President of Psychophysiologic Disorders Association, Dr. David Clarke comes on the podcast to talk about emotional awareness and expression therapy. He talks about the incredible results he has had using Pain Reprocessing Therapy to treat chronic pain and the difference in can make in your practice and life.
“One physician who learned these ideas told me at a conference that it had put the joy back into her work. So, it really can turn a practice around to learn how to do this.” -Dr. David Clarke
In episode 163, Dr. Jen Barna welcomes Dr. David Clarke to the podcast! Dr. Clarke is a gastroenterologist, President of the Psychophysiologic Disorders Association and author of They Can’t Find Anything Wrong! Psychophysiologic disorders are somatic illness symptoms induced by hidden stressors. When he began his practice as a GI doctor, Dr. Clarke noticed a large number of his patients had symptoms, some so severe they resulted in multiple hospitalizations, with no identifiable underlying cause. This observation was the beginning of his journey toward identifying these patients and connecting their physical illness with hidden stressors, and then treating them with what is known as Pain Reprocessing Therapy with tremendously successful results.
In the first half of this episode, Dr. Clarke shares the reasons that psychophysiologic disorders can be common in healthcare workers, and how they are also very common among patients. He tells us the five different types of stress he looks for in the systematic process he uses to evaluate patients, to identify the different kinds of stresses that can commonly produce physical symptoms. He also shares success stories of patients he has treated. This is a fascinating field and according to Dr. Clarke, “When you are aware of it and know to look for it, that is how you achieve the best outcomes.” This is a two-part interview, so please join us for Episode 164 on Thursday for the continuation of this conversation!
David D. Clarke, MD is President of the Psychophysiologic Disorders Association. He is also Assistant Director at the Center for Ethics and Clinical Assistant Professor of Gastroenterology Emeritus both at Oregon Health & Science University (OHSU) in Portland, Oregon, USA. As Faculty Associate at Arizona State University and at the Cummings Graduate Institute for Behavioral Health Studies, he teaches graduate courses on Psychophysiologic Medicine. His book for patients, They Can’t Find Anything Wrong!,(Sentient Publications, 2007) was praised by a president of the American Psychosomatic Society as “truly remarkable.” He was also the lead editor for the professional textbook Psychophysiologic Disorders (KDP Publishing, 2019) which has sixteen contributors from five countries.
He is board-certified in Gastroenterology and Internal Medicine and practiced Gastroenterology in Portland from 1984 to 2009. During that time he diagnosed and treated over 7000 patients whose symptoms were not explained by diagnostic testing.
Dr. Clarke is a graduate of Williams College (Phi Beta Kappa) and the University of Connecticut School of Medicine where he received the Mosby Award for Clinical Excellence. He completed internship and residency in Internal Medicine and fellowship in Gastroenterology at Harbor/UCLA Medical Center in Los Angeles. He has been a Visiting Professor at the Royal Children’s Hospital in Brisbane, Australia and at Oxford University in England. Dr. Clarke has lectured extensively on Psychophysiologic Disorders to health care professionals and the public across North America and in Europe. He has appeared on over 100 television and radio broadcasts throughout the U.S. Websites are Stressillness.com and PPDAssociation.org.
Some additional references related to Pain Reprocessing Therapy:
A film about a radical cure for chronic pain
THIS MIGHT HURT
How therapy, not pills, can nix chronic pain and change the brain
Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial
Yoni K Ashar et al. JAMA Psychiatry. 2022.
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Please enjoy the full transcript below
Dr. David: One physician, who learned these ideas told me at a conference that it had put the joy back into her work. So, it really can turn a practice around to learn how to do this.
Jen: Welcome to DocWorking: The Whole Physician Podcast. I’m Dr. Jen Barna, founder and CEO of DocWorking and cohost of the podcast. Thanks so much for being with us here today. We’re so excited to bring to you physician guests and to hear about their accomplishments, but most importantly about their lives outside of medicine and how they’re balancing it all. Today, I’m very excited to bring to you, my guest, Dr. David Clarke, who is at the forefront of treating unexplained physical illness caused partly or completely by hidden stresses. Dr. Clarke is a President of Psychophysiologic Disorders Association and author of They Can’t Find Anything Wrong, a book published in 2007 that looks at four dozen selected stories to help the reader uncover and manage their own hidden stresses.
Dr. Clarke has been featured in numerous newspapers and magazines, he’s done over a hundred broadcast interviews for television and radio. He’s also the lead editor of Psychophysiologic Disorders, which was published in 2019, written for healthcare providers, but often prescribed to patients. His seminars to healthcare professionals in the public have been described as life-changing. In those, he provides insight into stresses that most people fail to recognize and by identifying those, he can lead his patients to successful treatment. Dr. David Clarke, Welcome to DocWorking: The Whole Physician Podcast.
