visitors to our hospital ED received a diagnosis of Not Yet Diagnosed (NYD)
such as chest pain NYD, abdominal pain NYD or headache (NYD). For example, 75.8%
of 26,430 patients presenting to our own ED with chest pain were given a discharge diagnosis of ‘chest pain NYD’ (3).These are a few of the many diagnoses given for unexplained
symptoms. Clearly MUS is the single major cause of ED visits.
Correspondence address: Allan Abbass, MD, Director of Psychiatric Services, Dalhousie University Room
8203, 5909 Memorial Lane, Halifax, Nova Scotia, CA,B3H 2E2. Email: [email protected].
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Abbass et al (4) described patterns of somatization and a method derived from Davanloo’s
Intensive Short-term Dynamic Psychotherapy (ISTDP) to directly diagnose this process in
most cases. Somatization was attributed to unconscious emotions that produce unconscious anxiety and various defenses against this anxiety. Patterns of somatization, based
on 40 years of videotape-based research by Davanloo (5), were categorized in 4 main pathways: striated muscle tension, smooth muscle tension, cognitive perceptual disruption and
conversion (4, 6). Descriptions of these and common examples seen in the ED are presented
in Table 1.
Anxiety Format
Striated muscle
Smooth muscle
Cognitiveperceptual
disruption
Conversion
Table 1: Somatization Patterns and Examples (7)
Observations during emotion-focused
diagnostic assessment
Progression from hand clenching, arm tension,
sighing respirations to whole body tension
Acute or chronic spasm of smooth muscle
Anxiety affecting the cognitive and
perceptual fields
Loss of tone in some or all voluntary muscles
Examples of Emergency Department
presentations
Headache, globus hystericus, chest pain,
hyperventilation, shortness of breath, panic,
back ache, abdominal wall pain
Irritable bowel symptoms, abdominal cramps/pain,
reflux, nausea, bladder spasm, bronchospasm,
coronary artery spasm, hypertension, migraine
Visual blurring, blindness, mental confusion,
dizziness, pseudoseizures, paresthesias,
fainting
Weakness, unilateral or bilateral paralysis, aphonia
A 2009 review of 23 studies of short-term psychodynamic psychotherapy (STPP) for a
range of somatic symptoms found generally significant and sustained benefits in psychiatric
symptoms, somatic symptoms and healthcare utilization (8). Moreover STPP brought 46%
improved treatment retention. Two other studies found STPP to be superior to controls, including relaxation training, in treating panic disorder (9,10), a frequent cause of unexplained
chest pain in the ED (11).
One of the methods of STPP, Davanloo’s ISTDP has demonstrated effectiveness in several
conditions that predispose to excess ED usage. These include panic disorder (10), functional
movement disorders (12), pelvic pain/urethral syndrome (13), chronic back pain (14) and recurrent headaches (6). In a naturalistic study, treated patients experienced a marked drop in
both physician visits and hospital use which persisted in 1 and 3-year follow-ups (15, 16).
ISTDP begins with an assessment called a “trial therapy” (17, 18) which evaluates the patient’s
physical responses to emotion-focused interviewing, thus, allowing detection of somatization in many cases. These methods are thus an important adjunct to traditional clinical assessment methods, complementing history taking, physical examination and other
investigations (18).
ISTDP Psychodiagnostic Evaluation of Somatic Symptoms
Blocked unconscious complex feelings about trauma to attachments (love, pain, rage and
guilt about rage) sets the stage for somatization. When a current event activates these
feelings, anxiety and defenses are mobilized (See Figure 1). If these feelings are unconscious to the patient, the subsequent anxiety and defenses may also be outside of awareness. This is the finding common in people who have been traumatized by someone close
to them: feelings of rage toward a loved one are unacceptable, frightening, and avoided
through somatization and other defenses.
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Figure 1.
To detect the process of somatization we must recognize how emotions are viscerally experienced and how they may be avoided or somatized. Davanloo discovered through
studying several hundred case videotapes that specific emotions manifest in specific ways.
This “emotion physiology” constitutes a norm to compare with a patient who somatizes
emotions. Rage, for example, is experienced as an internal energy sensation, heat or “volcano” which rises from the lower abdomen to the chest then neck, and finally to the hands
with an urge to grab and do some form of violence. Guilt about rage is experienced with
upper chest constriction, intense painful feeling with waves of tears and with thoughts of
remorse as if one harmed another with the rage.
These unconscious emotions activate some combination of striated muscle tension,
smooth muscle tension, cognitive perceptual disruption or motor conversion (See Table
1). The degree to which these feelings are experienced consciously, by definition, equals
the degree to which they are not being somatized at that moment (4). This allows one to
determine whether or not these emotions are contributing to current somatic symptoms.
See Abbass et al, in this edition of the Archives of Medical Psychology for further details in
interpreting these responses.
Diverse research has shown that patients with a range of conditions like hypertension, migraine, irritable bowel syndrome and other conditions internalize anger and thus increase
their somatic problems. Blocking and inhibiting of emotions, including anger, is a common
finding in somatizing patients in the ED.
Procedures
The ISTDP trial therapy and follow-up treatment sessions as needed were used to evaluate
and treat sequential MUS patients who frequently used the ED. The present study analyzes
the cost savings of the improved care of MUS patients in the ED as a result of introducing
ISTDP. Abbass, et al published the pilot study methods and results from implementing this
service in our local emergency department in 2009 (7).
Results
In this pre-post design study 6 ISTDP-trained therapists saw 50 patients who had been, on
average, high ED users. These patients averaged 3.8 treatment sessions and showed a
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marked, 69% drop in repeat ED visits from 4.6 visits the year before to 1.4 visits the year
after treatment. The average 3.2 visits per year reduction represents a US $910 (SD 18.2)
visit per patient reduction in ED visit direct costs the year afterward (95% CI).
ISTDP patients showed significant improvements on the Brief Symptom Inventory Somatization subscale moving from an average of 1.21 pre-treatment to 0.86 at termination. Patient selfreports showed moderately high satisfaction with the service (mean 7.4 on a 0-10 likert scale).
The service had a marked increase in referrals over the course of time. By the end of the
study 12 different ED physicians were referring patients for ISTDP evaluations reflecting a
change in the pattern of service delivery by EPs.
Revisit rates during the same time interval for 3 available comparison ED populations showed
either smaller ED use reductions or an increase in services use. First, we examined revisit
rates for all ED patients, which was weighted to match the ED visit distribution of the ISTDP
treated group: we found mean revisit rates went down by 16% year over year. Secondly, we
examined revisit rates for all ED patients with any of the same 4 main complaints (i.e., chest
pain, abdominal pain, shortness of breath or headache), which were weighted to match the
ED visit distribution of the ISTDP treated group: in this group the mean visit rate went down a
mere 4.3%. Finally, we examined revisit rates for patients referred to the ISTDP service but
not seen: this group had a 42% increase in ED use year over year. These represent the range
of a $199 reduction to a $565/ patient/year increase in year over year ED visit costs.
Clinical Case Vignette Using ISTDP for Diagnosis and Treatment of MUS
The above noted theory and practical points will be highlighted through the use of a typical
case vignette. The main points above will be highlighted with [Square Brackets].
The patient is a 24-year-old university educated single woman with a long history of anxiety
and somatic complaints including irritable bowel syndrome (IBS), nausea and migraine
headaches [functional disorders, likely somatization history]. She also reported historical
problems with compulsive skin picking (i.e., neurotic excoriation) to the point that open
sores have sometimes developed. She has seen a number of medical specialists including
gastroenterology and dermatology in the past for the above-noted complaints [high medical
service use]. Little resolution to her symptoms has been found to date [multiple MUS].
She is currently in a program of advanced professional study having already an undergraduate degree. She can be considered intelligent and articulate and extremely focused on her
professional achievement. She is in a relationship of approximately 2 years. She recently
became engaged to be married [recent interpersonal stressor]. She currently lived with her
mother and sister and reported during intake interview that she had long-standing worries
about her mother and often found herself in a parental role while growing up due to parental
drug addiction. Both parents had frequent conflict with each other and she recalls worrying
that she and her siblings would end up in child protective custody, due to her parents cultivating of marijuana involvement with drugs and neglect of the children. She reported clear
evidence of a history of bi-parental neglect in her upbringing [traumatized attachment].
Diagnostically, she met DSM-IV criteria for generalized anxiety disorder and dysthymic
disorder. Medically, she had symptoms of gastroesophageal reflux disease (GERD) and
Irritable Bowel Syndrome. She reported at least one past panic attack. Most recently, she
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describes chest pain and shortness of breath, in addition to her previously reported symptoms. On assessment she was taking no antidepressant medications and had not been
prescribed such medications in the past.
Ambulance transport to the emergency department (ED) was precipitated because of chest
pains and shortness of breath while attending university classes [one of the most common
MUS presentations]. Medical evaluation of her symptoms revealed neither cardiac symptoms nor any other medical causes for her complaints.
She reported that prior to her hospital visit she had been experiencing chest pains for approximately one week. She reported that when she began to experience her symptoms, including heart palpitations, earlier in the week, she sought comfort from her mother and
actually took her mother’s hand and placed it over her heart. While in the ED, she did not
appear to have any insight into emotional factors responsible for her physical symptoms.
