I went to the 46th Annual OHSU Primary Care Review, held at the Sentinel Hotel in Portland, Oregon last week.
It was excellent. It was surreal since the Sentinel Hotel started as a 1923 Elks’ Club and the satyr cupid friezes kept distracting me with the marble penises and war chariots during the lecture updating us on urinary incontinence.
Three lectures that I went to talked about Adverse Childhood Experiences.
This is the first conference that I’ve been to that anyone has talked about that study since I heard about it, in about 2005. I have not been to a lot of big conferences over the last few years because I opened my own clinic and money was tight.
Anyhow, the study is creeping into consciousness.
In the mornings, we had the big lectures in a large hall. There were three break out sessions in the afternoon, held in the main meeting, billiard room, club room and library. We all joked about Colonel Mustard and candlesticks.
A gastroenterologist, Dr. David Clarke, gave a two hour session titled “Hidden Stresses and Unexplained Symptoms II”.
1. How to uncover the cause of an illness when diagnostic tests are normal.
2. How to find hidden psychosocial stresses that are responsible for physical symptoms.
3. The process used to achieve successful outcomes in stress-related illness.
He talked about childhood stress. That if someone had a really difficult childhood:
“Surviving a dysfunction home is a heroic act and produces individuals who are:
a. reliable and get things done
So what is the down side? “Surviving a dysfunctional home also produces emotional consequences that may lead to :
a. Long-term relationships with partners who treat you poorly.
b. Addictions to nicotine, Alcohol, Drugs, Food, Sex, Gambling, Work, Shopping, Exercise.
c. Quick Temper or being violence prone
d. Anorexia and/or bulimia
e. Mental health problems such as nervous breakdown or suicide attempts
f. Sacrificing your own needs to help others
h. Learning not to express or feel your emotions.”
Got that? Right. Not everyone, not all the time, but the adverse childhood experiences add up. These reliable individuals may eventually get enough positive feedback to decide that they deserve a relationship that is actually good. They may get angry about their childhood or past bad treatment. “They may have a really hard time expressing that anger because they spent years learning how to suppress emotion and the feelings may be directed at people for whom there is still some caring. When there is enough of this anger present it can cause physical symptoms that can be mild or severe or anywhere in between.”
Let me give two examples from my own practice. I can’t remember their names or the details, so I am making those up: no hipaa violation.
The first was an elderly woman who came in with her husband for stomach pain. We started with a careful history. We tested for helicobacter pylori. We tried ranitidine. We tried omeprazole. We studied her diet and did an ultrasound to rule out gallbladder disease.
At the third visit I was starting to talk about an upper endoscopy. This was more than 15 years ago, back when we did not start with a CT scan. Her husband said, “Doctor, is there anything else it could be?”
I was surprised. “Well, yes. Depression is on the diagnosis list. Sometimes depression can present as stomach pain. Could you be depressed?”
My elderly lady covered her face with her hands, started crying and said, “I try not to be!” while her husband nodded.
We cancelled the endoscopy. I said it really was not something to be ashamed of and we talked about therapy. She did not want talk therapy and we tried paxil. She came back in two weeks, and already she and her husband were brighter and relieved.
Second case: again, stomach pain, this time in a four year old. Mom brought her in.
I did a history and did a gentle exam. The exam was normal. Her stomach was not hurting now. She wouldn’t say anything.
We established that the stomach pain occurred on week days only, not on the weekend. In fact, usually at the after school daycare, not in school.
“Is there a time at the school daycare that she has stomach pain?” Mom was shaking her head when big sister piped up.
“It happens before recess.” Mom and I turned to stare at the six year old.
I said, “What happens at recess?”
“The big kids knock her down,” said big sister, pissed. “I try to stop them, but they are bigger than me. She’s scared. The teachers don’t see.”
“Oh. Thank you for telling us!” Little sister was crying and mom hugged her and big sister. Mom did not need instruction at that point. She called me a few days later. She talked to the daycare, they watched and the four year old was protected. Her stomach stopped hurting.
Dr. Clarke also described a case, where driving through a town would trigger four days of nausea and vomiting that required hospitalization. This had been going on for 15 years. He figured out why that particular town was a trigger: when the patient recognized the why, he was able to go for therapy.
People aren’t lying about these illness, they are not making them up. Doctors have called it somatization, but really it is the body holding the emotions until the person is safe enough to deal with them. Doctors need to learn how to recognize this and help with respect instead of stigmatization and dismissal.
I hope that more doctors learn soon…
Dr. Clarke’s list for further reading is below. I don’t have any of these yet, but they are on my wish list.
They can’t find anything wrong!, by David Clarke, MD. See also www.stressillness.com
Psychophysiologic Disorders Association: www.ppdassociation.org
Caring for Patients, Alan Barbour, MD
Unlearn Your Pain, Howard Schubiner, MD
Pathways to Pain Relief, Frances Anderson PhD and Eric Sherman PhD
Ted talk about ACE scores: http://www.acesconnection.com/blog/nadine-burke-harris-how-childhood-trauma-affects-health-across-a-lifetime-16-min