Transcript Psych 353: Social Cognition

Module:
Health Psychology
Lecture:
Chronic illness and somatisation
Date:
16 March 2009
Chris Bridle, PhD, CPsychol
Associate Professor (Reader)
Warwick Medical School
University of Warwick
Tel: +44(24) 761 50222
Email: [email protected]
www.warwick.ac.uk/go/hpsych
Aims and Objectives


Aim: To provide an overview of the psychological
aspects of chronic illness and somatisation
Objectives: You should be able to describe …

common somatoform symptoms;

characteristics of somatoform disorders;
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cause, course and consequence of somatoform disorders;


principles of assessment, treatment and management of
somatoform disorders;
ways to distinguish between normal and abnormal
somatisation.
Greek Origin

Σωμα
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
Σωματικóς
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Somatic = 'of the body'
ψυχή

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Soma = 'the body'
Psyche = 'of the mind'
ψυχοσωματικός

Psychosomatic = 'influence of the
mind on the body'
Terminology
 Somatic symptoms: physical symptoms (assumption: with
physiological cause)
 Somatoform symptoms: physical symptoms without
(identifiable) physiological cause
 Psychosomatic symptoms: physical symptoms with
psychological cause
 Somatopsychic symptoms: psychological symptoms with
physiological cause
 Somatisation: expression of emotional problems in somatic
symptoms
 Somatic fixation: bias towards (automatic) medicalisation
of symptoms
Somatisation
'Somatisation is a ubiquitous and diverse
process in medicine, linking the
physiology of distress and the
psychology of symptom perception'
Joseph Ransohoff (1915 - 2001)
'... the history of medicine has written the
prehistory of psychosomatics'
William Osler (1849 - 1919)
'Representation of the
bodily processing of emotion'
Leonardo da Vinci (1452 - 1519)
Symptom Prevalence
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Over 1-week, 69%/1410 adults report
1> one symptom

Only about 10% of symptoms prompt
medical help seeking

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A physiological cause is found for only
a small proportion of the most common
physical symptoms presented in
primary care
20% of patients present with (primary /
main) physical symptoms that are not
explained by physical disease - 1 in 5
85%
15%
Organic Basis Found
No Organic Basis Found
10
9
8
Physiological Cause
Identified
7
6
5
4
3
Each primary care clinician in the UK
will have on average 12 patients
with chronic somatic symptoms
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3 yr incidence (%)
Symptom Presentation
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Of all the symptoms for which an identifiable physiological
cause can not be found, the most common are:
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Pain: related to different sites (e.g. head, abdomen, back) or
bodily functions (e.g. menstruation, intercourse, urination)
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Gastrointestinal: nausea, bloating, vomiting (not during
pregnancy), diarrhoea, intolerance of several foods

Sexual: indifference to sex, difficulties with erection or
ejaculation, irregular menses, excessive menstrual bleeding
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Pseudoneurological: voice loss, impaired vision, hearing and
balance/coordination, paralysis, hallucination, seizure, amnesia
Medical Specialties and Their
Patients with Problems
Patients with a wide range of
somatoform symptoms are
encountered not only in
primary care, but throughout
the specialities also
Specialty
Problem / Symptom
Orthopedics
-
Low back pain
Obs/Gyn
-
Pelvic pain, PMS
ENT
-
Tinnitus
Neurology
-
Dizziness, headache
Cardiology
-
Atypical chest pain
Pulmonary
-
Hyperventilation, dyspnea
Rheumatology
-
Fibromyalgia
Internal Medicine
-
Chronic Fatigue Syndrome
Gastroenterology
-
Irritable Bowel Syndrome
Rehabilitation
-
Closed head injury
Endocrinology
-
Hypoglycemia
Characteristics of Somatoform Disorders

