New Hope for Older Adults With Medical and Psychiatric Comorbidities

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SPECIAL REPORT: GERIATRIC PSYCHIATRY

An overwhelming accumulation of evidence indicates that older adults have increases in both chronic medical conditions and so-called “medically unexplained” somatic symptoms.¹ One example is the high prevalence of somatic symptom disorder (SSD) in older adults. SSD is a DSM-5 diagnosis characterized by 1 or more distressing somatic symptoms for at least 6 months, accompanied by excessive thoughts, feelings, or behaviors related to the symptoms.² A recent epidemiologic study found that the prevalence of SSD was 1.56 times higher in older adults (age 60 years and older) than in younger adults.¹ Nearly two-thirds (63.2%) of older adults met criteria for SSD vs 45.3% in younger adults. Moreover, 20.4% of cases in older adults were classified as severe vs only 12.0% in younger adults.¹ The extremely high rates of SSD, a psychiatric disorder, in older adults raise questions about the appropriate roles for psychiatrists and other mental health clinicians in treating somatic symptoms.

Historically, psychiatric providers’ main roles in patients’ somatic presentations have been limited to treating psychiatric comorbidities, such as depression and anxiety; providing patient education on stress management, physical activity, and avoiding alcohol and recreational drugs; and occasionally referring for cognitive behavior therapy to help patients manage or cope with symptoms. This strategy is sensible for symptoms from chronic medical illnesses that have a biomedical cause, such as cancer, rheumatologic, or endocrinologic diseases. However, psychiatric providers tend to use the same or a similar approach for SSD, often coupling their interventions with regular visits with primary care for reassurance, even though SSD-related symptoms rarely have a biomedical cause. For SSD, this standard treatment approach produces only modest improvements, with remission quite rare; only 21.4% of SSD patients were shown to enter remission at an average of 4 years of follow-up in a large study.³ Additionally, a 32-week trial of citalopram for 30 older adults with anxiety and SSD produced only small effect size reductions in somatic symptoms.⁴ Very recently, new paradigms and treatment strategies have been developed that provide new hope for older adults with troubling disorders such as SSD.

Neuroplastic Symptoms: A Treatable Set of Conditions

A more recent (and perhaps more useful) construct than medically unexplained symptoms, or SSD, is the concept of neuroplastic symptoms.⁵ Neuroplastic symptoms are real, physical symptoms (ie, not to be confused with malingering or factitious symptoms) caused by neuroplasticity in the brain rather than damage, disease, or dysfunction in the body. Examples of disorders that often end up being neuroplastic are most types of musculoskeletal pain conditions (eg, nonspecific back and neck pain, fibromyalgia), irritable bowel syndrome, some types of chronic fatigue, vertigo or dizziness, long COVID,⁶ and others. Stress is the reason for the neuroplasticity that leads to symptoms.⁵ As such, diagnosing a symptom as neuroplastic is not necessarily just a diagnosis of exclusion (although lack of a known biomedical diagnosis certainly increases the likelihood of a symptom being neuroplastic), but the diagnosis can be ruled in by evaluating the role of stress in the symptom’s onset and course, as well as other symptom characteristics, such as those listed in the Table.

TABLE. Characteristics of Neuroplastic Symptoms

Using these criteria, a recent study found that over 88% of back pain in an outpatient practice could be considered neuroplastic.⁷ It is important to reiterate that older adults, who do have many chronic medical conditions, often present with both neuroplastic symptoms and symptoms with a biomedical/bodily cause. Each should be diagnosed and treated appropriately by the relevant clinicians. Notably, making a diagnosis of neuroplastic symptoms should not be stigmatizing in the least. In fact, receiving this diagnosis is excellent news, because these symptoms are treatable, even in older adults.

Emotional Awareness and Expression Therapy

Recognizing the important roles that trauma, stress, and relationships have on neuroplastic symptoms (especially chronic pain conditions), psychologist Mark Lumley, PhD, and internist Howard Schubiner, MD, developed emotional awareness and expression therapy (EAET) in the early 2010s to directly target these major symptom drivers.⁸ EAET draws on several sources, including intensive short-term dynamic psychotherapy (ISTDP), written emotional disclosure, and pain reprocessing therapy.⁹ The basic premise of EAET is that trauma, relationship conflicts, and other forms of stress produce a sequence of difficult and often painful emotions, including anger, guilt, and sadness. Avoiding such emotions can lead to neuroplasticity that increases the likelihood of developing symptoms, whereas facing, processing, and releasing these emotions can lead to symptom relief.

