A Life Unexamined? - Physician, Know Thyself!

     A healthy, conscious relationship with one's own emotional life - ie self-awareness & self-acceptance - is rare, not just in patient populations, but equally among clinicians. Unconscious emotions continuously manifest themselves, to our detriment, influencing our thoughts, mood, speech, behavior, and our physical & emotional health.
     As mature adults, we owe it to ourselves & those around us to intentionally, intelligently, gently, progressively, cultivate self-awareness & self-acceptance. Mindfulness meditation is an evidence-based way of doing precisely this. Physician, it's time to know thyself! 
     See: http://mindfulnessforeveryone.blogspot.ca/2013/07/373-how-free-is-our-free-will.html

     "When feelings are frightening, conflicted, or deemed unacceptable they generate anxiety & defence mechanisms that act to blanket this anxiety (Fig. 1). This is usually the fate of emotions in children traumatized, abandoned or neglected by loved ones, who then have feelings of love mixed with rage and guilt about the rage. When these mixed feelings are unconscious to the patient, the subsequent anxiety and defences are also outside of awareness or unconscious. In essence, the rage or anger is turned inward into somatic symptoms both to protect the other person from the rage and to serve as a form of self-punishment for having the rage to begin with. Thus, the child develops the pattern of turning anger inward and is thus prone to somatic complaints, including abdominal pain, headache, depression, personality problems and other conditions. When later life events raise the threat of emotional pain and abuse, the rage is ‘turned inward’ into acute or chronic anxiety & somatization. The other person in the relationship is safe from the rage, but the process exacts a high toll for the adult sufferer through the range of symptoms and behaviours required to contain these emotions."
        Abbass A, Lovas D, Purdy A. Direct diagnosis and management of emotional factors in chronic headache patients. Cephalalgia 2008; 28(12): 1305-14.

Fig 1 - Relationship between unconscious feelings, anxiety, & defenses

Physical Symptoms from Unprocessed, Dysregulated Emotions

     "advances in research suggest that many medical symptoms without identified pathology may actually be caused by problems in psychophysiologic or brain-body pathways, such as abnormalities in smooth-muscle tone in the gastrointestinal tract during stress in patients with irritable bowel syndrome. Recent research also suggests that links between perturbations in brain physiology and physical symptoms are bidirectional. Changes in brain physiology secondary to stressful life events cause functional abnormalities in the body (such as abnormalities in smooth-muscle tone in the gut), and these functional abnormalities in the body are also associated with changes in brain physiology."
     Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med 2001; 134(9 Pt 2): 917-25.
 
     "Somatization ... the translation of emotions into the development or worsening of somatic problems or complaints, is a massive burden on patients, physicians, the healthcare system & society in general, accounting for a major proportion of family physician & specialty medical visits, as well as excessive tests, medications & hospital use. Furthermore, it is a major cause of disability, corporate financial loss and probably contributes to early mortality.
     (In one study) 19% of ... sufferers of recurrent headaches were felt to be manifestations of somatization. ... alexithymia, or problems identifying and feeling emotions, was strongly associated with recurrent headache. ... many headache sufferers are psychologically distressed ... poor insight into emotional processes or alexithymia prevented the detection & treatment of these factors. ... there is a need for the development of specific assessment methods to detect relevant emotional and psychological factors in headache sufferers.  
     Specifically, headache sufferers have been shown to have difficulty regulating anger. Many headache patients tend to turn anger inward towards themselves. This effect was experimentally illustrated when migraine patients and controls were subjected to an anger-provoking situation. The migraine patients exhibited significantly less overt anger behaviour & experienced a significantly greater rise in pulse pressure than controls in the anger-provoking situation. ... anger turned inward was the most predictive of headache. Almost half of their sample of headache sufferers scored highly on anger-in, compared with only one-sixth of the matched no-headache control group. The internalization of anger and/ or trouble identifying anger has been found in high rates in patients with conditions such as irritable bowel syndrome (IBS), depression and hypertension, which are often comorbid with headache." 
       Abbass A, Lovas D, Purdy A. Direct diagnosis and management of emotional factors in chronic headache patients. Cephalalgia 2008; 28(12): 1305-14.

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How I Feel Affects My Decisions & Patient Care

     "Historically, the prevailing view in medicine is that clinical decisions should be objective and free from contextual affective issues: one could not be objective and rational if emotion entered the reasoning process. Indeed, many of us would consider it a professional virtue to be able to rise above the emotional pull of clinical situations, to deliver cool, clear, analytical judgments. However, despite what we might believe, our feelings (affect) intrude into almost every decision that we make. Our daily interactions with others are influenced by conscious or unconscious social transference phenomena which are affectively polarised in ways that range from subtle to substantial. Similarly, specific clinical situations provoke lesser or greater degrees of affective valence. In fact, our first response to anything is an affective one that governs the future direction of our relations — we tend to trust our first impressions and stick with them. To then understand the role that affective state has in clinical decision making seems important. 

     The best evidence might be degraded when it is unconsciously passed through an affective filter."
       Croskerry P, Abbass AA, Wu AW. How doctors feel: affective issues in patients' safety. Lancet 2008; 372(9645): 1205-6. 


     "Within mindfulness, the busy physician may find a practical place to begin. Through the cultivation of mindfulness, the busy physician can find clues to the self and to the other, as well as to the aspects of inter-being that not only set the intention of the medical encounter but also provide boundless information and the basis for right action."
       Physician, Know Thyself, Michael Krasner, Shambhala Sun, September 2007.

 

snellius   www.dpreview.com