Dr. David: Thank you, Jen. It’s great to be with you.
Jen: I’m so interested in hearing about your work. And given the stresses that our profession as healthcare providers is under now more than ever, but it’s always the case that we’re under a lot of stress based on the work we do, and the kind of chronic stresses that we tend to suppress in order to do our work, and show up for long hours. So, my first question for you is, how often do you see stress-induced illness in the medical population itself of healthcare workers?
Dr. David: Yeah, it’s not infrequent. Certainly, if anything, it’s a little higher prevalence from what I can tell than in the general population, because we’ve got a very stressful job. One of the biggest stresses is, that studies have shown about 40% of the patients who come into primary care have no biomedical explanation for their symptoms. Most of us, myself included, got no formal training about what to do for these patients. The patients are frustrated, they’ve still got their symptoms, they’re perfectly real symptoms, just as real as symptoms in people with structural abnormalities or organ disease. And yet, there is no diagnostic explanation for them. We reached the end of the road, we start to wonder if it’s all in their heads, we get frustrated, the patients get frustrated, and it contributes to physician burnout, frankly. And yet, it turns out, if you know what to look for, you can uncover the issues that are responsible for these symptoms. There are a number of different kinds of psychosocial stresses that can be involved.
But if you know how to find those, you can diagnose and treat them as successfully as anybody else and you can turn these patients around from a source of significant frustration into being very rewarding. One physician who learned these ideas told me at a conference that it had put the joy back into her work. So, it really can turn a practice around to learn how to do this. And then, of course, many healthcare professionals suffer from the same hidden stresses themselves. Many of us have gone into medicine because of a strong desire to help other people, but that can be linked to not always the healthiest background I’ve found. When people understand those links, they’re able to make changes that can produce a better work-life balance.
Jen: That makes a lot of sense and I do think often people can neglect themselves and caring for themselves in the name of showing up for others in this profession, which can lead to stress-induced illness. Before we start talking about the types of stress and how to identify it, can you tell me some of the illnesses that are associated with stress, some of the illnesses that we may be seeing in ourselves and in our patients?
Dr. David: Oh, my gosh, it’s literally from head to toe. Migraines, tinnitus, temporomandibular joint problems, visual disturbances, pseudo-seizures, difficulty swallowing, low back pain is a huge one (something like 70% to 85% of low back pain turns out to be psychophysiologic in nature) and cervical spine pain as well. Also joint pain, abdominal pain, irritable bowel syndrome, fibromyalgia, pelvic pain, interstitial cystitis, numbness and tingling in the extremities, chest pain, chronic cough. I mean, the only common denominator is that these patients with psychophysiological disorders tend to have more than one symptom at a time. The patient with the positive review of systems, it just goes on and on and on that they’ve got one symptom after another, but it can be almost anything.
Some of the clues that it’s a psychophysiologic disorder or PPD for short are that there’s more than one symptom. My personal record patient had 27 different symptoms that he was suffering from symptoms that moved around from place to place, pain that doesn’t correspond to a particular nerve distribution. So, somebody with pain in their entire arm, for example, those kinds of things can be clues that you’re dealing with a PPD. But the range of symptoms, it’s all over the place.
Jen: When you’re looking at symptoms that don’t match, for example a structural problem, if you have a patient who has a finding on an MRI, say an MRI of the spine, but then the symptoms are out of proportion to what you would expect for that finding. In other words, it’s not that there’s not a finding, but the symptoms persist longer than you would expect or they’re not responsive to typical treatments. With those types of patients potentially benefit from identifying underlying stressors and similarly patients with other illnesses, such as even Parkinson’s disease or other types of illnesses that can potentially be exacerbated by unidentified stressors?
Dr. David: Yeah, you’ve touched on a couple important points there. Number one, sometimes, when you go do diagnostic tests, you do find some minor abnormalities. There’s a famous paper by Jensen from the 90s in the New England Journal, where they took about 100 patients, who had no symptoms at all, and did MRIs of their spine, and found that a majority over the age of 40, and a significant fraction under the age of 40, had abnormalities in their spine on the MRI. It is very common for people with those abnormalities that are not causing symptoms to be present in people with a psychophysiologic back pain. A lot of those patients get surgery done on them and the outcomes are terrible. The percentage of patients that improve in response to spine surgery done for pain is well under 50%. The reason is that the abnormalities that you see are just a part of normal aging and they’re not responsible for the symptoms. So, you have to be really careful about when you find an abnormality to really think carefully about whether that abnormality is responsible.
The female pelvis is another one. An early study from the late 1980s found that about a third of women with chronic pelvic pain had abnormalities at laparoscopy, but so did a control group of women with no pain. Was the endometriosis, the adhesions, the ovarian cysts really responsible for the pain in those women? Probably not. They went further in that study and asked about childhood sexual abuse, which is one of the causes of psychophysiologic disorders later in life and it was threefold higher in the pain group compared to the non-pain group. Yeah, finding abnormalities isn’t always the answer in somebody with these symptoms.