For instance, a patient who is preoccupied with guilt and fear about a traumatic violation against them, such as a robbery, may require help accessing a sense of healthy anger that could contribute to greater motivation, a sense of agency, and empowerment. Another patient may hold onto anger and resentment after experiencing a trauma but miss a sense of sadness for oneself that can lead to greater self-compassion.¹⁰ Patients are encouraged to feel each feeling physically during the session (eg, a bodily experience of rising heat or energy for anger, crying for sadness) and to release the feeling using visualization (eg, to imagine lashing out in anger or imagine giving a hug with sadness).¹¹ Visualization is a critically important and powerful technique for releasing feelings, which was discovered by Habib Davanloo, MD, the founder of ISTDP.¹² Visualization is a compromise between suppressing an impulse (which can be hurtful to the patient) and acting on it (which can be hurtful to the patient or others)—but in this case no one gets hurt because the impulse is expressed only in the imagination and in words, rather than outwardly through actions.¹³

A dozen clinical trials have evaluated between 1 and 8 sessions of EAET for adults with various neuroplastic symptom presentations, including fibromyalgia, chronic pelvic pain, irritable bowel syndrome, and musculoskeletal pain.⁸ Two trials in Sweden^14,15 evaluated an online self-help version of EAET based on Schubiner’s book¹⁶ for adults with SSD that showed promising results. In addition, our group has led 3 clinical trials of EAET focused on older veterans with chronic musculoskeletal pain.^17-19 Our most recent randomized clinical trial, published in JAMA Network Open, evaluated EAET delivered as a single 90-minute individual session followed by 8 weekly 90-minute sessions in small groups of 6 veterans vs the same number and type of sessions of cognitive behavior therapy for chronic pain (CBT-CP).¹⁸ At the end of treatment, 63% of veterans randomly assigned to EAET experienced a clinically significant (at least 30%) reduction in the severity of chronic pain compared with only 17% of veterans randomly assigned to CBT-CP.¹⁸ EAET was also more effective at reducing depression, anxiety, and posttraumatic stress disorder symptoms, and higher levels of these symptoms moderated a greater reduction in pain severity after EAET but not CBT-CP. Overall, these results indicate that “addressing the emotional body”²⁰ is a powerful technique for improving chronic pain in older adults—and this likely applies to other neuroplastic symptoms as well.

Concluding Thoughts

Psychiatrists and other mental health clinicians have rarely attempted to directly address older adults’ somatic symptoms, despite their frequent co-occurrence with common psychiatric symptoms we do treat, such as depression and anxiety.¹ Reasons could include assumptions that older adults’ somatic symptoms are necessarily biomedical and a lack of tools to accurately assess what symptoms are caused by the body and what symptoms by the brain. Yet, the recent concept of neuroplastic symptoms includes highly effective and evidence-based diagnostic and treatment approaches—especially EAET—that can be applied by mental health clinicians, bringing new hope for older patients with these troubling symptoms.

Dr Yarns is a board-certified geriatric psychiatrist, assistant professor in the UCLA Department of Psychiatry and Biobehavioral Sciences, and assistant director of the VA Health Systems Research Center for the Study of Healthcare Innovation, Implementation, and Policy at VA Greater Los Angeles Healthcare System. He has practiced, taught, and researched EAET for older veterans over 8 years. Ms Freitas is a research coordinator at VA Greater Los Angeles Healthcare System currently working with Dr Yarns to investigate EAET for older veterans.

Disclosures

Dr Yarns has conducted professional training in EAET, a treatment mentioned in this article, and has received fees for this training. Ms Freitas has nothing to disclose.

References

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17. Yarns BC, Molaie AM, Lumley MA, et al. Video telehealth emotional awareness and expression therapy for older U.S. military veterans with chronic pain: a pilot study. Clin Gerontol. 2024;47(1):136-148.

18. Yarns BC, Jackson NJ, Alas A, et al. Emotional awareness and expression therapy vs cognitive behavioral therapy for chronic pain in older veterans: a randomized clinical trial. JAMA Netw Open. 2024;7(6):e2415842.

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