However, she did agree to a follow-up interview in the Medically Unexplained Symptoms
(MUS) clinic, which occurred one day after her ED visit.
When greeted in the waiting room for her initial appointment, the patient was anxious, experiencing shortness of breath, and clutching her chest. She appeared flushed and quite
stressed physically. In the early stages of the interview, unconscious anxiety (UA) was
noted by the therapist and evidenced in the form of deep respirations and hand clenching,
indicating striated muscle response as the discharge pathway of UA.
She reported experiencing chest pain and heart palpitations which brought her to the ED
the previous day. These symptoms persisted throughout the early phase of the interview.
When the therapist asked whether some of the external stressors that the patient was describing might be related to some of the observed anxiety, the patient did not make this connection. This indicates that the patient was unaware of the anxiety: it was primarily
unconscious. Instead, she was focused on the somatic complaints she was suffering. There
was thus evidence that she was alexithymic, showing difficulty recognizing, identifying or
experiencing her own emotions.
The therapist proceeded with inquiry into the patient’s current symptoms.
Therapist: So, I notice that coming in here you’re very tense and anxious and you are
experiencing that mostly in your chest?
Patient: Yes, but also my arms and hands are numb, like they’re asleep. (patient becomes
more anxious and squirms when reporting symptoms).
Therapist: Now, in terms of the symptoms you describe here today, is anxiety usually a
problem for you?
Patient: No. This has never happened (a reference to the chest pains).
Therapist: So in terms of emotions, what kind of emotions, feelings do you have inside
yourself?
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Patient: (no verbal response). The patient sighs, breaks eye contact with the therapist,
and reaches underneath her sweatshirt and massages the left side of her chest. The therapist continues with a focus on her underlying feelings in the moment.
Therapist: You know what I mean by emotions?
Patient: (no initial response: patient sighs, looks away from the therapist).
With this emotional focus the patient begins to bring more and more defenses in to the
room. Her defenses included rumination, intellectualization, and repression. The therapist
continues with a focus on underlying feelings in the moment and the patient continues to
defend. This allows the therapist to see the manifestations of both defense and anxiety, and
to acquaint the patient with both.
Therapist: What feelings do you have beneath the anxiety and tension?
Patient: ahh, (another deep respiration is observed but then the patient becomes more
flattened in her physical response). [This flattening out, or loss of muscle tone is a marker
that anxiety may be channeling into the smooth muscle of the GI tract or elsewhere. This
suggests a tendency to repress and somatize emotions.]
The patient is also now quite slumped over and is becoming more disengaged from the
therapist. Continued focus on underlying emotions is utilized by the therapist, with the addition of clarification. It is evident to the therapist that the patient is curious about the therapist’s line of questioning. The patient once again begins to become more engaged with
the therapist and makes brief, but important eye contact. [It is noteworthy at this portion of
the interview that the patient is beginning to experience a rise in complex feelings with the
therapist: experiencing positive feeling at his efforts, but also irritation at the not so subtle
challenge to her habitual avoidant behaviors (defenses).]
One noteworthy observation is when the patient takes her own hand during this part of the
interview and places it over the left side of her chest, in much the same way that she wanted
her mother to comfort her approximately one week earlier. She is now experiencing chest
pain during the interview. At this juncture it is apparent that the patient gives evidence of a
psychosomatic process where avoided feelings are translated to somatic anxiety in the form
of deep respirations and tightness in her chest. The patient also notes heart palpitations.
At this point in the interview, the role of the therapist is to continue to focus on underlying
feelings and to help mobilize them to the point of consciousness of possible. At this point,
the impact of this effort is mobilization of unconscious anxiety and accompanying defenses.
Therapist: What kind of feelings do you have?
Patient: (still no immediate response, and the patient continues to look away). Then the
patient looks at the therapist and eventually responds “lots, probably”? Here she acknowledges some underlying feelings. (Another deep respiration is noted). The patient also has
a brief smile.
She adds to her response:
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Patient: I try not to focus on these things! I go to school full-time.
The patient goes on to describe that she is engaged in full-time professional studies and
begins to tell the therapist that it is her belief that if she allows herself to experience many
of the feelings that come up in her life that she fears she would not be able to cope. She
reports a habitual pattern of avoidance.
Therapist: Okay, so one of the things that happens is when you get a whole lot of emotions
stirred up in your life, part of you that tries to move away from these? (Patient nods). You
feel you could not hold things together? All right, hmmm.
Patient: There are lots of other things, that if I concentrated on, I would go crazy.
Therapist: So what you’re telling me is there is a lot going on in your life, not just school
things?
Patient: (Nods agreement)
Therapist: but you worry that if you allowed a lot of this stuff [i.e., feelings] to enter into your
consciousness (patient nods) it wouldn’t be good for you?
The patient now becomes much more attentive to the therapist and re-adjusts her posture,
sitting up straighter and not being as slumped as she was in the initial stages of the interview. Eye contact also improves considerably. At this point in the interview the patient has
been acquainted with the link between unconscious feelings, anxiety and defenses. The
therapist continually reminds the patient, directly and indirectly as to the self-destructive nature of this process. This is intended to turn the patient against her own defenses.
The therapist also asked the patient if a similar phenomenon of avoiding feelings and the
creation of anxiety occurred in the past. This invites the patient to begin to make linkages
with current and past events and clarify the chronicity of this process. In the subsequent
15 to 20 minutes the therapist and the patient collaboratively explore recent and past relational events in which the patient is able to see that she avoided emotions at her own expense and the expense of the relationship itself. The patient described a long-standing
history of somatic complaints including GI problems, dermatological problems, migraine
headaches, and most recently chest pain. She then described that these issues go back
far into her childhood. This provides an opportunity for the therapist to make a dynamic inquiry into the patient’s past attachment patterns. The patient goes on to describe early attachment trauma, including chronic parental neglect, and circumstances where she was
often responsible for adult decisions in the household. Then she is able to acknowledge,
at least intellectually, that this created anger toward her parents. However, given the guilt
associated with experiencing this anger, the anger becomes internalized resulting in guilt
laden unconscious feelings. Her history of experiencing anger has primarily been directed
inward resulting in somatic complaints.
It becomes clearer during this phase that the patient has long-standing patterns of anxiety
managed by avoidance, repression of emotions and externalizing of problems. While this
has created as a defensive structure, over many years it has resulted in a detrimental im40
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pact on the patient, predisposing her to negative responses to external stressors, including
her most recent legal difficulties. She identified anger and rage toward the perpetrator of
the assault, yet has internalized these feelings, resulting in UA and somatic complaints.
Later in the session the patient goes on, in some detail, to describe emotions which were
recently activated in her regarding her sister’s boyfriend’s decision to end his relationship
with the patient’s twin sister. The end of her sister’s relationship mobilized the patient’s
own past feelings of being abandoned by her parents. Here the unconscious anxiety was
once again observed and the therapist helped the patient continue to identify and experience her avoided emotions.
Therapist: So…. you have some anger with this guy? So, let’s just see how you experience
this anger in terms of the emotion of anger in your body…if you don’t turn it back on yourself…and if it does not turn into anxiety. How angry were you in terms of a feeling?
As the patient focuses on the specific event involving her sister’s boyfriend, she begins to
experience the neurobiological pathways of rage in relation to the therapist. The therapist
facilitates this process.
Therapist: That aggressive force? if you could not protect someone from it… if it got really
big in you…. just as a force, how would it go?
Patient: (patient hesitates and makes several deep respirations)
Therapist: How would it go if you don’t get anxious?
Patient: It would want to lash out (patient is gesturing freely with signs of a drop in anxiety
with rage replacing anxiety).
Therapist: How would it go? If you don’t get crippled with anxiety, how would it go?
Patient: It wants to be aggressive.
Therapist: It wants to be aggressive?
Patient: Yes, to be aggressive.
Therapist: If we look at this together, just you and I… if this aggressive force was felt and
you couldn’t protect someone from it…If it got really big as a force? How would it go…
physically, just in terms of thoughts, fantasy.
Patient: It wants to lash out.
Therapist: It would want to lash out, how would it lash out? What would it do?
Just the force. The anger.
Patient: Probably like this (the patient reaches out and grabs the lapels of her jacket with
both hands and pulls).
What then follows is a sequence of 15 minutes of focus on the somatic experience of the
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rage related to a current event where the feeling is gradually activated and physically experienced. When the rage is experienced, it replaces the unconscious anxiety about this
rage. During this sequence, a portrait is developed of an angry and aggressive impulse,
which the patient likens to a boxer, being destructive and inflicting harm to her sister’s
boyfriend. Following this, is the immediate passage of guilt laden feelings related to the experience of this rage. This brings about an immediate reduction in anxiety for the patient.
From there, the patient and therapist went on to link these feelings with some parallel traumatizing events in her childhood. The latter part of the session focuses on recapping of the
links between feeling-anxiety-defense and past-current-therapeutic relationships. These
linkages have been reviewed with the patient indirectly and directly, and repeatedly,
throughout the session. By the end of the session the patient is able to consolidate how
feelings from the past are reactivated by current events and reminiscent of her way of dealing with the feelings in the past. Because the patient was able to experience feelings related
to past and current events during the initial session, she was able to acquaint herself with
the experience of these emotions, with a resulting reduction in anxiety in this one session.
