Psychiatry & Psychotherapy Podcast - Writing to Overcome Trauma and Improve Your Mental and Physical Health

Episode Date: August 23, 2024

In this episode, we dive into the fascinating world of expressive writing and explore how turning your trauma into a narrative can lead to real mental and physical benefits. Join us as we break down the science behind the Expressive Writing Paradigm and share groundbreaking research by Dr. James Pennebaker and others. From reducing PTSD symptoms to improving mood and stress levels, discover how this simple yet powerful technique can help you process emotions, gain new insights, and ultimately promote long-term healing. By listening to this episode, you can earn 1.0 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome to the Psychiatry and Psychotherapy Podcast. I'm your host, David Puter. This is your gateway to the intriguing world of mental health. As one listener put it, this is the podcast that your psychiatrist listens to. And we're incredibly proud of that endorsement. Whether you're a loyal, active listener who's been kind enough to reach out, maybe send an email at DM or put in a review, or you're new to this community. We have an exceptional opportunity for you, not only to learn, but to also, earn continued medical education credits with each episode. Our credits are meticulously designed to empower you in your field, demystify complex mental health topics, and transform your learning journey into a truly rewarding experience. To access this and more, just visit Psychiatrypodcast.com. We're grateful to our valued subscribers who are already reaping the benefits of these credits. Your support is instrumental in allowing us to devote time each week to curate. this podcast, sharing cutting-edge insights, featuring top professionals, and exploring the latest

research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined with Emerald Norman. She is a fourth-year medical student going into psychiatry at Lomelinda University, and we've been working on a project. She actually did some research in undergrad on expressive writing and mental health. And today we will be talking about writing to overcome trauma and improve mental and physical health. We will be talking about some different studies. We'll be getting into the details.

We're talking about how to develop your own practice of expressive writing. And also in cognitive processing therapy, there's some writing that they do. And we'll be talking about that. and we'll be talking about our own experience of trying this out. So welcome to the podcast. Thanks for having me, Dr. Peter. So yeah, do you want to kind of just share a little bit about your paradigm of expressive writing? Yes, of course.

So one of the lead voices on expressive writing as a way of kind of dealing with trauma is Dr. James Pennebaker, PhD. He's done a number of studies that kind of look at expressive writing and how it can help in a variety of ways. He kind of got started after he started doing research surrounding on trauma disclosure and how people, and he found that people who disclose their traumas were able to, one, move through them more effectively and to have benefited. in both their physical and emotional health down the line. So he kind of is like the main

leader in this field looking at expressive writing. And kind of the idea is that when you write expressively, you're able to kind of vent and disclose that trauma, not hold it in. And that allows for, I guess, a decrease in stress. We talked about in a number of papers, there's a decrease in rumination, which has a connection with depression. So that's kind of the paradigm, the kind of idea that you're writing, you're disclosing your trauma, and all of that is making it easier for you to both process the trauma and release that stress from your body physically. Yeah, so I think that's a good intro.

I've listened to actually some audio podcast of him as well. and we looked at this paper that is from 1988 talking about did disclosure of trauma influence psychosomatic issues and specifically around childhood that you know they looked at people who had no trauma who had trauma but confided that in other individuals trauma and did not confide it in anyone and how big of a difference were those groups? It wasn't that big of a difference, but it was a statistically significant difference. And that's something that I feel like, even in my own study that we found when I was in, you talked a little bit about this, but when I was an undergrad, we looked at using Panne Baker's paradigm,

expressive writing and the effect it has on state anxiety. And what we found is that it had a very, very, very small effect, really, but it was significant. And I think that's kind of the important part where it's like expressive writing is not the only thing that you should be doing, but it's a good adjunct to therapy or whatever other form of processing you're using to deal with your trauma. And that's the same thing that we find in this study. the difference in total illness, which is in the table that will be in the document, is pretty small, but it is statistically significant. Yeah, so that the physician visits for illness with no trauma was like 1.14. If they had confided trauma, it was like 1.75. If they had trauma but not confided, it was 2.0.

So there were more physician visits, not a huge jump for people who did not confide, but it was higher. And so, you know, as I've heard him talk about this on other podcasts, he'll say, like, therefore, you know, writing can be one way of confiding. And, you know, we'll talk about where there is an impact and where there is not maybe as big of an impact in writing. and we'll get to eventually talking about cognitive processing therapy and about how dissociate, if someone has a high level of dissociation, writing actually helped them quite a bit. So let's get into, maybe just as we begin, like, what is expressive writing? Like, what is a normal protocol in these studies? Just so we kind of have an idea of what we're talking about.