A class of disorder defined by
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presence of physical symptoms
that are not fully explained by the
presence of a medical condition;
symptoms cause clinically
significant distress and
impairment;
psychological factors judged
important in symptom onset,
severity, and/or maintenance;
symptoms are chronic,
independent of one another and
not intentionally produced.
Somatoform Disorders
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Somatisation disorder (Briquet's syndrome): A history of many
physical complaints beginning before age 30 years that occur over
a period of several years and result in treatment being sought
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Conversion disorder (conversion hysteria): Symptoms or deficits
affecting voluntary motor or sensory function
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Hypochondriacal disorder (hypochondriasis): Preoccupation with
fears of developing or having a serious disease, based on
(mis)interpretation of bodily symptoms, which persist despite
medical reassurance
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Somatoform pain disorder (psychogenic pain): Disabling pain of
sufficient severity to cause treatment being sought
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Body dysmorphic disorder (dysmorphophobia): Preoccupation
with an imagined defect in appearance, or if real / present,
concern is markedly excessive
Somatisation Disorder
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Description: A history of many physical complaints beginning
before age 30 years that occur over a period of several years
and results in treatment being sought or significant impairment
in social, occupational or other areas of functioning
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Epidemiology: 10 X> females, familial pattern for 10-20% of 1st
degree female relatives;
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Course: Chronic, fluctuating and rarely remits. Diagnostic
criteria usually met before age 25 yrs.
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Cues: Symptom onset / progression following loss; symptom
amplification with stress
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Other features: Complicated medical history; numerous (12+)
somatic complaints; Dr shopping
Somatisation Disorder: A 10-Year Example
Date
(Age)
Symptoms
(life event)
Referral
Investigation
Outcome
1990
(21)
Abdominal pain
GP to surgical
outpatients
Appendicectomy
Normal
1992
(23)
Nausea
(boyfriend in prison)
GP to Obs/Gyn
outpatient
Pregnant
Termination of
pregnancy
1994
(25)
Bloating, abdominal
pain, (divorce)
GP to gastro
outpatient
All tests
normal
IBS diagnosis; treat
with Fybogel
1995
(26)
Pelvic pain
(wants sterilisation)
GP to O&G
outpatient
Sterilised
Pelvic pain for 2yrs
post-surgery
1997
(28)
Fatigue
(dissatisfied at work)
GP to infectious
disease clinic
All
tests normal
Self-diagnosed ME,
joins self-help group
1998
(29)
Aching,
painful muscles
GP to
rheumatology clinic
Mild cervical
spondylosis
Tryptizol 50 mg,
pain clinic referral
1999
(30)
Chest pain
(lost job)
A&E to
chest clinic
Normal; probable
hyperventilation
Refer to
psychiatric services
Conversion Disorder
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Description: Symptoms or deficits affecting voluntary motor or
sensory function
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Epidemiology: Rare condition; acute onset in adolescence or
early adulthood; twice as prevalent
in females; more common in rural
populations and lower SES
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Course: Recurrent symptoms with
short duration
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Cues: Traumatic events; stress;
inability to cope
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Other features: high suggestibility;
prone to seizures and convulsions;
unaware of retained functions
Samuel Pepys recorded
conversion disorder after the
Great Fire of London in 1666
Hypochondriacal Disorder
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Description: Preoccupation with fears of developing or having a
serious disease based on (mis)interpretation of bodily
symptoms, which persists despite medical reassurance
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Epidemiology: About 3% and 5% prevalence among general
population and primary care outpatients, respectively
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Course: Onset at any age, but typically early
adulthood; familial deaths and illness; media
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Cues: Heightened awareness of physical self;
symptom amplification when stressed
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Other features: Dr Shopping; background
expertise
Somatoform Pain Disorder
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Description: Pain of sufficient severity to cause clinically
significant distress or impairment and treatment being sought
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Epidemiology: Precise prevalence unknown but likely to be
fairly common; small female bias possible; variable onset age
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Course: Chronic, fluctuating and rarely remits
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Cues: Often develops from illness or accidental injury; symptom
amplification when exposed to illness, accident cues and stress
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Other features: Dr shopping (often precipitated by maximum
dose); risk for multiple registrations; pharmacologically
informed; initiated and discontinued various CAM formulations
Body Dysmorphic Disorder (BDD)
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Description: Preoccupation with an imagined defect in
appearance, or if present, concern is markedly excessive
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Epidemiology: Prevalence unknown in general population;
10-30% in mental health settings
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Course: Onset early adulthood; increasingly
distressing; potential for suicidal ideation
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Cues: Unclear; possible sensitivity / bias
to facial feature priming
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Other features: Typically remain single;
examined potential for plastic surgery
BDD?
What causes somatisation, and when?
What?
When?
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Aetiology is poorly understood,
but biological, psychological
and social factors are (likely to
be) involved
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Predisposing factors increase
the chance that particular
symptoms may develop and/or
become important