The second part of your question is, what about somebody with a well-documented organic disorder? Can psychophysiologic stress exacerbate that? Yeah, you can have coexistence of psychophysiologic symptoms and organic disease symptoms simultaneously. One of my stories that I share with my medical audiences is, a patient of mine with ulcerative colitis was well documented to be flaring up and was treated appropriately, but didn’t get better. They were hospitalized, treated more aggressively, but also appropriately, but still didn’t get better. They were scheduled for proctocolectomy, but my colleague who was his primary gastroenterologist noticed that his diarrhea pattern was a little atypical. He was having most of it within a few hours a day and the rest of the day he was asymptomatic, which struck my colleague as a little strange, which it was. So, he repeated the colonoscopy found that the colon mucosa now appeared grossly normal. They canceled the surgery, asked me to see him and it turned out that he was suffering the long-term consequences of having been sexually abused as a boy. It was only when that issue was addressed with psychotherapy that his physical symptoms finally resolved.
It’s entirely possible to have both a psychophysiologic source of symptoms and an organic one at the same time in the same patient, which can really drive you crazy as a physician. But if you’re aware of it and you know to look for it, that’s how you achieve the best outcomes.
Jen: One thing that you mentioned in your book, They Can’t Find Anything Wrong is “types of stress.” Would you mind telling us about how to identify different types of stress, and how that can help us to then find and identify the underlying source?
Dr. David: Yeah, there are five different kinds of stress that I look for, and it’s a systematic process that I use to evaluate a patient looking for all the different kinds of stresses that can commonly produce physical symptoms. The first one, very simple, is just stress that’s going on in your life at the moment and that can be almost anything. I first do a careful chronology of the patient’s symptoms. When and where did they start, what kind of pattern have they had over time? Because I may later on be able to find chronological links between when and where their symptoms were occurring or what initially triggered their symptoms and what is causing the flare up over time. But yeah, just any kind of current life stress that the patient may not have connected to their illness or they may not even mention it. In fact, they usually don’t mention it. One anecdote that I share with audiences is, there was a woman who was experiencing domestic violence two or three times a week, but she never thought to bring it up when she was evaluated by a whole string of physicians, but it correlated exactly with the duration of her illness.
The second one is a subset of the first and that afflicts many healthcare professionals, which is, a person who basically devotes their time and energy to helping the needs of other people in their world, whether it’s a patient, or a family member, or a neighbor, or coworker, but they tend not to have the ability to put themselves on the list of people that they take care of. Often, you can trace the roots of that to a childhood environment, where they didn’t get sufficient opportunities to play, that their attention as a child was focused on other things in their environment. They didn’t learn those self-care skills. As adults, they don’t know how to put the rest of the world on the shelf for a bit and just focus on their own needs. If you don’t know how to do that, sooner or later, it tends to catch up with you.
Third major area that I look at, and the majority of my patients suffer from this one, and it was a big shock to me in my medical education, is childhood stress. Many of us have heard about ACEs nowadays. The ACEs study adverse childhood experiences study came out in 1998, American Journal of Preventive Medicine. Felitti and Anda are the lead authors, I highly recommend that paper. What I found in my practice is that, people who suffered stress as children, it can be a range of things. Sometimes, it’s out and out physical or sexual abuse, but in many other patients, it’s more subtle, like treatment of the child that lowers their self-esteem on a long-term basis is one of the common denominators. And that can have all kinds of impacts on a patient’s personality, on issues that might trigger their stress in the present day, and on also buried or repressed emotions that if they can’t be recognized cognitively, they tend to be expressed somatically instead. Many of these patients will tell me about their childhood stress, sometimes horrifying stories, but you’ll hear them talk about this in the same tone of voice that they use to read a grocery list. For example, there’s no emotion there and you think, “Well, they’re very calm when they’re talking about this. Maybe they’ve processed it all, maybe they’ve dealt with it successfully,” but their unexplained physical symptoms tell you otherwise and there’s a whole treatment process for that.
Then, the last three areas that I look at are simply mental health conditions that are presenting somatically instead of psychologically, depression, post traumatic stress and anxiety disorders. It turns out that if you take the whole universe of those conditions, a majority of them present to the healthcare system with somatic symptoms instead of mental health symptoms. They get missed in primary care. My depression patients for example, many of them won’t deny feeling depressed. They’ll be frustrated, they’ll be exasperated, they’ll be desperate to have their somatic symptom, whatever it is, addressed. But they’ll say, “No, I don’t really feel that depressed.” But ask them about waking up in the early hours of the morning. Ask them, “Is their energy level down, their appetite off, have they lost interest in activities they used to enjoy, are they crying for little or no reason, have they felt like their life isn’t worth living, have they had thoughts of harming themselves?” And you get positive answers to those questions and the diagnosis becomes clear.