Like, what question do they ask? How long do they have them? Okay. So specific writing intervention typically is based on Dr. Pennebaker's work. Other authors have kind of co-opted and changed it in whatever way they found most useful for their studies or for the way that they want to conduct therapy. But going off of Dr. Pennebaker's original work, he would have the participants write for 20 minutes over three days. and he asked them to write about their deepest thoughts and feelings around an emotionally disturbing event that they experienced in their life right now. And he also asked them to tie their topic in with past stressful or traumatic experiences, their relationships with others, how they relate to their parents, friends, relatives, and how it affects them in the past, in the future, in the present, how it affects their self-concept.

So very kind of broad, abstract questions, but that encourage people to have a, to think deeply and kind of have the freedom to take the writing wherever they would like to. Great. Okay. Let's talk about this one article, the 2010 study by Joshua Smith, how expressive writing decreased anger and tension, but not PTSD symptoms. Let's talk about that study. Yeah, so in 2010 study by Joshua Smith, he used a very similar paradigm to Dr. Pennebaker in that he had his participants write for 20 minutes and do three sessions, but he had them all do it in one day, separated by 15-minute rest intervals. And he kind of separated within the prompts how he wanted them to write. So for the first prompt, he wanted them to identify and label the event with their thoughts and feelings. for the second prompt, he asked them to tell a story about the event and how it affected them. And then for that third prompt after the last 15-minute interval, he had them reflect on what they had written previously and then re-tell their story with any new insights

that they had gained from writing the previous two prompts. And they used the P-O-M-S, which is the profile of mood-state subscale, to basically measure changes in the mood states of tension, depression, anger, vigor, fatigue and confusion. And they also used the PTSD symptom scale interview to assess for like PTSD symptoms severity. And like you said, there was no change in PTSD symptom severity, but they did find a change in their palm scores. The palm scores did decrease in three domains. So in the mood state of tension, depression, and anger. Tension and anger decreased with a P.O. of less than 0.5, and depression for the P of less than 0.1, meaning, of course, that anger and

tension were the only statistically significant decreases. Yeah, so I think the decrease was substantial in anger. It was around negative six. Intention. It was around negative five. And how many points were anger and tension out of for the total palms subdomain? So for the total pump, subdomain's anchor was out of 48 and tension was out of 36. Okay. So yeah, you can see that those drops were both statistically significant and probably substantial for just such a short intervention. You know, we're talking about one day, one hour riding to get some anger decrease is significant. They also looked at cortisol, salivory cortisol, a baseline.

post, anything interesting from that? Yeah, so again, it was a pretty small shift, but they did find a decrease in cortisol for the experimental condition by a measure of about two in animals. And while that's pretty small, we know that cortisol is an indicator of stress in the body.

So that is that this, you know, one-hour winding condition did decrease physical stress in the body. A little bit, a little bit. A little bit, yeah. It doesn't get that. Honestly, the anger decrease, the tension decrease, that gets me somewhat hopeful that there might be more here that we should look at this a little bit deeper. So, okay, let's go on to cognitive processing therapy. with writing or without writing.

There was a very nice study by Patricia Resick. She was on my podcast a couple months ago. This was a 2012 study. Tell me about this one. Yes. So this study looked at CPT therapy in treating individuals who have PTSD. They measured the amount of PTSD symptom change.

and they also measured dissociation in the population that they were studying. Let's get a little bit granular with that 30-itam, multi-scale dissociation inventory. What were some of the subdomains of that, and how did they score it? Yeah, so there were six different types of dissociative responses that they looked at. So the first was disengagement. Second was depersonalization. The third was derealization. The fourth was emotional constriction slash numbing.

They also looked at memory disturbance and identity dissociation. And they indicated, the participants indicated on a scale of 1 to 5, or 0 to 5, 0 being never and 5 being very often, how frequently they experienced each item. And so as a result, you know, the higher their score was, that means the more dissociated they were. Yeah, I think this is an interesting scale. So they wanted to look at not only dissociation, but the different subdomains of dissociation. They looked at it pre and post. And in this study, just to let you,

you know, there's a randomized control trial of CPT, like the cognitive processing therapy alone, cognitive processing therapy with the writing portion, and just the writing portion. and we're going to talk about what those entailed in a little bit. But just to give you an idea, this was, you know, pretty big study. Pretty well done. As with all of Resix studies, they're pretty fantastic in how they're done.