Following the initial psychodiagnostic interview, the patient participated in four (4) additional
sessions and continued to report symptom reduction and improvement. She did not require
any emergency department visits since the initiation of treatment. Furthermore, a decrease
in somatization was also reported. She also reported being much more observant of the
interpersonal relationship patterns and making changes in dealing with her mother, fiancée,
and others.
Over this 4 session period her Brief Symptom Inventory global rating went from abnormally
high 1.17 to 0.74 which is in the normal range. This typified results of the recently published
sample (7).
Conclusion
We have herein described an emotion-focused approach with broad applicability to ED
users with MUS. The ISTDP method was demonstrated to be feasible, practical, fiscally
relevant and cost effective. While further research is warranted, the lack of effective
alternatives and converging supportive evidence suggest this evaluative method can be
considered a viable adjunct to day to day Emergency Services.
References
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Stephenson DT & Price JR. Medically unexplained physical symptoms in emergency
medicine. Emerg Med J. 2006, 23, 595-600.
Pollard CA, Lewis LM. Managing panic attacks in emergency patients. J Emerg
Med.1989, 7, 547-52.
Unpublished data. Queen Elizabeth II Health Sciences Centre Emergency Department database.
Abbass, A. Somatization: Diagnosing it sooner through emotion-focused interviewing. J Fam Pract. 2005, 54 (3), 231-239.
Davanloo H. The technique of unlocking the unconscious in patients suffering from
functional disorders. Part I. Restructuring ego’s defenses. In: Davanloo H. Unlocking
the unconscious. Chichester, England: John Wiley & Sons, 1990, 283-306.
Abbass A, Lovas D, Purdy A. Direct diagnosis and management of motional factors
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in chronic headache patients, Cephalalgia 2008 Dec, 28(12), 1305-14.
Abbass A, Campbell S, Magee K, Tarzwell R. Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with
medically unexplained symptoms; preliminary evidence from a pre-post intervention
study. CJEM. 2009 Nov, 11(6), 529-34.
Abbass A, Kisely S, Kroenke K. Short-term psychodynamic psychotherapies for somatic symptom disorders: Systematic review and meta-analysis. Psychother Psychosom 2009, 78, 265-274.
Milrod B, Leon AC, Busch F, et al. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry. 2007 Feb, 164(2), 265-72.
Wiborg I & Dahl A. Does brief dynamic psychotherapy reduce the relapse rate of
panic disorder? Arch Gen Psychiat. 2006, 53, 689-694.
Fleet R, Lavoie K, Martel J-P, Dupuis G, Marchand A & Beitman B. Two year followup of emergency department patients with pain complaints: was it panic disorder?
CJEM. 2003, 5(4), 247-54.
Hinson VK, Weinstein S, Bernard B, et al. Single-blind clinical trial of psychotherapy
for treatment of psychogenic movement disorders. Parkin Related Dis. 2006, 12,
177-180.
Baldoni F, Baldaro B, Trombini G. Psychotherapeutic perspectives in urethral syndrome. Stress Med. 1995 Jul,11, 79-84.
Hawkins J. The role of emotional repression in chronic back pain: a study of chronic
back pain patients undergoing group psychodynamic psychotherapy as treatment
for their pain. Part of PhD Dissertation. New York University. 2003.
Abbass A. Intensive short-term dynamic psychotherapy in a private psychiatric office: clinical and cost effectiveness. Am J Psychother. 2002, 56(2), 225-32.
Abbass A. The cost-effectiveness of short-term dynamic psychotherapy. Expert Rev
Pharmacoeconomics Outcomes Res. 2003, 3(5), 535-539.
Abbass A, Joffres MR, Ogrodniczuk JS. A naturalistic study of Intensive Short-term
Dynamic Psychotherapy trial therapy. Brief Treat Crisis Interven 2008, 8, 164-170.
Abbass A, Joffres MR, Ogrodniczuk JS. Intensive Short-term Dynamic Psychotherapy trial therapy: Qualitative description and comparison to standard intake assessments. AD HOC Bull Short-term Dynamic Psychother 2009, 13(1), 6-14.
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Implementing an Emotion-Focused Consultation Service to Examine
Medically Unexplained Symptoms in the Emergency Department
Allan Abbass
Robert Tarzwell
S. Gerald Hann
Irmingard Lenzer Samuel Campbell David Maxwell
Queen Elizabeth II Health Sciences Centre
Halifax, Nova Scotia
Abstract
Introduction: Providing an emotion-focused assessment service to explore emotional contributors to medically unexplained symptoms (MUS) is a culturally new concept within the
traditional model of emergency medicine. We developed a multi-step approach to educate
physicians and patients on how such a service might benefit them. Results: Patients reported high satisfaction with the service and more physicians referred greater numbers of
patients. The institution supported the service, providing permanent funding, giving it an
award and nominating it for a national quality award. Dealing directly with emotional contributors to symptom formation is a new approach to the emergency care of patients with
MUS. This diagnostic and treatment innovation was accomplished successfully, with data
supporting reductions in ED readmission and reductions in overall costs. The steps we
took appear to have played a role in the service being both beneficial and well received by
patients and physicians. Further study and replication of these methods is warranted.
Introduction
A typical model of emergency department care is one where patients present with subjectively alarming symptoms, which may require rapid intervention. Shortness of breath, chestpain, abdominal pain, and headache—the major presenting complaints that we investigated
in our pilot service—are frequent causes of ED presentation. They also happen to be symptoms with causes ranging from benign to catastrophic. Within current paradigms, patients
are triaged by level of urgency when they present, using widely accepted, evidence-based
criteria, to direct speed and intensity of investigation and intervention. Patients, whose
symptoms are judged to be benign, medically unexplained, or anxiety driven are commonly
given reassurance and then discharged. As reported by Abbass et al (1), for at least some
of these patients, unless underlying factors are explored and dealt with definitively, readmission to the ED is common, coupled with high costs and frustration on the part of treating
doctors and patients alike.
Somatization or the translation of emotions into the development or worsening of somatic
problems or complaints (2, 3) accounts for a large proportion of these ED visits (4, 5). We have
previously described (See page 35 of this issue. ed.) the patterns of unconscious anxiety
Correspondence address:: Allan Abbass, MD, Director of Psychiatric Education, Dalhousie University, Room
8203. 5909 Memorial Lane, Halifax, Nova Scotia, CA B3H 2E2. Email: [email protected]
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and various defenses against this anxiety, which translate into common ED presentations
(6). We have also described how a pilot service using a brief treatment called Intensive
Short-term Dynamic Psychotherapy (ISTDP) led to both decreased ED readmission rates,
decreased health-care costs overall, and was viewed as satisfying by patients and referring
physicians (1, 6).
In setting up this pilot study, we realized that ED physicians might be reluctant to consider
emotional factors in symptom-formation, in part because of medical education deficits in
this relatively new area of science. Patients may also be reluctant, perhaps feeling that
their urgent symptoms are being dismissed. Furthermore, the traditional role of mental
health in the ED is oriented to behavioral emergencies: suicidality, homicidality,
agitation, and functional decline due to acute decompensation of the mental state via psychosis, mania or depression. Exploration of emotional factors in physical symptom formation has not historically been within the purview of psychiatric emergency services.
Here, we discuss the specific steps undertaken at the QE II Health Sciences Centre to provide emergency physicians with the skills to detect whether emotional factors might be
playing a role in symptom formation, how to engage the patient in a non-threatening
discussion of emotional factors of their symptomatology, and how our service approached
patients referred for assessment, including patients who initially felt threatened or
dismissed by the referral.
I. Methods
1. Diagnosing Somatization in the ED Patient
A key element we helped the ED physician understand is how we orient an ED patient to
the evaluative interview of ISTDP, which is called a trial therapy (1, 2, 3) . It is important to remember that these patients presented to a hospital for a physical evaluation and not to a
psychologist for emotional assistance: thus, an interviewer has to establish a collaboration
to examine whether or not emotional factors are producing or worsening his or her presenting physical complaints. Patients coming to this interview can arrive one of the following
ways:
A. Ready to focus on emotional factors
Patients ready to focus on emotional processes arrive with active unconscious anxiety
in the form of striated “anxiety with hand clenching and sighing, or anxiety in smooth
muscle with GI upset for example. These are signs of receptivity and readiness to examine emotional factors. Other signs include verbal statements of interest in emotional
contributors.
B. Consciously Defending
These patients are guarded and wary about interacting with the therapist. He or she
isn’t yet a patient (or client) to work with. The nature of the interview, goals and methods need be reviewed to see if he or she is willing to examine possible emotional factors. In our experience it is rare for a person to decide not to engage in the interview
once they have arrived in the office and been explained the process.
C. Unconsciously Defending
Such a person is typically tense and intellectualizing, detaching, defying, complying
or using one or another unconscious defense mechanism. This is a marker of mobi45
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lized unconscious emotions, which are being avoided unconsciously by whatever set
of habitual behaviors that were learned over the lifetime. This is dealt with through a
range of interventions central to ISTDP technique that include clarification of the defenses, turning the patient against the defenses and challenging the
defenses (7).
