Case 2: Smooth muscle anxiety
This patient is a 38 year-old woman with severe incapacitating GERD, irritable bowel syndrome, and depression who was disabled from work for 2 years at the time of consultation. This woman had a very relaxed posture with relaxed hands and an absence of obvious anxiety. After 10 minutes of exploring situations and events that make her stomach worse, we arrive at the following point.
- DOCTOR: Can you tell me about another time when your stomach felt worse?
- PATIENT: Yes. There was once when my sister-inlaw did something and it made me angry. Yeah, when people make me angry I don’t tell them, I just avoid them.
- DOCTOR: Can you describe one of those times, so we can see how that affects you.
- PATIENT: Once she was arguing with my brother, like they usually do….
- DOCTOR: How did you feel then?
- PATIENT: … Now I just got that again [pointing to her stomach and chest with upward motion and burps]
- DOCTOR: Heartburn? Just came on?
- PATIENT: Yeah, heartburn, just came on.
- DOCTOR: Is there anything else you notice? Like in your stomach?
- PATIENT: No, just that … but I can hear my stomach churning.
- DOCTOR: So is it when you have anger your stomach churns and you get this acid?
- PATIENT: Must be….
- DOCTOR: …because in your approach to talk about anger you got cramps and acid. So is that one way the anger goes?
- PATIENT: Yes it must be, but I never thought of that part. [Stomach stops churning and heartburn stops as we talk about it for few minutes.] You know, this all started to get worse when my fiancé dumped me. [She goes onto describe a story of being not only rejected but also feeling humiliated by how it was done. She never felt emotional about it but just got severe diarrhea and was confined to her room for 3 weeks.]
- DOCTOR: How did you feel toward your fiancé when he dumped you that way?
- PATIENT: I was just so sick and depressed. I didn’t feel any anger. [Patient burps again this time rubs abdomen due to some discomfort.]
- DOCTOR: Did you get the stomach upset just now again?
- PATIENT: My stomach is upset again. Just the noise and acid again.
- DOCTOR: So again, when we focus on the feelings, the cramps and acid come back.
- PATIENT: For sure. What can we do about that?
- DOCTOR: Can we try to help you identify these feelings before they go to your stomach, to try to interrupt that process. Can you tell me about another incident like that?
The patient required 3 one-hour sessions to improve her tolerance of anxiety, so she could intellectualize about feelings rather than have them directly affect her stomach. The feelings of rejection had triggered rage and guilt about rage associated with sexual abuse by her brother and the abandonment she felt from her mother when she told her mother about it. With 12 sessions of therapy, she was able to stop her IBS medication, anxiolytic, and antidepressant.
This vignette is typical for patients with primarily smooth muscle unconscious anxiety. The patient had no visible anxiety but had GI symptoms when focusing on emotions about recent trauma. The symptoms were mobilized and reduced repeatedly, confirming a link with emotions. Note that outwardly she looked calm, but the emotions mobilized were being shunted to her GI tract.
Incorporating emotion diagnostics into practice
To perform these interview procedures, the physician must understand emotion physiology and the patterns of somatization as outlined above. This is entirely intuitive to many physicians the first time seeing this material: they can readily employ that which they already know. In general, though, physicians reading this will want to ponder it and see how it may apply case by case as they develop skills with it over time. Senior clinicians have usually done these assessments by default, by pressure from patients, or because they learned elements of this over time from various experiences.
Helpful short-cuts
Family physicians trained in emotion assessment note that abbreviated elements can easily be incorporated into a patient-centered assessment process. For example, one may ask how “stress,” “emotions,” or “anger” affects the person and their body or ask how the person handles anger in specific incidents.
In an initial patient questionnaire, one can include a few questions that encourage the patient to think about how stress affects them and to describe their body’s tendency to experience anxiety. When they later present with symptoms, one can use these baseline data to aid in the new assessment. Thus, a culture of considering emotional factors can be woven into practice, weakening any resistance to the idea that emotions and health, mind and body, are tightly bound.