So, okay, talk, oh, and let's also talk about the PTSD post-traumatic diagnostic scale. What did you learn about that one? Yeah, so we found that the post-traumatic diagnostic scale, It was made up of a 24 item self-report scale. So 20 of the items had to do with the 20 DSM-5 criteria for meeting like a PTSD diagnosis, and they had four additional items that address like the duration, symptom onset, and effect that PTSD had on the person's life. And a higher score, again, it was from zero to four,

kind of commenting on the severity and frequency of what they were experiencing. So zero would be, I never experienced this. symptom, or it would be I experience a symptom six or more times a week, or I experience it severely, and a higher score would represent a more severe symptomology. Perfect. I think it's valuable, and we were talking about this as we worked together on this project the last two weeks, I think it's very valuable. Thinking through as we look at pre and post and the types of ways that people were scored,

are the change is big enough to actually be clinically significant to me as a provider? So there's statistical significance, P value less than 0.5. You know, this study shows that these two outcomes are different. There's only a 5% chance that they're not different. Okay, that's what that means. And then there's like clinical significance. And so when I'm looking at a study, I'm thinking to myself, like, okay, do these change enough for this to be something that I would spend the rest of my life talking to my patients about and doing

and training myself in? You know, because I don't want to do something that doesn't make sense. And so, you know, as we read through studies, this is the, me teaching medical students and residents, like, look at the measures. We looked back at the measures. We looked at how they scored it. you can see in table one of this study, how they show the means of the starting places

of different things like the dissociation. And so you can also see kind of how sick people are that were brought into the study, right? There was one study we looked at we did not include today, and they were looking at PTSD symptoms, but the scores were like super low. People did not enter the study with PTSD,

but they were wanting the writing intervention to decrease PTSD. and yet there was no PTSD and the people that came into the study in the first place. Okay, so these people came in with some dissociation scores that were, like I'm kind of looking at, the mean was around 64, 65, 61 for the different groups.

So the other thing I look at when I look at a study is like, okay, were they randomized well? You know, like are the scores very lopsided one way or the other? Because then we're going to expect different outcomes. comes in different groups just because of the lopsidedness and the scores, right? So let's talk about what this study found and then maybe we'll rewind to talk about what the different groups really did. Okay. So what did this study find in regards to low dissociation

and high dissociation? Yes. Okay. So the study basically tiered, it's participants based on their MDIs, like the multi-scale dissociation inventory scores into high dissociators and low dissociators. And when they did their analysis, they kind of included that tiering, and they found that their PTSD diagnostic scale scores were about the same for people who had low levels of dissociation and kind of medium levels of dissociation. But for people who had high levels of dissociation, in kind of the post-treatment and six months follow-up, they found a significant difference in their scores. The most pronounced difference was found in kind of the subgroup of MDID personalization. So just looking at that one of those six factors of dissociative response.

So for people who scored within the two standard deviations above the mean score for MDI depersonalization, they found PTSD scale values of 7.75 for those who were doing the CPT with the writing intervention and 27.93 for those who were doing CBT without the writing intervention. So that's kind of a pretty big difference. So 775 versus 2793. And the only difference between the two being having written the account and having not written the account. Yeah. So, okay, let me repeat that in the way that I understand it, just basically saying the same thing again so people can hear it twice.

So in patients with high levels of depersonalization, like two standard deviations above the mean. they they scored a lot better in the final analysis like in their final time of checking in them they scored a lot better in their PTSD symptoms if they had the writing component and the cognitive processing therapy component okay so it was the combination that was powerful without the writing component, they scored a lot higher on their PTSD symptoms. Okay. Their score was around 7.7 if they got cognitive processing therapy with the writing.

It was 27.9 if they got the cognitive processing therapy without the writing. That's a 1.1 to standard deviation difference. And so this is where I start getting excited about like, okay, I think we found something really cool here. And so in summary, what is, you know, the writing portion that they did in this cognitive processing therapy? What is the writing portion? And how is it helpful? There were other things that we learned from the study.

But I think I want to talk about like specifically what was, what is cognitive processing therapy? What is cognitive process therapy with the writing? Right. So Dr. Patricia Resick actually wrote. a manual for a CPP specifically for a PTSD. The one I looked at was specifically for veteran and military patients,

but I believe it's the same. Yeah, she worked largely with that population, but I think she has said CPD actually works better outside of the military population, because, you know, as we all who have worked in the VA know, often vets come with a number of comorbidities. But go ahead. Yeah. So all that, just to introduce where I'm getting this information from,

in her manual, he basically wrote out what the writing intervention would be, if you were to do what they call the CPT therapy, not the CPTC, which is the non-writing intervention, but CPT. So it reads, please begin this assignment as soon as possible. Write a full account of the traumatic event and include as many sensory details as possible. Include many of your thoughts and feelings that you recall having during the event. Pick a time in place to write so that you have privacy and enough time and don't stop yourself from feeling emotions. If you need to stop writing at some point, please draw a line on the paper to stop, begin writing again, pick it to next session, etc.

