Different kinds of brief psychotherapy are valuable instruments, especially when limitations of pharmacotherapy are prominent, for example in patients with renal or hepatic insufficiency(1). Among them emotional disclosure due to its simple and feasible pattern can be used as a useful method for management of anxiety and depression in patients with various medical situations.
Talking or writing about emotional or stressful experiences can improve physical and psychological health, these findings has been documented in both clinical and non-clinical populations(2). Also the immediate impact of expressive writing or talking can be as increased distress and negative mood and physical symptoms, but this happening is Temporary. This intervention can lead to diminished physical and psychological distress in long term (3) such as improved immune system functioning in Patients with HIV infection(4), reduced blood pressure(5), improved lung function in cases of asthma (6), improved mood/affect and decreasing anxiety in kidney transplant recipients(7), reduced pain in patients with breast cancer and in women with chronic pelvic pain(8-10), fewer intrusion and avoidance symptoms in patients who suffers from post -traumatic stress disorder (11,12). Feeling of greater psychological well-being (13), improvement of academic function in students (14) is achievements of emotional disclosure in non-clinical population. Another positive effect of expressive writing is improvement of working memory capacity (15). This article describe one specific medical condition that pharmacotherapy by psychotropic medications was impossible. In these resemble situations importance of brief psychotherapy becomes more obvious.
case report:The patient was a 29 y/o single girl, unemployed,lisence of the literature. She lived lonely after lossing her parents since 7 years ago.She was referred by GI-Man to psychiatrist due to sever anxiety. Since 12 months ago the patients medical condition was managed with impression of idiopathic hepatitis. The patients anxiety began since about 4 years ago. After that the patient decided to manage her anxiety by self curing. So she abused benzodiazepines(alprazolam 8 mg per day). Gradually she lost the appetite . the weight decrease from 60 to 41 kg. this decrease happened during 3 years. When she was visited by her family physician, multiple w/u for assessment the cause of wt loss were done. Elevated liver enzymes were discovered(SGOT= , SGPT= , Alk p= , D bili= , t bili= ). Family physician helped the patient to discontinue alprazolam. No change in liver enzyme was seen. She was severely anxious. She had lost her function. The physician plan was referral to GI man ( for assessment the medical cause of the elevated liver enzymes) and introducing the patient to psychiatric day clinic ( for anxiety management).The patient referred to GI man. Various work ups were done for finding the cause of liver dysfunction.serial LFT showed elevated enzymes. Liver biopsy was normal.abdominal sonography was normal. The final impression was idiopathic hepatitis. Due to diminished dosage of benzodiazepine the patient was anxious. She participate in day clinic classes for 2 months.it was not completely useful. Temptation of the benzodiazepine abuse was Annoying. She suffered from irritability,decreased concentration, insomnia, decreased appetite, muscle tension, anticipatory anxiety, crying, decreased energy, agitation . recently she became impulsive. Any abnormal finding was detected in past medical history. Substance history was negative. There was no abnormal finding in family hx.In common session with GI man , we discussed about different choices for anxiety management.Some psychothropics with renal metabolism and or psychotherapy were different therapeutic choices. Final decision was selection of psychotherapy as the first line. The patient lived lonely. She needed emotional support and close observation for prevention of benzodiazepine abuse. Admission in hospital was the therapeutic team’s recommendation.April 2017 She admitted in psychosomatic ward. Due to her psychiatric history, it seemed that expressive emotional therapy can be the best choice for management of anxiety.the first 3 sessions were related to discovery of important stressors in the patient’s life. The stressors ranked .what asked from the patient in the psychotherapic sessions was talking about her deepest emotions and thoughts that she experienced in various stressful conditions.after 4 sessions she became expert to differentiate between thoughts and feelings.during hospital course she participate in 23 sessions.the psychotherapy desiged as individual therapy. Each meeting prolonged about 30 minutes. The other times of the day she wrote her emotional disclosure home work for 30 minutes .the home work content was used for the next face to face visit. she also could participate in Occupational Therapy with other patients. During 4 weeks of admission gradually the patients anxiety decrease. The anxiety condition were assessed by HADS questionnaire. The patient completed the questionnaire weekly. The HADS score chart was as below: 1st assessment = , 2nd assessment= , 3th assessment= , 4th assessment= . during this period irritability and agitation disappeared.the patient reported improvement in sleep quality. The patients concentration improved. The most interesting finding was decrease of liver enzymes since the second week of admission.the liver enzyme’s decreasing pattern is reported in table 1. During this period she received no psychotropics.
It seemed that the patient was ready to leave hospital. Follow up visites designed weekly . the patient’s medical condition assessed by checking LFT biweekly. The LFT evaluated for 3 months.no increase in liver enzymes was detected during this follow up period.The results are reported in table 2.
Successful outcome in
expressive writing requires:
a correct statement of the facts
revealing subconscious thought processes
being able to discuss the writing with a significant other
being able to write freely for one’s self
verbal expression of emotion while writing.