D. Confused
This patient arrives but does not have any idea what he or she is doing in the office.
This may be a failure of the referring professional to explain (or offer the pamphlet) or
is a product of low psychological mindedness in the patient. It may also be that in this
patient’s case, there is no link between the symptoms and emotional factors. Such a
person requires a clear explanation about the interview, and perhaps further explanation of the concepts of unconscious, emotions and anxiety about emotions.
E. Combinations of the above
A patient may arrive with more than one of these states of mind. The priority is as
follows: First, a conscious understanding of the process must be provided. Second,
conscious defenses must be handled by conversation and decision making. Third,
unconscious defenses must be addressed. Finally, unconscious anxiety and emotions
can be examined. Then, the patient and interviewer can begin to assess whether or
not there are emotional contributors to the symptoms in question.
2. Actively Exploring Emotions Interviewing
Examination of the emotional system progresses from observation to active exploration, in
concert with the patient. When meeting with the patient one observes the patient upon
coming into the office for the presence of visible unconscious anxiety. Then, in the context
of a supportive therapeutic relationship, one may explore emotionally charged situations
that exacerbate or generate symptoms. One may also ask in what way strong emotions like
anger affect the patient’s physical problems. Asking about specific recent events and feelings that were triggered leading to the ED visits usually mobilizes emotions, giving the interviewer and the patient a direct look at how emotions affect him or her physically. If a
patient is anxious in the office, the best place to focus is on the feelings that generate the
anxiety during the interview.
3. Managing Excess Anxiety
If the patient becomes anxious when focusing on emotions, one may help him or her
relax by asking the patient to intellectualize about the specific bodily anxiety symptoms.
This reduces the anxiety by using the defense of intellectualization. Alternatively one
may change topics or areas of focus temporarily.
4. Interpretation of Responses
In a previous videotape, case-based study we found that during the trial therapy, somatic
symptoms could briefly increase or decrease, disappear, or might not change at all. Each
of these responses has diagnostic and etiological implications in the patient with physical
symptoms. These interpretations are described in Table 1.
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Table 1. Interpretation of responses to emotionally focused assessment
Response
Interpretation and
Response
Response 4b: Symptoms are
improved or removed by
emotional focus or emotional
experience in the office
The diagnosis is (was)
somatization of those emotions.
Follow-up to see if gains
are maintained
Response 4a: Symptoms go
up with emotional focus then
down after focusing away from
emotions
Response 4c: No change
in symptoms
Response 4d: Unclear response
Beware of
The diagnosis is likely somatization.
Prescribe emotion-focused
psychotherapy and monitor
for gradual symptom removal
False positives due to
coincidental symptom
changes in interview
Health problems unrelated
to the somatization could
always be present
Somatization is unlikely to be
the cause of the symptoms.
Look for other physical causes.
False negatives due to high
defenses, sedation, lack of
cooperation, inadequate focus
by the therapist
May or may not be an emotionbased component in the symptoms.
Repeat test, consider other
diagnostic tests or referral for
emotion-focused diagnostic testing
Table 1 outlines the response patterns seen in screening patients with the ISTDP method:
4a. Somatic symptoms varied with emotional mobilization, both increasing and decreasing
with emotion activation. For example, chest pain increases with a rise in unconscious
anxiety with sighing respirations and this varies with the amount of reported chest pain.
This suggests somatization was a contributor to the symptoms. Such patients would
be directly provided ISTDP treatment.
4b. Symptoms were removed or markedly diminished with emotional processes in the interview: for example, a patient with a recurrent headache comes in the interview with a
headache which abates directly when the emotions are experienced (3). This finding
strongly suggests emotional causation or at least strong emotional contribution to symptoms that have now abated. These patients would also be offered a course of ISTDP.
4c. No change is seen. In this case there is no symptom variance with emotional mobilization or experiencing. This finding may suggest emotional processes are unlikely to be
contributors and that additional medical testing is warranted. An example of this was
a person with recent onset confusion: After additional medical review it was found she
had central nervous system effects from an anti-malarial drug, which abated when it
was stopped. In cases with no change and who already had extensive medical testing,
a brief series of exploratory psychotherapeutic sessions may be warranted to see if
symptoms may abate with more treatment.
4d. An unclear response may be derived where no conclusions can be drawn. This finding
suggests the interview should be repeated or a brief series of sessions be provided to
further attempt to evaluate emotional contributors.
Caveats for each of these interpretations include false positives and false negatives. Unconscious anxiety can be present comorbidly with medical conditions. Some conditions
can be worsened by, but not be caused by, unconscious anxiety. Responses could be coincidental, although minute-to-minute changes in chronic symptoms are less likely to be by
pure chance. For these reasons, repeated mobilization within the assessment interview is
suggested to confirm any positive findings.
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5. Review and Planning of Active Emotional Interviewing
This interview process is concluded by reviewing the findings with the patient in the same
way one would the findings on any psychological or medical test. Management options
would depend on the findings and may include another interview, further medical investigations, referral for psychotherapeutic treatment or follow-up to see his or her response to
the interview itself. This review and planning process is illustrated in the companion article
to this (6) and in a description by Patricia Coughlin (8).
Within the limitations of this assessment method, the clinical utility of this assessment
method has rendered it our core diagnostic and treatment instrument for MUS in all medical, surgical and ED patients. In our institution, we use this approach to screen patients before they receive brain implants for idiopathic tremor, electronic stimulators for bladder
dysfunction and electroconvulsive therapy for a range of psychiatric presentations (9).”We
co-screen patients with neurology who are being assessed for pseudoseizures and consult
to general surgery prior to specific procedures in cases where somatization is suspect. All
of these assessments are provided as urgent consultations with the same preparatory explanation as we provide ED patients.
II. Adaptation to the Emergency Department:
Changing the Treatment Culture of the ED
In the pilot study, we introduced this technology to a new setting—that of a busy urban
emergency department. This was achieved through the following processes:
First, we established working relationships between our clinicians and some emergency
physicians already interested in the area of somatoform disorders. This relationship was
facilitated by the fact that Doctor Abbass practiced as an emergency physician in the
hospital some years before.
Second, we provided videotape-based education workshops of 1–2 hours to the emergency
staff. The education sessions covered the following key points. First, we reviewed the basic
metapsychology underpinning the evaluation we use (2, 3). We showed videotape to illustrate
the difference between emotions, such as rage, and the somatic patterns of anxiety when
rage is mobilized. Then we covered how to approach the ED patient about referring to the
service including the notion that we do not assume psychological causation. We also reviewed the patient information pamphlet we prepared. This was a simple information piece
to give to patients and explain the purpose of referral. It outlined, that the purpose was to
see “whether or not” emotional factors were contributing to symptoms. In addition, we covered how emotional reactions in the physician could blur recognition of somatization or interrupt the treatment process (10, 11). These workshops relied on videotape of actual cases
and allowed case discussion with staff. We presented the literature and provided copies of
relevant articles. Finally, we reviewed how to make referrals for ISTDP evaluations.
Third, we introduced rapid access referrals to the service where emergency patients were
seen in less than 2 weeks when possible and made ourselves available by phone as needed.
Fourth, we showed videotapes of emergency-referred cases we had seen to the referring
physician to illustrate what we did and the outcome.
Fifth, we made literature readily available to emergency physicians and other staff, including articles on the interview methods we used and outcome research.
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Finally, we provided a month of on-site consultation / liaison with emergency physicians.
This on-site consultation was provided by a senior ISTDP trainee and resident in psychiatry
(RT). In this period brief, on-site liaison was provided to help emergency physicians learn
who may benefit from referral to the service and to explain what we do.
The central philosophy in our consultation/liaison and education was as follows: we never assume that emotional factors are present, but we also do not assume they are absent. Rather,
we do a direct diagnostic evaluation through emotional mobilization coupled with close observation of the responses to this process and see if we can make a determination on causation. Another concept that was helpful is the notion that nearly every illness is made worse
by stress. This is why we called our assessment a “Diagnostic Interview for Stress Factors”
and explained this to each patient. By using this concept we never lost sight of the possibility
that a medical condition could be evolving or subclinical: we made medical referrals on a few
occasions when medically warranted. This philosophy made the service acceptable to physicians hesitant to send patients for emotion-based assessment. Otherwise, they may have
feared the patient would be seen and told the problems are “in the patient’s head” as opposed
to actual end organ phenomena with cause to be determined.
Extending education on this evaluative approach to the university-hospital specialty medical
departments, to undergraduate medicine and to postgraduate medicine all aided in the development of ISTDP services in this ED over a 10 year period. Over these years we had provided over a dozen presentations to medical-surgical specialty grand rounds. We provided
annual half days of videotape training to all junior surgical residents, to all residents as a
group, and to all family medicine residents (12). Annual presentations to undergraduate medicine has now been converted to a full week of curriculum on “Emotions and Health” in second
year medicine. By the time new emergency physicians were recruited over the past 10 years,
all local graduates had seen some of the materials and videotapes demonstrations. This familiarity helped this service to take hold and be supported widely in the institution.
Results
We previously reported patient self-reported satisfaction, physician verbal reports of satisfaction and a high rate of referrals from more ED physicians as a response to the pilot
study (1). Based on these responses, we were awarded a $50,000 (USF) “Innovation Grant”
to further study and implement this diagnostic and treatment service in the ED in 2009.