So basically, she's asking them to give a detailed event of what, happened and they're allowed to talk about their thoughts and feelings around the event. But the main point is for them to include as many, like, details as possible. So I think this could actually be considered like an expressive writing, an expressive writing intervention because she does, she does encourage them, or the writer, at least, it does encourage them to include as many thoughts and feelings that they have during the event, which is kind of similar to the prompt that Dr. Pennebaker gives us. Okay, here's a portion that I found interesting. So basically, session one of the cognitive processing

therapy with the writing portion included an assignment to write an impact statement. That's what they call it, about the perceived cause and the personal meaning of the index, the worst event, the worst trauma. And then after reading and discussion, in the meaning of the index trauma in session two, patients were learning to identify relationships among the events, thoughts, emotions. It included worksheets at the end of session three. Patients were assigned to write a detailed account of the worst trauma, including the sensory details, thoughts, emotions. And then patients were instructed to read the account every day. in session four and five patients were to read the trauma account allowed to the therapists

who assist the patient in processing emotion challenging the maladaptive thoughts about the meaning of the events through a Socratic dialogue and writing about additional traumatic events may occur in session five but the focus of CPT shifts to teaching the patient to challenge and change the beliefs about the meanings of the events and implications. of the trauma in their life. So they're kind of challenging some of the cognitive distortions that may be there. And then in session six, they are taught

to identify problematic thinking that come to represent a style of responding to the trauma. So any guilt specifically they would look at. Guilt was one of the things that Patricia Resick talks a lot about. It's like it's just not helpful for someone to have any guilt about a specific trauma because that guilt kind of holds them and holds them from grieving and processing and moving through it. Okay. So you can see from this that the writing kind of like deepens some of the

work. It brings out, it brings out some of the, you know, what meanings occurred, how they, why they thought this trauma occurred specifically. Interestingly, in this specific study, which I highly recommend anyone who's interested in this, read, interested in trauma therapy, read. The third group was the writing only. And it's like they, I think it's worth talking about this group because if you look at this study, these people got better too. So in the writing only protocol,

basically they were told to write in the same way that I just described, but instead of the instructor challenging the beliefs, they would just more give like education, empathy, and so they were in these sessions writing instead of in therapy, but they were going through a lot of the same questions, and they were not the therapist after we're hearing from the patient who was reading them to them. So it's not like they were just writing it with no,

response from a therapist. They were reading what they had written to the therapist. And the therapist would give them supportive comments, empathy, facilitate emotional processing, provide education, but not conduct any cognitive therapy or try to challenge the cognitive distortions. Okay, so you could see how that's very active. It actually, I would say, is a form of therapy. It's not just writing. And I think that's important to note because of how each group did get better. Okay. Anything else you'd want to add on to those two descriptions of the different groups? Or anything jump out at you as different than expressive writing?

Not particularly. I would say, I feel like you said it very well. You summarize everything real. but it is very interesting that even without the kind of more active interpersonal forms of therapy, that people were still able to kind of breach that same ground and still improve a lot. Okay, so one of the things that they noticed in patients with higher dissociation, so when looking at patients with two standard deviations above the mean of this group, dissociation-wise, they found that in those that were in the writing group, they had a faster

decrease in symptoms. Okay, they all kind of ended up at the same place eventually, but they had a faster decrease in symptoms. The second thing we've already talked about, but I think it's worth mentioning again, is that the depersonalization group, had a more significant decrease in symptoms. And so depersonalization means, and I did a whole episode on this in the past, it's like someone who doesn't feel quite, like they don't feel like they're habitating their body anymore.

They don't feel like they're part of themselves. They feel distant from their selfhood. And so when I think about patients with depersonalization, I think to myself, these are people that they don't have like a narrative of story for what happened and why they are feeling the way they are. And so I think there's something very powerful for this specific group to write out and just have it for themselves.

This is what happened. This is the truth of my story. You know, this is why I feel the way I do. Yeah, I agree. I feel like it gives them the chance to kind of tell their own story to themselves, which I feel like can just reintegrate them into their own personal narrative. Like they're at this place where they feel separate from what's happening to them. And this kind of allows them some synergy between what happened to them, what's happening to them,

and accepting it, who they are, bringing it all together back into, one story and allowing them to tell that story. Yep. And interestingly, in the low dissociation group, the group that did not have the writing had a steeper slope of getting better faster. So in the low dissociation group, the writing could actually slow down progress, it seemed. So I think that's worth noting as well from the study. So a lot of nice pearls from this study, yeah, I think they all got better to a large degree.

