Transcript Somatisation and Somatoform Disorders

Somatisation & Somatoform Disorders
What are they,
What to tell patients and How?
Professor George Ikkos
Liaison Psychiatry Consultant
MRCPsych MRCP
“And, poets, your brain is in your body.”
Mind Body and Psychosomatic Problems
Useful websites for professionals recommended
by Professor George Ikkos
Mind and Body
A Psychiatric Summary by
Prof George Ikkos and Dr Susie
Lingwood
Background (1)
• Depression is a broad and heterogeneous
diagnosis
• Central to it is depressed mood and/or loss of
pleasure in most activities
• A chronic physical health problem can both
cause and exacerbate depression
• Depression can exacerbate the pain and distress
associated with physical illnesses and adversely
affect outcomes
Basic Emotions
Joseph E. LeDoux, Emotion Memory and the Brain
Scientific American, 2002
• Fear
• Panic (and Care)
• Rage
• Seeking (and
Lust)
• Play
• (Disgust)
• (Joy)
Copyright: Scientific American
Brain, Autonomic Nervous System
Integrative/ Psychosomatic Medicine
Stress, Brain and Body
Wilkinson and Pickett, “The Spirit Level”, Allen Lane/ Penguin
Acute Stress
• Brain: acute alertness
– Less perception of pain
• Immune tissues:
– Readied for possible injury
• Circulatory system:
– Heart beats fast and blood
vessels constrict: more
oxygen to muscles
• Adrenal glands:
– Secrete hormones to
mobilise energy supplies
• Reproductive organs:
– reproductive functions
temporarily suppressed
Chronic Stress
• Brain: impaired memory
– Increased risk of depression
• Immune tissues:
– Deteriorated response
• Circulatory system:
– Elevated blood pressure and
higher risk of cardiovascular
disease
• Adrenal glands:
– High hormone levels and slow
recovery from acute stress
• Reproductive organs:
– Higher risk of infertility and
miscarriage
Subcortical Emotion
Thalamus
Septum
Emotions/
Motor
Responses
Amygdala
Interoceptive
Awareness
Tectum
Dorsal
Tegmental
Area
dACC
Body
Experienc
e
Basal
Forebrain
ReMap
Amygdala
Hippocampu
s
Locus
Coeruleus
Hypothalamic
Nuclei
THA
Hypothalamus
Body
Map
Interoceptive
Input
S.E.L.F.
Raphe
Nucleus
(23) Insula
Medically Unexplained Symptoms
• http://www.rcpsych.ac.uk/expertadvice/improvin
gphysicalandmh/medicallyunexplainedsymptoms.
aspx
• http://www.rcpsych.ac.uk/expertadvice
Mental Disorder
Not Mental Disorder
Medically Unexplained Symptoms
Medically Unexplained
Symptoms
Clinical Somatisation
 Functional Mental Disorders
 Functional and Dissociative Neurological
Symptoms
 Functional Somatic Syndromes
• Including Various Pain Syndromes
 Somatoform Disorders (including Somatoform
Pain)
Medically Unexplained
Symptoms
 Organic Physical + Mental Disorders
Clinical Somatisation
 Functional Mental Disorders
 Functional and Dissociative Neurological
Symptoms
 Functional Somatic Syndromes
• Including Various Pain Syndromes
 Somatoform Disorders (including Somatoform
Pain)
Organic Mental Disorders
Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Medically Unexplained Symptoms
Organic Mental Disorders
 Iatrogenic conditions
 Psychotropic side effects of medication
 Other side effects medication
• Which may be misunderstood for
somatisation
Functional Mental Disorders
www.rcpsych.ac.uk/expertadvice.as
px
Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Functional Mental Disorders
Medically Unexplained Symptoms
Functional Mental Disorders
www.rcpsych.ac.uk/expertadvice.as
px
 Mood and anxiety disorders
 Schizophrenia and non-affective psychoses
 Eating, Body Dysmorphic and
Hypochondriacal Disorders
 Autism Spectrum Disorders!!
