International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Nature of Panic in Endometriosis Patients - Arnold Wilson, PhD
Good morning. My name is David Herzog. I'm the director of MIGS at Staten Island University Hospital, Northwell Health. I'd like to thank the Endometriosis Foundation of America and Dr. Kin for inviting me to moderate this session, I'd like to introduce Dr. Arnold Wilson, who is an instructor in psychiatry at Columbia University School of Medicine and a training and supervising psychoanalyst at the Institute for Psychoanalytic Training and Research. He has authored numerous scholarly publications and has served on the editorial boards of the Journal of the American Psychoanalytic Association, the International Journal of Psychoanalysis and Psychoanalytic Psychology. Welcome to Dr. Arnold Wilson.
Hello, friends and colleagues. I'm a clinical psychologist and I've consulted on probably hundreds of cases of women who have endometriosis. Along the way, I of course have learned a great deal and what I would like to convey to you is what these women have taught me, and today I'm going to focus on the role of panic, which is a significant part of the whole endometrial experience. As I listened to more and more young women describe their internal world, I became very sensitized to panic. Over time, I heard it everywhere conflicts about containing and managing panic saturated my conversations.
I have now been consulted by over 350 young women and struggled with each one of them to understand how they have crafted their lives to accommodate the panic of endometriosis. Panic and endometriosis are inextricably linked. It is rare to find a woman as yet properly untreated for endometriosis who is a stranger to panic. It is an open secret how contemporary psychiatry struggles with phenomenological approaches to diagnosis. A colleague and a respected and brilliant diagnostician told me that 30% of the patients who referred to him for treatment resistant depression, which treatment resistant depression means individuals who don't respond to medications do respond when they're treated for panic disorder rather than depression. That's a phenomenal and dreadful fact. When I say clinicians now, I mean surgeons, palliative care doctors, PTs, pharmacologists, psychologists, reproductive endocrinologists, and so on. These clinicians labor under what, in my opinion, is a striking paucity of cumulative knowledge when faced with panic. The American Psychiatric Association has what's called practice guidelines and for panic disorder, as well as for other disorders, and their panic guidelines do not mention endometriosis, although in other ways they're quite comprehensive. I'm happy to share these guidelines with anyone in the conference. All you have to do is email me. You can get my email through Cassandra and the Office at KIN Endometriosis.
I'm going to hypothesize something, which is that the panic of endometriosis is unique. It is not comparable, the same as the forms of panic that we see that are subsumed under the rubric of panic disorder. It's not the panic of the inexplicable. It's not the person who panics when they have agoraphobia. It's not the obsessional panic. It's not existential panic. After a while of hearing this over and over and over again, I began to understand what it was. It's the uniqueness of endometriosis and the endometrial panic. Most ideas about panic end up either rationalizing this away or minimizing its distinctiveness on the surface. The presence of panic in an endometriosis in endometriosis seems like a no-brainer. Who would not panic if her interior organs were under such a full scale systematic assault? However, if I understand the prevailing situation, the place of panic and endometriosis is far more complicated than initially meets the eye. I was very surprised when I picked up the finding over and over again that many women retrospectively reported having panic attacks before the onset of endometriosis symptoms often before the onset of menstruation. You can write that off as a pre morbidity, but that oversimplifies the picture. Why are 6-year-old girls, 9-year-old girls having debilitating panic attacks and then going on to develop endometriosis? I wondered, is this an artifact or is it a specious finding?
Recently we have begun hearing about secret or occult endometriosis, which has no clear discernible symptoms. The relationship between the latent disease process and the occurrence of symptoms is identical to that of the pre-adolescent girl having panic attacks best addressed by conceiving of endometriosis as a complex system In psychiatry, this might be turned as syndrome endometrium. Panic is correctly understood, I believe, as one part of a complex system and not in and of itself a discreet pathology or in any way secondary to other parts of the system. Panic is a part of the end endometriosis symptom due to the complex interplay of physical, emotional, and psychological factors associated with this condition. Here are some psychological factors that underlie how panic manifests in women with endometriosis, chronic pain, hormonal fluctuations, the impact on the quality of life, psychological stress associations with other mental health conditions, fears of medical procedures, social and emotional isolation. That's one that is really not to be underestimated. The incredible isolation that many women with endometriosis have isolation from their friends who will not understand when they won't go out with them on Friday or Saturday night and trying to explain their situation to other people who often will either scoff at it or think they're hysterics or say there's something wrong in your nain.
So I want to touch on what I think of as the pathophysiology of endometrial panic in describing a complex system. We are bio-psychosocial. We look for the biological, the psychological, and the social and their interaction. So I want to begin with the biological factors that may be playing a role here, but I want you to be clear that I'm describing factors that contribute to endometrial panic and not to endometriosis itself. These factors I'm about to list help us to consider why panic can proceed. Overt symptoms of endometriosis in adolescence, the biological factors are multifaceted and interconnected. Chronic inflammation, hormonal imbalances, HPA, axis dysregulation, neurotransmitter dysfunction, central sensitization are key contributors. Collaboration between healthcare providers, including gynecologists, endocrinologists, pediatricians, and mental health professionals is necessary to address the endometriosis syndromes, physical and psychological aspects over the early phases of the female lifespan.