You know, they all got better. So all of the groups got better. Let's talk about this other clinical trial conducted by Oliver Glass and his team. Okay, great. This actually was my favorite study of the ones that we looked at because, as I'll talk about later, it used different forms of writing rather than just the Penne Baker paradigm of expressive writing. So this was a six-week intervention study that was conducted by, you know, Mr. Dr. Glass and his team, and they were using a program title of Transform Your Life Right to Heal.

That kind of, it was actually created by one of Pennebaker's colleagues, who was kind of one of the arbiters of this study. and the program included like a writing prompt that was very similar to what Dr. Pennebaker used in his experimental work, but it also incorporated five other styles of writing, including what they call transactional writing, which is where they encourage the participant to focus on the perspective and feelings of those around them rather than just themselves. they had them do poetry where they were supposed to express themselves using metaphors.

They had them do affirmative writing which focused on identifying personal strengths and aspirations. Legacy writing which encouraged the writer to reflect on what values were important to them and then mindfulness writing as kind of the last style where they were encouraged to be

kind of aware and attentive and have like kind of a distance between them and what they were writing about so that they could assess and kind of accept the things they were writing about. And I thought that was so cool. But basically, they had 39 adults who volunteered to do the study. And they had them once a week for six weeks come to a location and write out either on a computer or in a journal these writing assignments. and they had them right basically for 15 minutes, five minutes in between with these different prompts.

So the outcomes assessed were resilience, stress, rumination, and depression symptoms. The primary outcome was resilience. They used the Connor Davidson Resilience Scale, which is a 25-item scale that ranges with total scores from 0 to 100 and looks at various kinds of aspects of resilience. Let me just, let me read some of these. I think it's really cool.

I always like to see how people define things. And I hope it's not too nerdy for everyone listening in. But it's like, so they had questions like the ability to adapt to change, do they have close and secure relationships? Sometimes fate of God can help. Sometimes fate or God can help. So that's kind of like a positive view of the world, right? can deal with whatever comes their way.

Past success gives them confidence for new challenges, see the humorous side of things, and so on. So it's like these are kind of like things that people have found in other studies that have been found in more resilient people. So they put together the scale and it's from zero to 100. So what did this study find the change was? Yeah, so they found a,

increase in resilience scores of about 10, and they used the Cohen's D to determine effect size, and they found it had a very large effect size. So, like, 0.75. So think about it like this. The scale is from 0 to 100, and these people went up 10 points, which is like, cool, that's 10%. That's good. Okay. Just in one intervention of writing, that's pretty amazing.

What other scales did they use, and what do they find from those scales? Right. So the secondary outcomes were stress, rumination, and depression, or perceived stress. So in order to measure the stress, they use the 10-item perceived stress scale. That one is scored from 0 to 4 on a 5-point scale. And a total score, the higher the score indicates a higher level of perceived stress. And again, the study that we're looking at, which is a number of perceived stress. And again, the current study that we're looking at, Dr. Glass, they found a difference in perceived stress with an approximate decrease of a 6.1. Okay, so this is a 10 item scale. So 10 times 4 is 40, so there's 40 points. Right. Right. So, and a six point difference in a 40 point scale sounds good. Awesome. Yeah, Cohen's D was .76, so a little bit decreased in perceived stress. All right, what other scales did they use? Okay, so the other scales that they used were, to look at depression,

they looked at the Tony Item Center for Epidemiological Studies Depression Scale. And this scale is also like a self-report zero-four scale. Highest possible score is 60, and the team found, that depression scores decreased by a mean of approximately six. And then lastly, they use the 22 item rumination response scale in order to measure rumination. This is also a four-point scale. And they ask basically about the frequency of each rumination item, one being almost and never, four being almost always, and then kind of questions that are, you know, considering rumination. So how alone do you feel?

how often do you think about a situation, wishing it had gone better? Dimensions kind of like that. And what they found was that the RHS, the rhenation response scale scores, decreased from baseline with the mean of about 8.6, and the effect size of 0.82. Yeah, so significant, probably significant enough to try this. I mean, this is cool. Interestingly, when I listened to one of his podcast, he said something like, you know, there might be a limit to the effectiveness of this. So he's had some people who like keep trying it over and over again, and it's not helping.

And he's like, hey, maybe do something else. So if you're listening to this and you're like, Dr. Peter, you don't understand. I write all the time. I'm not getting better. It's like, okay, let's try some other things. Let's try therapy. Let's try exercise. Let's try, you know.