The funds were used to support a fulltime equivalent psychologist position in the ED. This
position was shared between two senior psychologists (SGH & IL) with experience and
training in ISTDP. They worked collaboratively and provided liaison and ISTDP services in
the ED.
Although we did not collect written feedback from ED physicians, verbal feedback continued to be very positive: fourteen of these physicians referred over 50 patients to the service
over a 5 month period. Patients rated the service highly with an average self- reported satisfaction level at the 8.7 out of 10 level on a Likert Scale. These are improvements over the
previous pilot and suggest assimilation and acceptance of the service both among referring
emergency physicians and, therefore, patients themselves.
Since utilizing this Innovation Grant, support in the Institution has been such that we have
been provided funding for 1.2 full time equivalent psychologist positions in the ED.
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The service was awarded an institutional “Quality Award 2010” and was nominated as a
national “Leading Practice” by Accreditation Canada in 2010.
Conclusion
Medically unexplained symptoms are common. Emotion-focused therapies, such as ISTDP,
can play a role in the diagnosis and treatment of emotional factors underlying symptom formation, where such factors exist in a given patient. The prevailing model of care in EDs had
been triage, exclusion of ominous causes, and reassurance in cases where no medical or
surgical therapy was appropriate. Our intention was to modify that model to include focused
psychodiagnostic evaluation as a third modality, one that could be made available rapidly
for diagnostic and therapeutic purposes. Having no precedent in the Health Sciences Centre, we developed the method described above to facilitate implementation of our service
on a pilot basis into a busy urban ED. Extensive educational ground work in the university
and hospital facilitated this cultural shift.
The successful implementation of a service to explore emotional factors in medically unexplained symptom formation can be concluded from patient and physician satisfaction, reduction in ED readmission rates, and net reduction in health costs related to ED use. What
is less clear is whether our specific approach to physicians and patients played a role in
that success. While we would argue from converging evidence that it did, replication of this
implementation method in other centers would be necessary to offer independent validation
of the claim. Furthermore, it may be possible to implement such a service with fewer steps,
in a shorter time scale, but just as successfully. These remain open questions. While we
are planning formal evaluation and further study of this service, we hope that medical and
psychological colleagues will take up the challenge to bring and research such services in
this important area of clinical need.
References
1. Abbass A, Campbell S, Magee K, Tarzwell R. Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with
medically unexplained symptoms; preliminary evidence from a pre-post intervention
study. CJEM. 2009 Nov, 11(6), 529-34.
2. Abbass A. Somatization: Diagnosing it sooner through emotion-focused interviewing.
J Fam Pract’ 2005, 54(3), 231-239.
3. Abbass A, Lovas D, Purdy A. Direct Diagnosis and Management of Emotional
Factors in Chronic Headache Patients. Cephalalgia. 2008 Dec;28(12):1305-14.
4. Stephenson DT, Price JR. Medically unexplained physical symptoms in emergency
medicine. J Emerg Med. 2006, 23, 595-600.
5. Pollard CA & Lewis LM. Managing panic attacks in emergency patients. J Emerg
Med. 1989, 7, 47-52.
6. Abbass A, Campbell S, Hann SG, Lenzer I, Tarzwell R, & Maxwell R. Cost Savings of
Treatment of Medically Unexplained Symptoms Using Intensive Short-term Dynamic
Psychotherapy (ISTDP) by a Hospital Emergency Department. Arch Med Psychol.
2010, 34-43.
7. Davanloo H. Unlocking the Unconscious: Selected Papers of Habib Davanloo, MD.
Chichester: John Wiley and Sons; 1990.
8. Coughlin Della Selva P Emotional Processing in the Treatment of Psychosomatic
Disorders. J Clin Psychol. 2006, 62, 539–550.
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9. Abbass A & Bains R. ISTDP and Electroconvulsive Therapy. Ad Hoc Bull Short-term
Dynamic Psychother. Dec 2009.
10. Croskerry P, Abbass A, & Wu A. How Doctors feel: Affective issues in patient safety.
Lancet. 2008, 372, 1205-06.
11. Croskerry P, Abbass A, & Wu A. Emotional influences in patient safety. J Patient
Safety. In press.
12. Abbass A. The case for specialty-specific core curriculum on emotions and health.
Royal Coll Outlook. 4, 2005, 5-7.
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Principles of Alcohol Detoxification for Collaboration among
Psychologists and Other Medical Professionals
Jerry Morris
Bates County Memorial Hospital
Abstract
The abuse of alcohol leading to the chronic health conditions associated with alcoholism
is one of the most common comorbid treatment issues seen in the practice of psychology.
Detoxification from the abuse of alcohol creates the need for professional collaboration
between psychological and medical care and the mutual understanding of the skills required for both the short-term physical crisis and the long-term rehabilitation of the patient.
Current efforts to improve quality and efficiency of care are focusing on the Concept of the
Patient Centered Medical Home (PCMH) since primary medical care is the main venue for
providing mental health treatments. This article, extracted from the workshop presentation
at the 2009 National Alliance of Professional Psychology Providers conference, highlights
the principles of alcohol detoxification to enhance this mutual understanding for professional practitioners. It familiarizes psychologists with foundational detoxification skills for intraprofessional communication. This article also discusses the pathophysiology involved in
detoxification and recovery from addiction. Need for psychological interventions are emphasized since detoxification procedures alone are insufficient for lifestyle rehabilitation and recovery from addiction.
Background
Alcohol detoxification brings into sharp focus the need for integration of mental health/
substance (M/SU) abuse care treatment with primary care. This one instance of where the
patient’s needs for professional collaborative care should not be ignored. Croghan and
Brown (1) point out that current “efforts to improve the quality and efficiency of primary care”
are focusing on the concept of the Patient Centered Medical Home (PCMH) since primary
care serves as a main venue for providing mental health treatments. Although the PCMH
concept maybe arguable from the standpoint of providers of outpatient psychological interventions, it is important for these providers to consider the value of PCMH in delivering
treatments for their patients, especially those with a potential medical crisis, such as during
alcohol detoxification. Detoxification can be done in a licensed health care facility where
staff monitoring is available on an inpatient basis or on an outpatient basis where family
members are trained to monitor the patient and their response and concerning emergency
procedures and a predetermined action plan.
Cooper (2) reports that home detoxification has been successfully used in the United Kingdom since the 1980s and is widely used in the United State because of the willingness of
Correspondence address:: Jerry Morris, PsyD, MSPharm, Director of Behavioral Health,
Bates County Memorial Hospital, 615 West Nursery St. Butler, MO 64730
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patients to undertake detoxification in the home or on an outpatient basis when the safety
their care is assured. The use of detoxification in the home or on outpatient basis permits
greater privacy for the patient and decreases costs making home detoxification a preferred
method for patients and many specialists in substance abuse treatment. Psychological practitioners that consider practicing in a medical facility that professes to embrace the PCMH
concept may find vestiges of the archaic standards of care that may still prevail. The persistence of this old-line model may interfere with proven psychological interventions. Hence, it
is worthwhile to review some of the issues the trained medical psychologist may encounter.
Principles of Detoxification
The medical psychologist guiding patients through the detoxification phase is encouraged
to keep the following tenets in mind:
• Detoxification alone is not an adequate treatment.
• Only medication regimens or detoxification procedures or protocols with established
safety and efficacy should be used.
• Providers must control the patient’s access to medications to the greatest extent possible.
• Initiation of withdrawal should be individualized.
• It is preferable to substitute a long-acting medication for a short-acting drug of addiction
(alcohol detoxification-slowly metabolized benzodiazepine such as diazepam or
chlordizepoxide Valium or Librium) that will cause a gradual decline in blood levels and
a more controlled reversal of neuroadaptation. In the elderly this should include starting
with 1/3 to ½ of the usual adult dose for 24 to 48 hours and re-evaluate and then titrated
as necessary to control symptoms over 5-7 days.
• Medication should not be the only component of treatment. Psychological support is
extremely important in reducing patient distress, and it is often helpful for them to be
physically active, e.g. walking or exercising.
• Initiating support therapy immediately but with sensitivity for how hypersensitive, emotional, and uncomfortable the patient may be, is necessary. It is always helpful for the
patient to have the psychology, physiology, neuropsychology, and course of detoxification and transitioning to psychotherapy. Self-help meetings, changing social and relational environments (changing locales of activity and/or change of companions), relapse
prevention and crisis plans should be negotiated and established as part of the rehabilitation program. The patient should have a 24-hour emergency number if family and
social detoxification is used, and the family should undergo psychoeducation and inclusion in the established monitoring and safety net.
Detoxification literature (2) suggests that in many instances, effective home detoxification
can be considered when:
• there is no evidence of severe withdrawal, e.g. tremor, hallucinations, disorientation
where there is no past history of delirium tremens or of seizures;
• there is the presence of supportive relatives who elect to stay with the patient during
the period of detoxification;
• where there is no evidence of a medical illness such as pneumonia or pancreatitis;
• when no previous history or evidence of suicide is contemplated;
• where the patient does not have any access to the drug from which they are being
withdrawn;
• and where a co-morbid mental disorder is not so severe as to make home and family
monitoring and cooperation unlikely.