Here are some of the key biological factors that may contribute then to panic and endometriosis. Acute and chronic inflammation, I'm not going to go over them right now because we're racing the clock. Hormonal imbalances, same problem. Dysregulation of the hypothalamic pituitary adrenal, HPA axis. That's the axis that controls the body's stress responses. Neurotransmitter dysfunction, endometriosis may very well disrupt the balance of neurotransmitters such as serotonin, gaba, norepinephrine, which are critical for mood regulation well before the onset of symptoms. Immune system activation, endometriosis may or may not be an autoimmune disease. I believe it is. And the reason that I believe it is, is really not because of the, I have any hard research on it, although there is some soft research, but because when I consult with the women who I see almost invariably when I talk with them about who their uncles, their aunts first, second degree probands, it almost always turns out that there's a smoking gun somewhere. There's the aunt who never had children. There's the grandmother who made it her life's mission to lecture all her brood about how a woman's role is to suffer with period pain and so on and so forth. And all of a sudden it's like a light comes on for so many patients when they realize the genetic pool from which they are and how prevalent it is and how it can easily converge on endometrial symptoms.
Okay, now the concern that I have is how to manage panic for the pre-surgical endometriosis patient. The vast majority of the consultations I've done are for the benefit of the group that does endometrial surgery and needs to know what's going on with this individual and what are the factors at play that will help them be better surgeons. A long time ago, Dr. She can refer to what I do as providing an emotional MRI and I think he's right. So I went out and I designed a brief treatment, a 10 session treatment for treating panic in presurgical women. So we're not talking now about treating panic. We're not talking about treating panic in women with endometriosis. We're talking about treating panic in women with endometriosis who are about to have surgery. Now, this is a model that can be exported. Anyone in the world who does endometriosis surgery can use it and the model, it's a 10 session treatment model. It helps patients connect their psychological distress with their physical symptoms and empowers them as best I can to process their grief, their guilt. There's a lot of guilt in women who have endometriosis, who have committed the crime of being endowed with the right to have children.
I emphasize new coping strategies, but what I want to emphasize is that the general framework of my brief treatment, my 10 session treatment for endometrial panic must be tailored to each individual's needs and epigenetics. And I must also say that the person who's conducting the brief treatment or the therapist, let's call it the therapist, should be knowledgeable about endometriosis and its potential impact on mental health. There are not many clinicians who are, there needs to be training in neurology in the nature of disease states, of autoimmune states, and of being a therapist, and there's not many people who can do that. But we need to launch that kind of training program. And of course, collaboration with medical professionals is essential for comprehensive care.
And parenthetically, I would say remember that this is a brief intervention and some patients may benefit from longer term therapy to address some of the emotional issues that continue to plague them, and in fact, can be exacerbated by the surgery. It is not easy getting better from endometriosis. Five minutes. Thank you. Okay, I've been told I have five minutes and I'm going to leap ahead. I thank you for, I'm going to skip the specifics of the intervention. Same story. Anybody who wants a copy of my brief 10 session treatment for presurgical panic disorder, please email me and I'll send it to you and you can get my email address from Cassandra.
The second one is that we can and should provide a specifiable treatment for panic that will have broad implications for recovery when paired with a bonafide surgical treatment. I'm going to now amplify these two points. Point one, a systematic review of the empirical evidence concerning panic disorder in young girls and adolescences was undertaken by an bot, several MI bots. AI bots noted panic disorder in young girls. Panic disorder in young girls prior to adolescence predicts a high risk of persistent anxiety disorders, mood disorders, substance abuse disorders, and significant impairments. No kidding. Notice the absence of endometriosis or for that matter, any autoimmune disease, family, physicians, healthcare providers should recognize going forward the presence of panic in girls as a potential predisposing factor for later endometriosis. I'll say that again. If you're a pediatrician, if you're a nurse practitioner assessing young girls and they're having panic attacks, do not exclude the hypothesis that endometriosis is on the way. It should also set off automatically a review of the genetics of that child.
Now, I'm not methodologically naive. I'm naive in many ways, but I happen to be a good methodologist and I'm clear that my findings are anecdotal. Correlations can be illusory and causality cannot be established by post hoc. Ergo proctor hack follow back studies, a longitudinal study with adequate controls and a sample of properly diagnosed girls with panic disorder, who are then followed forward as necessary. However, until such studies are conducted, a cost benefit analysis of what I propose strongly weighs in on the side of the benefits, contemporary translation medicine insists that we really cannot afford to wait. There is a dangerous lag from the labs of experimental research to the frontline trenches of clinical practice. Finally, some further observations on uniqueness of endometrial panic. Again, my model is easily exported. It can be done in Italy, it can be done in France. It can be done in Antarctica, but it must be stressed that the clinician has broad training and know-how the treatment must be narrow. You're not looking at a broad reorganization of a personality, you're focusing on panic. It's based on other brief treatments that have been articulated, but it stands apart from them. Last paragraph. Okay, I'm on time.
What follows is hypothetical. My evidence, of course is anecdotal and not rigorously tested. The implementation of my model is cost effective, I believe, and will pay for itself medical utilization. Research in much of modern medicine shows how preemptive strategies such as the one I am outlining saves vastly greater costs than the expenses incurred by providing it as a later treatment. After the disease has flowered a similar utilization. Research usually finds something in the neighborhood of a five to one cost benefit savings. We will see faster recovery times, we will see much less use of surgical medications, post-surgical medications and the taking up of physician and hospital resources. The patient will return to work earlier, be more available for family life, but what is not at issue is that the woman will be saved a lot of pain and misery and that cannot be quantified.