So, yeah. Okay, keep going. Yeah. Just to kind of talk about what, like, to respond to that, I feel like a major thing that we've learned from these studies is that it really is the population that you're studying, that determines the fact that it's going to have. One thing that they mentioned specifically for this study

was that all of the participants volunteered to be in the study. So they were, and they did not get any form of compensation. So they were already interested in writing. So that's another, like, thing to mention, which is, like, these people who receive this benefit, we're already kind of interested in writing as a way of therapy. So if you're not interested in writing as a form of therapy, maybe it won't have the same effect.

Well, I would say try it, try it, try it at least a couple times. No, I think there's something really cool about, you know, a one-day intervention having a cool decrease in symptoms. Like even if it's 10%, 10%, it's just a little bit less suffering. We're moving in the right direction. And one thing he talks about and some of his other stuff is he talks about some people. It doesn't seem to work. And so he has them try different things.

Try writing with your left hand. Some people didn't even want to write some of the stuff down. You know, so no one could ever read it. So he said, why don't you just write it in the air, you know? So just write it to yourself, basically. Some people enjoyed burning what they wrote afterwards. So, you know, to just be able to write it, but then to get rid of. of it, you know. So there's this kind of aspect of there's not one monolithic way to do this.

See what works for you. See what works for your patient. And go with that. Yeah. And another thing I thought was interesting about this study was that they also use a scale of 0 to 10 and they ask the patients to what degree was the writing meaningful and valuable for you? And for every form of writing, the average rating was above six. So the lowest rating was the poetic style. And that still had an average rating of 6.92. So people enjoyed doing this intervention. People enjoyed doing this writing and they found it meaningful and valuable. And I just thought that was also really interesting. Cool.

Yeah, really cool. I want to jump to your study. Is there anything you want to mention about your study that you did? Or shall we leave that for the article right up? No, so I can talk a little bit about it. Again, this is like a little baby, mini- undergrad study. But basically what we did is we recruited participants from within the college that I went to, and we separated them into two groups.

So one group did an expressive writing intervention for 15 minutes. This was only one intervention one day, one period of writing. And the second control group also did a form of writing, but they just wrote about basically their time management skills or what they were supposed to write about, like what they did during the day. Okay. And then we used the state trait anxiety inventory, specifically looking at the state anxiety portion,

which was created by Dr. Spielberger. It's a pretty old scale that developed in 1983. And we basically used that. It's a 20-itam scale to measure anxiety. So we measured anxiety pre-intervention, post-intervention, 30 minutes post-intervention, and then 15 days post-intervention, to see how anxiety fluctuated between the two groups. And we found pretty, pretty small effects, but we did find that there was a decrease in anxiety

over both interventions, which we kind of speculated was that maybe people were not, people were still writing expressively in our control group. Maybe instructions weren't clear enough that they weren't supposed to talk about their feelings because I actually was the person that was reading through all of the writings. Okay. And what did you find in reading their writings? That people who were writing about their day would be like, oh, this happened to me today and it made me so upset because my teacher was supposed to do this.

And I never said that I was going to do it, but then I did end up doing it. And now I'm so annoyed. And I'm like, you are writing expressively. You are confounding the study. But yeah, so we did kind of include that in our discussion, which is that we kind of feel like people maybe were still kind of writing expressively, and maybe that's why they also had a decrease anxiety in anxiety. But still, the effects sizes were very small.

The change in their state trait anxiety measures were pretty small, but still statistically significant. So clinically significant, I don't know, but statistically significant, yes. Yeah, and I think one thing that this study shows is it didn't increase anxiety to write. Right. You know, some people say like, oh, isn't writing or just ruminating on your problems? Isn't that just bad? Like, doesn't that make you worse?

More depressed? More anxious? No, it doesn't. If anything, it's going to decrease a little bit. Okay. I think I would like to jump to talking about the physical benefits of writing. Can you talk to me about this study by Joshua? Smith into 1999.

Yes. So in 1999, Joshua Smith and his team examined the relationship between expressive writing and physical symptom improvement in asthma patients and rheumatoid arthritis patients. So they had a sample of about 112 patients, 61 asthma patients,

51 rheumatoid arthritis patients. And they had them complete and expressive writing protocol and then they assessed their physical symptoms for the asthma. They used spirometry, specifically the FV1, which is the forced expiratory volume within one second. So how much air you can push out in one second? They measured that in their asthma patients. And for the rheumatoid arthritic patients, they had them evaluated by a rheumatologist who looked at symptoms, severity, distribution of pain, tenderness, swelling,

in the affected joints, presence and severity of deformities, assessment of daily living capacity, and general psychosocial functioning in order to determine symptom reduction in that group. And what they found was those who did the expressive writing intervention, they had like improvements in their physical symptoms. So for the asthma group, they found a 60, an improvement in FAB 1 from 63.9 to 76.3 at their two-week follow-up. And then for the rheumatoid arthritis group, they found a global decrease in rheumatoid disease activity as determined by their physicians at the four-month assessment. And my first thought was like, well, you know, what if everyone got better?