Biopsychosocial contribution
will vary between people and
across somatoform disorders size and interaction
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Precipitating factors trigger
increased physiological selfawareness, e.g. stress,
depression, anxiety, illness
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Clinician factors may
contribute to somatisation, i.e.
iatrogenic harm
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Perpetuating factors make it
more likely that somatoform
symptoms will persist,
Aetiological Formulation
Example for a chronic pain patient
 Easiest to work through stage columns
 Each 'Factor X Stage' cell can have multiple entries, or none
Stage of Illness
Aetiological
Factors
Predisposing
Precipitating
Perpetuating
Biological
Genetic
Injury
at work
Lack of
mobility
Psychological
Externalising
explanatory style
Trauma
Fear
avoidance
Social
Dissatisfaction
at work
Employer
response
Litigation
Medical
Treatment
Targets
'Rule-out'
investigations
Somatic
Fixation
Distinguishing Normal & Abnormal Somatisation
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Symptoms: are symptoms beyond the norm?
Consider multiplicity, severity, and chronicity
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Coping: do symptoms significantly impair role functions?
Consider social, familial and occupational roles
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Belief: is there resistance to explanation and reassurance?
Consider affect, refractoriness, and illness discourse
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Internalised: has the 'sick role' been accepted?
Consider illness explanations - as a way of life
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Excessive: extensive but unsatisfactory service use?
Consider consultations, providers, and treatments
Principles of Assessment
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Be vigilant to iatrogenic harm, e.g. be a part of the solution and
not the problem
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Identify patients' concerns and beliefs, e.g. illness
representation
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Contextualise patients' health-related experiences, e.g.
previous illness, symptoms, contact with medical services, etc.
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Review recent history of current symptoms, paying particular
attention to possible life events, i.e. stressors
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Ask questions about patients' reaction to and coping with
symptoms, e.g. habitual patterns of poor coping
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Use screening questions for psychiatric morbidity
Somatic Symptoms and Psychiatric Co-morbidity
Patients with
Psychiatric Morbidity (%)
The more somatic symptoms a patient has, the less likely it is that their
symptoms reflect the presence of physical disease and the more likely
there is co-morbid psychiatric morbidity (depression & anxiety)
0
5
10
15
Number of Somatic Symptoms
20
Principles of Treatment
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Validate patient experience, e.g. explain that the symptoms are
real and familiar to doctor
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Provide a framework, e.g. describe how psychological factors
(ABC) may exacerbate somatic symptoms
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Offer opportunity for discussion of patient's worries at the
earliest opportunity
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Give practical advice on coping with symptoms and encourage
return to normal activity as soon as possible
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Discuss and agree a treatment plan that includes a planned
follow up and review
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Encourage specific tasks before next meeting, e.g. identify
three situations that worsen symptoms
Treatment Aims
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Treatment focus should be on coping with symptoms and
impairment rather than on symptomatic cure
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Target perpetuating factors
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Depression, anxiety, or panic disorder
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Chronic marital or family discord
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Dependent or avoidant personality traits
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Occupational stress
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Abnormal illness beliefs
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Iatrogenic factors
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Pending medico-legal claim
Management Strategy
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Proactive not reactive: arrange to see patients at regular, fixed
intervals
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Broaden agenda: establish a problem list and allow patients to
discuss relevant problems
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Minimise providers: only one or two providers to reduce
iatrogenic harm
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Co-opt a relative: a therapeutic ally to help implement and
monitor the management plan
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Cope not cure: cure is an unrealistic expectation, instead aim
for containment and damage limitation, and remind patient at
each consultation
Conclusions
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Common: Somatoform symptoms are common and occur in all
medical specialities
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Harm: Somatisation is chronic, disabling, distressing and
destructive
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Cause: Multiple biological, psychological and social factors
predispose, precipitate and perpetuate somatisation
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Treatment: Focus on coping with symptoms and impairment,
and removing perpetuating factors
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Management: Somatisation can be managed effectively in
primary care
Summary
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This session would have helped you to understand …

common somatoform symptoms;

characteristics of somatoform disorders;

cause, course and consequence of somatoform disorders;


principles of assessment, treatment and management of
somatoform disorders;
ways to distinguish between normal and abnormal
somatisation.
Any questions?

What now?

Obtain / download one of the recommended readings

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a) integrated template
b) ESA question
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