PTSD is the same. A lot of times, nobody asks about whether the patient’s been through a trauma and the patients don’t bring it up unless you ask. Anxiety disorder is the same. One out of every 13 patients in primary care, that’s what they have. And yet, they may have had it for so long that it just feels normal to them, and they don’t bring it up, and even when you ask them, “Do you feel anxious, worried, fearful, nervous?” They’ll say, “No, not really.” But you can find if you’ve done a careful chronology that their symptoms are much less severe or less frequent when they are in what they consider a “safe environment.” If they leave the safe environment, then their symptoms come on and that tells you that you’ve got an anxiety disorder.
Really brief anecdote, there’s 16-year-old girl with severe diarrhea, and on her bad days, she was putting herself on a water only diet. She was taking up to a dozen Imodium tablets by 1 o’clock in the afternoon and still having diarrhea through all of that. But it turned out, and nobody else had gotten this chronology, that her bad days were always on Tuesdays and Thursdays. On the weekend, she was asymptomatic. There’s no biomedical issue in your large intestine that is going to behave like that. Only your brain knows that it’s Tuesday or Thursday and it turned out she was extremely anxious about her performance as a varsity soccer player in her high school, and Tuesdays and Thursdays is when they played their games. So, those are the stresses I look for. It’s astounding. When I first started in this field, I didn’t expect to see more than a handful of patients every year with this. Once I started looking for it, it was everywhere. Five or six patients a week, even in a specialty practice that was 100% referral based.
Jen: Well, it’s remarkable how common this is and how under-diagnosed it can be, and I think when you look at the population with symptoms, there’s such a huge variation in ways of somatic presentation. And currently, there’s mounting evidence for neuroplasticity, and the ability of the brain to rewire and fix problems that are actually originating in the brain as you alluded to only the brain would note that it’s Tuesday or Thursday. So, how does neuroplasticity tie into the treatment of these types of disorders?
Dr. David: Well, all of these different kinds of stresses that I just reviewed are amenable to treatment. The one that may be furthest from the experience of most frontline clinicians is the long-term impact of childhood stress. What I’m looking for there are three major areas to address. We can call personality traits, unrecognized emotions, and triggers. The personality traits, they actually to be honest, they tend to be characteristics that make for great medical professionals. Attention to detail, reliability, self-sacrifice, compassion for others, but all of those excellent qualities can be taken to extremes. Self-criticism is another one that I see commonly. But in these patients, they tend to have gone so far down the road that they actually become harmful to the patient. But when the patient sees that those characteristics came from their mistreatment as children, if they can see the connections there. None of us is born being hypercritical of ourselves, for example. We have to learn that. And if we can figure out who taught us how to do that and how they taught us how to do that, then we can make changes that lower our stress level.
The second major area is the unrecognized negative emotions, typically anger, fear, shame, grief, guilt. People have these things, and they have them typically about people whom they also care about or would like to reconcile with. But one of the techniques that I use there is, asking the patient to imagine their own child or a child they care about, growing up in the same environment they did, suffering the same adversity that they did. When a person looks back at their own life, they tend not to see accurately the magnitude of what they suffered. But if they think about one of their own kids, and imagine themselves as a butterfly on the wall of their childhood home, and they’re watching their own kid try to cope with everything they had to cope with, it gives them a completely different perspective. It helps them to connect with some of those negative emotions, which they can then journal about or talk to a therapist about. When you put those emotions into words, they don’t need to be expressed somatically quite so much.
And then, the third area for the childhood stress are certain triggers. Many of my patients are still in contact with people who mistreated them as children, even as adults. The very first story in my first book was about a woman who was hospitalized at Stanford 60 times over 15 years with no diagnosis. All of her symptoms were linked to encounters with her verbally and emotionally abusive mother. As soon as she saw that trigger, she was able to work on it cognitively and her physical symptoms basically went away after a one-hour conversation. So, finding those present-day triggers that are linked to the past can make a huge difference. By doing these three relatively simple things well within the range of most mental health professionals, you can make an enormous difference in people’s outcomes.
Jen: Thank you for joining us today on DocWorking: The Whole Physician Podcast. I’m Dr. Jen Barna and I want you to know this conversation with Dr. David Clarke is going to continue on Thursday. I hope you’ll tune back in and hear more about what Dr. Clarke has to tell us. And please like and subscribe wherever you’re listening. Please let us know what you’d like to hear more about. We welcome you as part of the DocWorking community and we hope that you’ll check us out at docworking.com. Thanks again. See you next time.
Amanda: I’m Amanda Taran, producer of DocWorking: The Whole Physician Podcast. Thank you so much for listening. Please don’t forget to like and subscribe, and head over to docworking.com to see all we have to offer.