But the control didn't get better. That's what's crazy. It's like the control group did not get better. And my second thought was like, well, we do writing. So I run this IOPP partial program and we do a lot of writing in there. And especially for psychosomatic patients who can't verbalize emotions, sometimes they can write emotions. Sometimes they can like start to be congruent, you know, talk about how they really feel what's really going on inside of them in writing. So I'm like, okay, yeah, maybe that's part of the success in these patients who had a little bit improvement in their physical.

symptoms. It's kind of cool. Yeah. Yeah. It's worth trying. It's interesting. Another thing that they found was that there was like a difference in the time frame of the improvement for the asthma group versus the rheumatur arthritis group. So they're kind of talking about in the discussion how that could indicate that maybe there's a difference in the mechanism for different like chronic conditions in how writing affects it. And so I thought that was interesting too. I think next, we're probably going to talk about stress and the kind of endocrine system response to stress, and also the immunological response to stress. So it's like there are different avenues by which expressive writing or stress reduction or rumination reduction could be affecting physical symptoms,

as we talked about earlier, like the change in cortisol. It could be different for kind of different disease mechanisms. And it's not a change in a singular thing, right? And, and And cortisol, just salivary cortisol is a really poor indicator in my mind of stress of what's really going on because there's so many fluctuations of that throughout the day. There's so many different inflammatory markers. But I think the big point is that if you can reduce stress, if you can reduce rumination, if you can reduce anxiety, yeah, your body calms down. You know, patients will in some way get some symptoms from.

stress when stress is beyond the capacity for them to deal with it they'll get migraines irritable bowel fatigue fibromyalgia you know pain will increase inflammation will increase I have a I have a friend who's like joints swell up when he gets stressed yeah and for a while I was like man I think you have rheumatoid arthritis eventually we learned out it was gout so he has gout attacks when he gets stressed you know because gout is from like cells breaking down more than usual in the body and when you get stressed maybe there's more apoptosis cells breaking down so okay yeah yeah kind of personal story there yeah i did pretty bad dyshydotic eczema on my i don't know if you can see it on the camera

now but i get pretty bad dyshydraulic eczema and it players up a lot when i'm stressed so like when I was studying for step two just a couple of weeks ago, like my hands were literally falling apart. Yeah, it was bad. But now it's a lot better. I've been using cortisol cream as well, so that kind of helps a lot. But yeah, I can definitely have some firsthand experience. My body definitely responds to stress it very physically. So. Yeah, what was it like? I know. So when you started this, I was like, you know, why don't you do this? Why don't you try to write? Was that, let's talk about what that was like for you. Yeah.

So first thing is I have tried journaling in the past, and it's always been hard for me because I just have a hard time sitting down and focusing and doing one activity. And I've just always kind of been like that. I have not been officially diagnosed with ADHD, but I have been referred to be diagnosed, and I just keep forgetting to do the appointment. But I don't know. I don't know why. I just always had a hard time just like sitting down. I felt that too when I sat down to try to, I did this with you actually.

I had a, I was like, oh, I should check my email or oh, I need to like, you know, pull up my social media. Or, you know, there's all these like little distractions, you know, or like. So it's just, it's hard to sit there for 20 minutes. It really is. But I did it because we were doing it for this podcast. So, okay, go on. It was, for me, it was hard. just to get started. Like, it was hard to get myself to, okay, sit down. I need to lock in. I need to do this. But once I actually did get started writing, I felt like the time passed so quickly. And then by the time the timer went off, I was still like, had a bunch of things I wanted to say. And for even one of the days, I just continued writing anyway, because I was like, I just want to get everything out. But yeah,

I found like it was, it definitely showed me some areas of congruence in my life where I can see how my past traumas have kind of affected me now and how I respond to situations now, how I build my self-talk now. And I kind of talk about this at the end of the article. And all of the all of the studies and protocols we've booked at, they've been looking at how people experience, like, symptoms weeks and months kind of after the intervention. But I would say even immediately after the intervention, I felt a little bit better at just a general sense of better betterness. Like I got something out. I released something. You know, and that's kind of what we found too in our study. We had them, when we studied anxiety, we had them do a retake the

anxiety inventory 30 minutes after writing. And that's when we found the largest decrease. Interesting. And it came back up after the 15 days. Yeah, you know, I was expecting to be distressed after writing. There was some, it's like I had anxiety to sit there and write about my anxiety. But then afterwards I was like, I was like, okay, wow. Yeah, that was really powerful. That was really good.