Functional and Dissociative Neurological Symptoms
www.neurosymptoms.org
Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Functional Mental Disorders
Functional Neurological Symptoms
Functional Dissociative Symptoms
Medically Unexplained Symptoms
Functional and
Dissociative Neurological Symptoms
www.neurosymptoms.org
• This website is about symptoms which are:
– Neurological (such as numbness, blindness and
blackouts)
– Real (and not imagined)
– But not due to neurological disease
• Symptoms like these are surprisingly common but
are difficult for patients and health professionals to
understand
• Its like having a software problem rather than a
hardware problem
www.neurosymptoms.org
Functional and dissociative neurological symptoms have been given
many different names over the years: e.g. conversion, hysteria
 Many of these labels are 'psychiatric' and are based on the
idea that the symptoms are 'all in the mind'.
 Psychological factors are often important to look at in
relation to functional and dissociative neurological
symptoms but the symptoms are not 'made up'.
 Most experts believe that these symptoms exist at the
interface between the brain and mind, between neurology
and psychiatry, which is why it is difficult when people
(and patients) ask "is it neurological or psychological?".
 The evidence suggests it is both, and that actually this
question doesn’t really make sense given what we know
about how movement and emotion pathways work in the
brain.
www.neurosymptoms.org
Does anyone make up these symptoms?
The answer to this question is undoubtedly (and unfortunately) yes, but it seems to be rare.
 For example, one man was filmed playing football when he said he was in a
wheelchair. Another was filmed lifting heavy bins when he said that he couldn’t
carry anything. In another case, a man who claimed he was blind and was suing for
damages was arrested for speeding on a motorway.
 When patients who are malingering like this are examined, they can have some of
the same positive signs as patients with functional symptoms but there are
important differences. They tend to have very inconsistent stories (because they
are making up that too). They don’t have the same kind of stories to patients
genuinely experiencing symptoms and there may be a legal case or other obvious
reason for the symptoms. (although this does not mean that everyone with a legal
case is making up their symptoms)
 There are also some people who make up symptoms in order to gain admission to
hospital or have an operation. When this happens it is called factitious disorder and
by general consensus, its also a rare condition. Its best thought of as a form of
behaviour like deliberate self harm.
 So, occasionally, people do make up symptoms and it can be difficult to tell. Some
doctors (and sometimes patients) make a terrible mistake in thinking that most
patients with functional symptoms are ‘making up’ their symptoms or ‘swinging the
lead’.
Functional Somatic Syndromes
http://www.nhs.uk/Conditions
Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Functional Mental Disorders
Functional Neurological Symptoms
Functional Dissociative Symptoms
Functional Somatic Syndromes
Pain Syndromes
Medically Unexplained Symptoms
Functional Somatic Syndromes
http://www.nhs.uk/Conditions
• Atypical Facial Pain
• TMJ Pain + Burning
Mouth Syndrome
• Migraine
• Hyperventilation
• Non-cardiac/ atypical
chest pain
• Functional Dyspepsia
• Irritable Bowel Syndrome
• Irritable Bladder
• Chronic Pelvic Pain
• Multiple Chemical
Sensitivity
• Chronic Fatigue Syndrome
• Fibromyalgia
• Non-specific lower back
pain
• Joint Hypermobility
Syndrome (Ehler-Danlos)
Functional Somatic Syndromes - Different?
The British Journal of Psychiatry (2004) 185: 95-96 Peter White
 There is a five-fold risk of chronic fatigue syndrome in patients suffering from
infectious mononucleosis (White et al, 1998), whereas there is no evidence that
fibromyalgia is caused by infections (Rea et al, 1999).
 The risk factor of childhood sexual abuse varies six-fold across different
functional somatic syndromes (Romans et al, 2002).
 A recent systematic review showed that ‘... psychosocial treatments have not
yet been shown to have a lasting and clinically meaningful influence on the
physical complaints of polysymptomatic somatisers’ (Allen et al, 2002). A recent
large trial of treatment of Gulf War syndrome found no significant differences
between CBT and control treatments (Donta et al, 2003). An accompanying
editorial by Hotopf (2003) correctly attributed this lack of efficacy of CBT to not
using an illness-specific model for CBT. In contrast, CBT is effective when
specifically designed to help improve the physical functioning of patients with
chronic fatigue (Whiting et al, 2001).
 the concept of a general functional somatic syndrome does not predict
prognosis, which varies by specific functional somatic syndrome. Fibromyalgia
runs a persistent and chronic course, whereas irritable bowel syndrome runs an
intermittent course with recovery being more common.
Functional Somatic Syndromes- Same?