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In order to have the clinician deem the patient as qualified for outpatient detoxification (3),
the patient must clearly agree to abstain from using any mood-altering agent, other than
those used for detoxification by the supervising prescriber. The patient must agree to participate in a treatment program under the direction of the psychologist. During the first few
days, the patient also needs a sober and responsible family member, friend, or AA sponsor
who will help undergo education with regard to team membership and communications, the
emergency procedures plan, and who will monitor the patient and encourage participation
in psychotherapy. This confederate or confederates will observe for serious signs of withdrawal, assist with medications, get the patient to the psychologist’s or team’s office and
dispose of any alcohol or drugs in the patient's home.
Because of the many potential medical complications of alcohol withdrawal, a complete
physical examination with appropriate laboratory tests is mandatory, with special attention
to the liver and nervous system. Indications for inpatient detoxification are as follows:
• Noted failures of previous outpatient detoxification;
• Lack of motivation on the part of the patient and/or family;
• Strong denial on the part of the patient or family;
• Severe impairment of cognitive or physical functioning;
• Insufficient psychosocial supports to ensure monitoring and reasonable
expectation of follow through on the emergency action plan;
• The living situation encourages continued substance abuse;
• There is risk of medically dangerous withdrawal syndromes;
• Coexisting medical or psychological illness requiring close observation.
The Institute of Medicine (4) reports inpatient detoxification has demonstrated that hospital detoxification does not improve long-term treatment outcomes.
Most licensed health care facilities have internal detoxification protocols that will guide the
psychologist who is consulting or prescribing. The consulting psychologist must be familiar
with these protocols before acting as hospital staff or referring patients to the facility. When
hospital detoxification is used for alcohol-dependence, the patient can be detoxified in a day
or two. In outpatient settings, patients can usually be detoxified from alcohol in 3 to 5 days.
Patients who are medically debilitated should detoxify more slowly. A high-calorie, highcarbohydrate diet supplemented by multivitamins is important. Dehydration should be corrected with fluids by mouth or intravenously. The supervising practitioner should stress the
importance of regular exercise as an alternative to craving alcohol.
Effective treatments for mental health and substance abuse illnesses are well established.
Yet, there continues to be a discrepancy between what care is effective and what care is
actually delivered. The 2006 Institute of Medicine (IOM) review (5) found that only 27 per
cent of the studies reported adequate rates of adherence to established clinical practice
guidelines. The report indicates that inadequate use of mental and substance-use (M/SU)
health care is a significant dimension of the poor quality of all health care. For instance, the
IOM report cited one review of the charts of 31 randomly selected patients in a state psychiatric hospital that detected 2,194 medication errors during the patients' collective 1,448
inpatient days of inpatient treatment under the direct supervision of physicians and nurses.
Of the errors, 58 per cent were judged to have the potential to cause severe harm (or to
represent potential incompetent treatment and malpractice).
Currently, hospital and primary care Medicaid and Medicare certification standards and
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federal grants and guidelines to implement healthcare reform and Integrated Care (1, 4) "pretend” that a minimal additional education can provide physicians with the behavioral health
diagnostic and treatment skills that take years of study and residency to master. Kunen et
al (6) point out this method has been tried and has failed. This same pretense has led to
using tranquilizers and pep pills to cure or handle the complexities of mental illness. Denial
of lifestyle and related habits, as well as behavioral maladies and substance abuse, has
led to treatment practices that are bankrupting the healthcare system.
The US Agency for Healthcare Research and Quality (7) indicated that over half of ER room
visits are related to mental disorder or substance abuse. Another pretense is ignoring the
fact that primary care physicians are already overburdened and do not have time or the
specific expertise to handle these complex problems and patients in their busy schedules.
Perhaps the greatest pretense/denial is that "psychiatrists are in sufficient numbers or sufficient training and expertise and distribution to take care of specialty diagnoses and complex behavioral health treatments in hospitals and primary care centers (8).
Dr. Nora Volkow, the former Director of National Institute on Drug Abuse (NIDA) testified
to Congress: “In fact, recovery from addiction is an established reality, achieved through a
variety of treatment modalities when they are matched for the needs of individual patients.
Numerous studies have shown that addiction treatments are comparable in effectiveness
to treatments for other chronic illnesses. (9)”
The Government (and NIDA) now holds that addiction is a long-term and treatable disease
much like diabetes, hypertension, or cardiovascular disease. It is now well established that
long treatment adherence and the maintenance of attitude and lifestyle components of recovery are as essential to the rehabilitation of addictions as they are with other chronic
diseases. In fact, dropout rates for addiction are similar to those for these other chronic diseases (10). Establishing the proper type, duration, and match of treatment has become an
essential part of the diagnostician’s expertise and clinical skills.
The research literature has shown that treatment must last, on average, at least 3 months
to produce stable behavior change and that the longer treatment lasts the more positive the
likely outcome (4). While the exact length of time will vary by individual, programs lasting at
least 90 days (and preferably longer) have been much more effective in reducing drug
abuse and criminal activity.
Treatment of over three months (regardless of the type) begins to show dramatic improvements in the percent of patients maintaining recovery. Obviously, a specialist’s skills related
to the type of therapeutic bonding during detoxification process and their ability to diagnose
and provide treatment for multiple disorders and problems related to substance abuse will
affect the duration of therapeutic engagement and thereby outcomes.
The IOM (5) holds that without a comprehensive strategy to improve the quality of health
care for people with mental conditions and alcohol or drug problems, high-quality care in
the nation's overall health system and better health for the public are goals that will remain
unmet. The report indicates that America will not have a quality health care program if
equal attention is not given to physical and mental health and substance abuse treatment.
Crogran and Brown (1) indicate that physicians will need significant additional training and
modifications to their training curriculums, and they will need collaboration with behavioral
health specialists to improve quality of care in our nation’s hospitals and primary care sys55
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tems. Bray and Rogers (11) indicated this collaboration is likely to occur only if physicians
and psychologists are located in close proximity and in active collaboration in training facilities. Currently, no standards in hospitals or nursing homes or other primary care facilities
exist to require adequate multidisciplinary care staffing to accomplish more than cursorily
screening and superficial treatment for mental disorders.
The multidisciplinary staffing deficits and their effects are acutely apparent in the area of
alcohol detoxification and the treatment of substance abuse. Medical personnel, rightfully
view detoxification and pharmacological control of cravings as paramount and focus on
the physical aspects of the case, but are not required by law to refer and do not routinely
provide linkages with behavioral health specialists. However, the psychologist and substance abuse treatment team view these facets of treatment as just the tip of the iceberg
and only the beginning of treatment. Psychologists with in-depth training and experience
view addiction as a more complex psychosocial and habitual and compulsive process that
takes much more than physical restabilization, control of cravings, and medical education.
These specialists understand that detoxification, while an opportunity to build a trusting
and enduring alliance and to program expectations for the course of therapy is only a small,
if not the simplest, part of treatment and recovery from addiction. Complex diagnosis and
ruling out or screening for co-occurring disorders commonly required. Furthermore, individualized and culturally and intellectually adapted treatment techniques, and intensive family
treatment are often necessary and maybe beyond the skill and experience level of physicians and nurses.
Psychologists and Foundational Detoxification Skills:
An analysis of the U.S. health system indicates that services for alcohol and drug conditions
have been isolated not only from other components of the health system but also from
each other, despite the fact that many people have both mental conditions and problems
with alcohol or drugs (1,3). The IOM and recent Integrated Care approach recommend merging statutes with emerging government concepts of healthcare reform in order to make collaboration and coordination of care the norm. Service providers should link, or merge
relevant areas of their own organizations and form ties with other providers. Government
agencies, purchasers, health plans, and accrediting groups are advised to create incentives
and policies to increase collaboration among all health care providers.
The U.S. Department of Health and Human Services (HHS) is admonished to lead these
efforts by establishing a permanent, high-level mechanism to foster greater coordination
across the department's mental, substance-use, and general health care agencies (1). This
integration of care is what many psychologists and others have been advocating for some
time (6, 12, 13). Some have said for years that more integrated care would find primary care
clinics, hospitals, nursing homes, and county and rural health clinics offering a wide range
of diagnostic and treatment services to include mental health and substance abuse assessment and treatment (12). It is well documented that these centers do a poor job of diagnosis of mental disorders and of linkage of the patient with proper treatment and treatment
expertise (14, 6, 12). Thus, many have pointed out that recent efforts to provide brief and superficial physician continuing education relevant to screening and prevention, and to put the
general physician in charge of supervising nurse delivered prevention programs is just
more of the same solution that leaves primary care centers poorly and inadequately staffed
without psychologists and other medical staff routinely available to diagnose and meaning-
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fully engage the mentally ill patient in behavioral interventions and rehabilitation programs.
Serious mental disorders, substance abuse, and some physical health problems rarely
occur in isolation from each other. There is now clear and compelling evidence that mental
health and substance abuse problems very often occur together and that their long-term
results contribute to the occurrence and negative course of heart disease, cancer, diabetes,
and some neurological disease (3). Our health care system’s track record for identifying
and getting appropriate treatment to patient’s with mental disorders is found wanting in
comparison to those of other countries (5). We have maintained that standards for accreditation and federal funding must be changed. Psychologists have advocated for certification
standards for health facilities to require that psychologists must be on staff at primary care
centers, hospitals, and other health facilities and that psychologists must be viewed as an
integral and essential part of the primary care team. Now a major analysis of the health care
system agrees!