That didn't stress me out. That made me feel better after. So I don't know what it is about like there's something about trauma we want to avoid talking or thinking about something traumatic But to actually go there It doesn't make it worse and that's that's one of the things that this study all of the studies that we read found right? Yeah Okay yeah any other big things jump out to you in this experiment For my personal experience personal experiment yeah

I guess I also was a little bit surprised about what I chose to write about. I didn't really talk about this in the article, but I've had like a couple of different things happen in my life. I mean, everybody does. And I think the things I wrote about were probably not from the outside perspective, things that people would consider to be like the most traumatic things that have ever happened to me. But they were things that I felt like I was still being impacted to, impacted by, to this day, if that makes sense. Because a lot of the stuff was more like emotional traumas rather than like, I've been in like a pretty bad car accident before when I was younger. But that hasn't affected me emotionally as much as like much smaller things that occurred

when I was maybe like in high school or middle school or stuff, like things that still kind of my self concept to this day. Well, don't negate how important those things were just because they were emotional. You know, I think they, of course they could be a big deal and of course it's important. That's true. That's true. I think like it just showed me that you don't have to be like a severe PTSD patient in order to have find benefit in writing about your trauma. Your traumas can be small and you can still find better, small however you define that. And you can still find like a lot of emotional benefit in writing about them. Yeah, absolutely.

I would agree with that. I would agree with that. I think, well, I would say to you, I would reiterate this idea that, like, at times we can feel like some of the things that happened to us, we should not feel very distressed by them. And I think, no, it's okay. It's like it's there for a reason. Maybe you don't fully understand why it was distressing as much as it was. Or maybe, you know, how can we have some increased compassion for, like, you know, a particular thing did really awaken. emotion and distress in us in ways that we didn't expect.

So, yeah, I would kind of reiterate that for you and for the audience as well as you endeavor upon writing about distressing things. How did the intervention go for you in terms of like what you felt like you wrote about? You know, I think it went well and I think I need to continue it. So I need to like create the discipline to like be like okay this is important. I'm going to spend 20 minutes. I get up pretty early. I'm just going to spend 20 minutes and keep going.

You know, I actually wrote some poetry as well. So I wrote just freehand. I wrote some poetry. It just came out, you know. So it's like, yeah, I wasn't going in with like an agenda. And I think some new thoughts came out to me that were kind of circle. circling around. And so that was helpful to kind of connect things that were maybe a little bit less connected in just my verbal mind thinking to put it down, connected it. You know, personally,

I wrote it. It's very personal. I don't want to share it. I won't share it with anyone. And that's okay. I think that's actually better is to write in such a way that it's like there's nothing, you know, you're not fearing some future person reading this and therefore restricting what you're going to put down, right? Yeah, Dr. Pennebaker actually talked about that in kind of an interview I launched with him where he said that he suggested basically that people write with, I think you talked about this earlier,

write with the intention of like burning or throwing away whatever you write, that you do have that kind of like freedom of expression. Yeah. Yeah. I think, I think that's good. Well, thank you so much for working on this with me and doing this project. And I think your write-up is awesome. I contributed a little bit. We talked a lot the last couple weeks about research and about how to read articles and stuff like that.

But you did a wonderful job pulling together some of the key articles on this. And it will be on Psychiatrypodcast.com. We'll write some continued medical education questions so people can get some CME for it. And yeah, it's great. Thanks for coming on. Thank you so much for having me, Dr. Peter. I've enjoyed this past two weeks, and I don't love research, but I definitely have gained some really valuable tips for learning how to read research

and be kind of competent in that field in the future. So thank you so much. Awesome. All right. Well, I hope if people are listening in who have maybe not read research, articles that much before as they've listened to more and more episodes from me. Maybe they gain an ability to sort of think through how to read them, how to think, is this clinically relevant? What can I take from this and apply it? I'm personally taking this idea that this could help most

people, but probably the most people, the highest percentage that will be helped the most is people with some level of dissociation. And I'm actually going to get a PDF of that dissociation scale. And if I think someone has dissociation, I'm going to have them do that scale to kind of see what it looks like as well. So that'll become part of my process coming out of this episode. So thanks for changing my practice moving forward, Emerald. All right, we'll leave it there for today.