Functional Pain Disorders: Time for a Paradigm Shift
2009
• Hypersensitivity to
experimental stimuli
• Compromised DNIC
• Evidence of structural brain
abnormalities
• Evidence of altered neurocognitive function
• Evidence of increased activity in
central arousal circuits and
sympathetic nervous system
• Evidence of common genetic
susceptibility
(endophenotypes)
Ch 25; E A Mayer and M C
Bushnel
Thalamus
Septum
Emotions/
Motor
Responses
Amygdala
Interoceptive
Awareness
Tectum
Dorsal
Tegmental
Area
dACC
Body
Experienc
e
Basal
Forebrain
ReMap
Amygdala
Hippocampu
s
Locus
Coeruleus
Hypothalamic
Nuclei
THA
Hypothalamus
Body
Map
Interoceptive
Input
S.E.L.F.
Raphe
Nucleus
Integration of Interoceptive Information
Interoceptive
Input
THA
pINS
mIN
S
aINS
Interoceptive awareness and emotional responses
Orbitofrontal
Attention!
PFC
!
Interoceptive
Input
MIS-MATCH!!!
THA
pINS
mIN
Insula:
S
Aversive Learning
aINS
Cingulate
Gyrus:
dACC
Limbic Motor
Cortex
Amygdala
Hippocampus
Body
Loops
Interoceptive
Awareness
Interoceptive
Expectation
Emotions/
Motor
Responses
ICD 10 F45 Somatoform
disorders
Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Functional Mental Disorders
Functional Neurological Symptoms
Functional Dissociative Symptoms
Functional Somatic Syndromes
Pain Syndromes
Somatoform Disorders
Somatoform Pain Disorder
Medically Unexplained Symptoms
ICD 10 F45 Somatoform disorders
• The main feature is repeated presentation of
physical symptoms together with persistent
requests for medical investigations, in spite of
repeated negative findings and reassurances by
doctors that the symptoms have no physical
basis.
• If any physical disorders are present, they do not
explain the nature and extent of the symptoms
or the distress and preoccupation of the patient.
ICD 10 F45.0 Somatization
disorder
• A definite diagnosis requires the presence of all of
the following:
(a) at least 2 years of multiple and variable
physical symptoms for which no adequate physical
explanation has been found
(b) persistent refusal to accept the advice or
reassurance of several doctors that there is no
physical explanation for the symptoms
(c) some degree of impairment of social and family
functioning attributable to the nature of the
symptoms and resulting behaviour
ICD10 F45.4 Persistent somatoform pain disorder
http://www.britishpainsociety.org/pub_patient.htm
 The predominant complaint is of persistent, severe, and
distressing pain, which cannot be explained fully by a
physiological process or a physical disorder, and which occurs in
association with emotional conflict or psychosocial problems
that are sufficient to allow the conclusion that they are the main
causative influences.
 The result is usually a marked increase in support and attention,
either personal or medical.
 Pain presumed to be of psychogenic origin occurring during the
course of depressive disorders or schizophrenia should not be
included here.
 Psychalgia
Psychogenic:
· backache
· headache
 Somatoform pain disorder
Personal Tips on Clinician Behaviour
 Comprehensive psychosocial assessment; INCLUDE MEANING!
 Impeccable consultation skills; DON’T MAKE IT WORSE!
 Validate Patient Experience
• “Showing courage and resilience”/ “Body can’t keep up with the mind”
• “Sensitive body”/ “sensitive body + mind”
• Possible evolutionary advantage!!!
 Discuss risk of iatrogenic harm
• Analgesic Dependence and abuse
• Analgesic exacerbated pain
 Use pictures
 Provide information
 Refer to websites
 “RE-ATTRIBUTION”- Target unhelpful cognitions;
• Focus on unnecessary or unhelpful health anxiety
 ACTIVITY SCHEDULING- with appropriate pacing and encourage fun
 Follow-up
 Consider further specific treatment:
• rehabilitation, psychological and psychiatric approaches, including
medication
Mental Disorder
Not Mental Disorder
Organic Physical Disorders
Organic Mental Disorders
Functional Mental Disorders
Functional Neurological Symptoms
Functional Dissociative Symptoms
Functional Somatic Syndromes
Somatoform Disorders
Pain Syndromes
Somatoform Pain Disorder
Medically Unexplained Symptoms
Organic Physical + Mental
Functional
Disorders
Mental
Disorders
Organic Physical + Somatoform
Mental Disorders
Organic Physical + Medically Unexplained
Symptoms