This is a real transition point for psychology and the healthcare system. There is a clear national recognition of the problem of poor quality, poor coordination, fragmentation and failure of the primary system to staff appropriately and develop the vision to treat all relevant
illness. Psychology has a chance to develop and forward a leadership vision using the
foundations of the IOM report. In our hospital emergency rooms we don’t have the personnel, interest, and formal mechanisms to identify the need for mental health and substance
abuse treatment and link them with appropriate specialists and program resources (6, 14).
Kessler, et al. (15) report that only about 40 percent of adults needing treatment for mental
disorder actually get treatment and a lower percentage of children and adolescents get
care.
The IOM also identifies the problem of effective mental health and substance abuse treatments being available, but that there is a lack of uniformity and that quality treatment based
on scientifically proven techniques are not available. Substance abuse treatment centers
often don’t have psychologists and psychiatrists, or have “drop in” doctors who are not really in the mainstream of service delivery. Mental health centers are distant and disconnected and poorly coordinated with primary care centers. Psychologists and psychiatrists
are not integrated on the medical staffs of both substance abuse and mental healthcare facilities. This results in discontinuity of care that is prevalent.
This situation of under-diagnosis and under-treatment of mental health and substance
abuse problems is rampant in our American health care system. The current healthcare
system was devised and has been maintained on a medical model of illness that predates
much of modern research. Mental disorders and substance abuse were excluded from
health insurance plans and ignoring the disabling prevalence and contribution to major
medical disorders that they cause. Medical guild interests imbedded as government regulators of public health policy have thwarted modernization of healthcare with more efficient
and effective biopsychosocial treatments. The primacy of the medical view of illness has
inflated the costs of healthcare by monopolizing treatments to medical facilities and has
denied access to care by existing outpatient resources not under control of medicine.
Recently trained physicians and health care administrators tend to recognize biopsychoscial and have formal multi-disciplinary management committees in their health care facilities
to plan, program, and implement best practices and specialists are available to improve the
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quality of care to mental patients. These new efforts often take into account the concepts
of “autoplasticity” in scientific findings that indicate even our brain can be revised with redesigned cyto-architecture forged by long-term interventions (5). Public health policy and
regulations must be changed to incorporate reimbursement for the use of this newer
biopsychosocial model.
If national organizations representing doctors of psychology do not act on this data, the information will not be used to change the medical model in these facilities and incorporate
the biopsychosocial model. The medical model establishment will quickly move to give
general physicians and nurses a “little” training in how to use depression scales and how
to deliver a “taste of cognitive or manualized therapy.” That approach has been tried and
documented to have failed (6). These patches are not likely to be substantive redress of
the major problems identified by the IOM report. Psychology as a profession has a brilliant
opportunity to assert itself. It must be seen if psychology can focus its’ national resources
and organizations on capitalizing on this opportunity to improve the health care system
and to shift it to the biopsychosocial model that is supported by the scientific evidence. In
order to relate to physicians and the medical members of the team, the medical psychologist must understand both the psychology and stages of recovery and pathophysiology
of addiction.
The following principles have not been reviewed by the FDA, but are well known clinical interventions. Psychologists are increasingly the first line professionals sought by families of
addicted individuals. Individuals suffering from addiction need comprehensive assessment.
This is required due to the high prevalence of dual diagnosis and mood disorders leading
to increased mortality and relapse and regressions. Further, many addicted individuals
need family therapy due to co-dependency issues, which reinforce and maintain addiction
and block recovery. Additionally, patients often need help with withdrawals and detoxification (provided by the medical psychologist practicing Level III-prescribing, or Level II consulting services in collaboration with a prescribing professional). Psychologists are one of
the few diagnostic and treatment specialists with all the training and skills necessary to
manage these patients. These principles focus on those detoxification skills that the Level
III or II psychologist needs to fulfill these roles. To relate to physicians and the medical
members of the team, the medical psychologist must understand both the psychology and
stages of recovery and pathophysiology of addiction.
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Pathophysiology
Figure1. presents a diagram of the areas of the brain highlighted that are involved in
detoxified with various classes of substances.
Figure 1
The physical aspect of addiction has been postulated to involve neurophysiologic reinforcement (reward) in the mesolimbic "reward pathway" (16). This pathway involves
dopaminergic neurons originating in the ventral tegmental area (VTA) and projecting to the
forebrain nucleus accumbens and surrounding area. These mid brain and more ventral
forebrain dopaminergic neurons are probably under continuous inhibition in the VTA. This
inhibition of action has been postulated to be mediated by gamma-aminobutyric acid
(GABA). Release of dopamine from these neurons onto the dopamine receptors in the
nucleus accumbens is theorized to produce positive reinforcement.
Alcohol and sedatives (benzodiazepines and barbiturates) are mood-altering drugs that
depress the level of central nervous system arousal. They are said to enhance the actions
of the GABA, an inhibitory neurotransmitter, which are mediated by the GABAA receptor (17).
GABA binds to its receptor and opens chloride channels. This is thought to hyperpolarize
the membranes and lower cell excitability. The long-term cellular changes engendered by
this recurring process (up regulation) seem to interact with the reinforcement pathways
through mechanisms that include the endogenous opioid systems and we know that craving for alcohol can be at least partially blocked by the opiate antagonist Naltrexone
(Trexan). Benzodiazepines and barbiturates are agents hypothesized to open the chloride
channels through their actions at specific receptors. Ethanol apparently interacts with the
GABAA receptor complex. There is not a specific receptor for ethanol.
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Symptoms of Alcohol Withdrawal:
• Restlessness, irritability, anxiety, agitation
• Anorexia, nausea, vomiting
• Tremor, elevated heart rate, increased blood pressure
• Insomnia, intense dreaming, nightmares
• Impaired concentration, memory, and judgment
• Increased sensitivity to sounds, alteration in tactile sensations
• Delirium (disorientation to time, place, situation)
• Hallucinations (auditory, visual, or tactile)
• Delusions (usually paranoid)
• Grand mal seizures
• Elevated temperature
These symptoms do not always progress from mild to severe in a predictable fashion.
Monitoring of the patients symptoms needs to be done every 1 to 2 hours. If systems become overwhelming, this may be a sign for additional medications, increased treatment
support, closer outpatient monitoring, a day treatment placement for closer monitoring
and flexibility in adjusting treatment (nursing, group counseling, individual psychotherapy
focused on deep breathing, relaxation, biofeedback, cognitive interventions to decrease
anxiety and help the patient understand symptoms without panic or escalation, interpersonal support).
Benzodiazepine Treatment of Alcohol Withdrawal:
Librium is currently the most commonly used medication for alcohol withdrawals in this
country. Benzodiazepines, such as chlordiazepoxide (Librium), clonazepam (Klonipin), clorazepate (Tranxene), and diazepam (Valium), are considered effective tools in ameliorating
signs and symptoms of alcohol withdrawal because these drugs decrease the likelihood
and number of withdrawal seizures and episodes of delirium tremens. Sera (Oxazepam)
or Ativan (lorazepam) are sometimes used with patients who have severe liver disease,
since neither of these medications is metabolized by the liver.
Regimens include:
Gradual, tapering doses are required. Benzodiazepines are administered on a dosing
schedule for several days and gradually discontinued. Dosing protocols vary widely among
treatment facilities. Patients may receive 50 mg of chlordiazepoxide (or 10 mg of diazepam)
every 6 hours during the first day and 25 mg (or 5 mg of diazepam) every 6 hours on the
second and third days. Omit the dose if the patient is sleeping soundly or showing signs
of over sedation.
• Symptom-triggered Therapy is sometimes indicated. Doses are the same and are
given when symptoms rise to an intolerable level (about every 6 hours plus or minus
depending on the individual).
• Loading dose protocol. In this protocol, the staff administers a slowly metabolized
benzodiazepine for only the first day of treatment. Patients in the moderate-to-severe
withdrawal receive 20 mg of diazepam (or 100 mg of chlordiazepoxide) every one to
two hours until they show significant clinical improvement or become sedated. This is
called “bringing the snow” in the profession. Some evidence exists that patients
treated with symptom-triggered therapy complete their treatment courses more
rapidly and require less medication than fixed schedule approaches.
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• Some patients can be withdrawn from alcohol without medication treatment, but there
are no sufficient guidelines for identifying which patients best fit this approach. Clinically it is safer and often more humane to provide medication step down schedules
for patients.
Less Used Medications:
Carbamazepine (Tegretol) is a medication used for the treatment of seizures and is sometimes effective in the treatment of alcohol withdrawal. Anticonvulsants with and kindling
properties may be superior in some patients to traditional benzodiazepines because they
simultaneously prevent withdrawal seizures and may reduce long-term neurological, behavioral, and psychiatric complications of alcoholism. Propranolol (Inderal) and other BetaBlockers are sometimes used for autonomic nervous system hyperactivity of some alcohol
withdrawal episodes. Rapid heartbeat, elevated blood pressure, sweating, and tremors are
ameliorated by these medications (Inderal and Tenormin) which act by blocking beta-adrenergic receptors. Beta-blockers do often reduce autonomic symptoms during withdrawal,
but they do not control hallucinations and confusion or withdrawal seizures. Inderal may
also increase the risk of delirium and hallucinations during alcohol withdrawal.
Treating Delirium Tremens and Seizures:
Delirium tremens (DTs) are one of the severe symptoms of alcohol or sedative-hypnotic
withdrawal. Patients with DTs with auditory, visual, or tactile hallucinations often need antipsychotic medications for control Haldol has been used extensive for these patients (PO
or by IM injection). Prescribers continue to give the regular dose of benzodiazepines during
Haldol treatment. Phenothiazines should not be used for these patients due to their exacerbation of chances for seizure.
Some studies have shown that benzodiazepines are useful in treating DTs.
Experts disagree as to whether phenytoin (Dilantin, and other anticonvulsants) should be
used in addition to sedative-hypnotic drugs in patients with a history of seizure, head injury,
meningitis, encephalitis, or a family history of seizure disorder.
Phenobarbital can be used for alcohol detoxification and is a favorite of older practitioners
who used it extensively in hospital settings where patients are controlled. It is oft used
when the patient is addicted to sedative-hypnotics and alcohol in combination.
Naltrexone is approved as an adjunct treatment to reduce relapse in alcoholics. Naltrexone
(previously called Trexan, and now called ReVia) is an opioid antagonist that has been previously used primarily to block the effects of heroin and thereby reduce the likelihood of relapse.
It has been shown to suppress urges and cravings in conjunction with supportive therapy.
Vitamins are often used to address characteristic vitamin deficiencies (particularly thiamine)
in alcoholics. Most clinicians agree that patients should be given thiamine and high-potency
multivitamins.
Antidepressant Drugs:
The literature indicates that as many as 30 percent of alcoholic patients may suffer from a
Major Depression beyond the detoxification period. These patients may benefit from antidepressant medication. The antidepressants can be used without difficulty in patients taking
disulfram and Lithium.
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A Special Problem:
Since vomiting precludes oral medication, intramuscular routes of administration (IM) are
sometimes necessary. Absorption of diazepam, (Valium) or chlordiazepoxide (Librium) after
IM administration is unpredictable. Lorazepam (Ativan) is more often used as a reliable
and predictable choice. Lorazepam is generally administered at 2 mg every hour until signs
and symptoms subside.
Medical Complications of Alcohol Withdrawal:
A key to managing withdrawal is maintaining the patient’s fluid and electrolyte balance.
Most patients can be supplied fluids orally in the form of juices and progressing to soups.
Finally, solid foods can be added only after the patient can tolerate liquids well. Patients
who may be dehydrating (due to vomiting or diarrhea) should receive intravenous fluids
containing electrolytes, dextrose, and thiamine (100 mg/bottle). Watch out! Not all detoxifying alcoholics are dehydrated, and some may be over hydrated (use caution in forcing
fluids and causing edema and systemic problems).
Hypoglycemia is a significant danger for these patients and oral fluids should contain carbohydrates. Orange juice is often used (using 10 percent ethanol in 5 percent dextrose
drip in most cases upon admission.
Fever should be investigated and determined as a symptom of withdrawal or a signal of infection. If infection is the cause, a physician or nurse practitioner should treat it by linkage
or referral.
In addition, watch for drug interactions during withdrawal. Anti-hypertensive medications,
clonidine, phenytoin (Dilantin) and methadone and rifampin and methadone are dangerous
combinations in these cases.
Psychological Disorders Co-occurring with Addiction:
Patients with psychological disorders present management problems, engagement and
retention problems, danger of suicide during detoxification and related stress and just afterward when they must reintegrate into the world without alcohol and familiar associates.
Psychological assessment, frequent sessions of psychotherapy in the first week, and particular care at 2 days, 4 days, and 7 days when physician and psychological stress is greatest is recommended.
Detoxification itself is not treatment; it represents a physiological adjustment that prepares
the patient for treatment. Patients should be prepared during detoxification for this reality.
In the treatment of addiction, establishing the frame, dealing with expectations, and using
the detoxification process to help the patient understand the interplay between the physiological, behavioral, relational, and lifestyle aspects of addiction is important preparatory
work for the approximately two years of treatment necessary to effect an enduring and solidified recovery.
This is another reason for the early involvement of the psychologist in the detoxification
process whether they are the prescribing professional, pharmacological consulting professional, or the behavioral health professional on the detoxification team. The data and clinical experience make a good case that the psychologist is an essential professional on the
detoxification team. This is true whether the detoxification is done in an outpatient setting
(a first line treatment), in a licensed healthcare facility, or a psychiatric hospital. Further,
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since the family is essential to the outpatient detoxification process and to ensuring the
patient’s engagement in necessary aftercare, the psychologist inclusion during detoxification allows for bonding with and engagement of the family and for effective family psychoeducational interventions and monitoring.
An essential point is that detoxification is a cart without a horse and likely doomed to failure
as a technique in a comprehensive intervention and treatment plan without a psychologist
diagnostician and behavioral health specialist to act as the adhesive and bridge to the required protracted care and patient compliance and adherence necessary for optimal outcomes. Without the involvement of the psychologist, one could make the case that the
detoxification is economically wasteful, inefficient, and even malpractice (providing inadequate treatment given the science relevant to positive configuration of the case and acceptable outcomes).
However, we know that treatment for substance abuse disorders is poorly coordinated with
detoxification, linkage among medical and psychological providers, and there is exceedingly poor diagnosis and treatment available in most areas of the United States (5). There
is much clinical and published evidence of poor treatment and diagnosis and probable malpractice. However, the Mental Health Parity and Addiction Equity Act of 2008 will provide
a stream of funding that will provide financial incentives for hospitals and primary care centers to add psychologists to hospital and primary care center staffs. We know that the proximity and collaboration of medical personnel and psychologists is crucial to the quality of
care (11). We know that hospitals and medical personnel doing emergency and detoxification
services are poor at recognizing and diagnosing the addicted and mentally ill patients and
getting them to appropriate specialty care (6, 14). It is well established that chronic alcoholics
demonstrate a high incidence of brain damage (19) and mental illness that is co-morbid to
addiction (18, 19) relevant to treatment planning post detoxification.
Because of the complex nature of assessment and diagnosis of the multiple types and
severity of addiction, co-morbid disorders requiring individualized treatment planning and
specialty interventions in most detoxified addicted individuals, a clinical psychologist with
specialized expertise in addictions treatment should be engaged with the patient as early
as possible in the detoxification process. To rise to this need, The American Board of Medical Psychology was founded to identify psychologists with postgraduate education and
preceptorship in psychopharmacology, behavioral medicine, and treatment of physical disorders with partial psychological etiology. These specialists have completed post graduate
organized training, passed one or more national examinations, and are prepared to provide
advanced diagnostic and treatment, and program leadership roles in America’s hospitals
and primary care systems.
The American Psychological Association provides a listing of psychologists with special
proficiency certification in the Treatment of Alcohol and Other Psychoactive Substance Use
Disorders (20). These specialists have amassed post graduate organized education and supervised experience in addictions diagnosis and treatment and have passed a national examination. They are ready to staff the nation’s hospitals and primary care centers and
primary care facilities to increase the quality of care in addictions. These two specialist
psychology groups are more than adequately prepared to staff hospital and primary care
leadership positions and direct substance abuse program psychologist, physician, and
nursing personnel.
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Medical psychologists are encouraged to use this and other documents from the Institute
of Medicine and the Agency for Healthcare Research and Quality (1) to educate their practice
partners, facilities management, colleagues, and community about effective substance dependence detoxification and comprehensive treatment planning. This and supplementary
information may be used to establish improved quality of care regarding individuals with addictions and for the development of appropriate local and facilities staffing and treatment
protocol expansion.
A Useful Instrument:
The Addiction Research Foundation Clinical Institute Withdrawal Assessment-Alcohol scale
(CIWA-Ar) is a public domain instrument that allows the practitioner and team to evaluate
the level of symptoms objectively each 24 hours of detoxification (http://www.erowid.org/
chemicals/alcohol/alcohol_ARF_withdrawal_scale.shtml and http://www.ncbi.nlm.nih.gov/
books/bv.fcgi?rid=hstat5.table.40602 ). The scales allow the rater to rate nausea and vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and orientation and sensorium and place them on
a 0-67 point continuum. Patients who score higher than 20 on the CIWA-Ar should be admitted to a hospital for further detoxification.
1.
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3. Galanter M. Network therapy for addiction: a model for office practice. Am J Psychia
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4. Institute of Medicine. Extent and adequacy of insurance coverage for substance
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and private drug treatment systems. US Dept HHS, Drug Abuse Services Research
Series No. 2. 1992.
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abuse services. Vol I. A study of the evolution, effectiveness, and financing of public
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13. Haley WE, McDaniel SH, Bray JH, Frank RG, Heldring M, Johnson SB, Lu EG,
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Tips for Clinicians. Prof. Psychol: Res & Pract. 1998 29 (3), 237.
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1991 London: Academic Press, Harcourt Brace Jovanovich.
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