Transcript SOMATIZATION DISORDER

SOMATOFORM DISORDER
Dr. Marwan A. Bakarman
Consultant Family & Community Medicine
Case study
Ahmed 35 years old present to PHC complaing of dizziness,
backache and indigestion.
His file show: for the last 7 month, he presented with the
following: abdominal pain, nausea, intolerance to 13
different foods, backache, shortness of breath at rest, chest
pain, dizziness, difficulty swallowing, palpitation.
Investigation: Blood test 5 times
chest x-ray 3 times, ECG ( 6 times), ultrasound abdomin (2
times), CT scan abdomin( 2 times), upper Gi endoscopy (2
times), colonoscopy once
ALL investigations were NORMAL
HOW YOU WILL MANAGE AHMED ?
But it really hurts Doctor. . . .
• Both conditions are defined in both ICD-10 and
DSM-IV
• Both disorders have stigma attached
• Symptoms are very real for the patients and often
their families and the condition needs to be taken
seriously
• Lack of physical diagnosis can be very frustrating for
patients
• Never underestimate the effect it can have on you,
the doctor
• Also a huge financial burden on health services
Somatization: Definition
• Presentation of physical symptoms that
are:
• unexplained after medical/physical
examination (i.e., medically unexplained
symptom).
• associated with significant concern, distress
or impairment
• as a manifestation of psychological distress.
Somatization Disorder
• Up to a quarter of all new OPA are related to somatic symptoms
• More common in females than males (10X)
• Symptoms tend to manifest themselves by adolescence, established by
age of 30
• Incidence does not increase with age (Costa and McCrae)
• Established link with child abuse (Bowman 2000)
• Often fail to respond to treatment, show passive interest in finding a cure
• High co-morbidity with:
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Depression (55%)
Anxiety Disorders (34%)
Personality Disorders (61%)
Panic Disorders (26%)
Somatization Disorder
Exercise
• How many symptoms can you list?
symptoms
Vomiting
Nausea
Diarrhoea
Back pain
Dysuria
Shortness of breath
Chest pain
Amnesia
Visual changes
Sexual apathy
Impotence
Irregular menstruation
Deafness
Lump in the throat
• Basically a minefield!!!
Abdominal pain
Bloating
Pain in arms and legs
Joint pain
Headaches
Palpitations
Dizziness
Difficulty in swallowing
Paralysis/muscle weakness
Dyspareunia
Dysmenorrhoea
Mennorrhagia
Seizures
Loss of voice
• The way we react to a patients somatic complaints
can relieve them OR exacerbate them
• Study (Salmon 1999) on patients perspective on
medical explanations showed 3 categories of doctors
explanation with varying degrees of success:
– Rejecting
– Colluding ‫التآمر‬
– Involving
The key is EMPOWERMENT
Somatization Disorder (Briquet’s
Syndrome)
• ICD-10 45.0
• Appearance of physical symptoms NOT accounted for by
physical pathology or autonomic arousal
• Chronic course, often fluctuating
• Frequently consult with many different doctors seeking
treatment, often with vague, inconsistent and disorganised
medial histories.
• Has impaired social/work/personal functioning
• Symptoms may be exacerbated by stress
• No element of feigning symptoms to occupy sick role
(Facititious Disorder) or for material gain (Malingerer)
Hypochondriasis
• DSM-IV 300.7 and ICD-10 45.2
• Criteria:
– Persistent belief in the presence of one or more serious
illness underlying a presenting symptoms
– Unable to accept reassurance from multiple doctors that
there is no physical illness
– Persistant for more than 6 months
– Causing significant impairment/distress
– Not delusional in intensity
Hypochondriasis
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Prevalence of 4.2-13.8% in general medical clinics
Equal prevalence amongst men and women
No increasing prevalence with age
No geographical factors
No evidence of genetic factors
Maladaptive behaviour can contribute
May be associated with childhood experiences
(chronic/serious illness in pt or family members/missing
school/traumatic experiences)
• May be associated with parental characteristics i.e.
overprotectiveness
• Chronic stable condition
Hypochondriasis
• Kendall (1974) proposed that it could be explained by learned
abnormal illness behaviour.
• Costa and McCrae (1985) demonstrated a link between
hypochondriasis and neuroticism (emotional maladjustment)
defined as
– “ a broad dimension of NORMAL personality that encompasses a
variety of specific traits, including self-consciousness, inability to
inhibit cravings, and vulnerability to stress as well as the tendency to
experience anxiety. . . .”
– Study consisting of 1000 pts looking at somatic complaints (Cornell
Medical Index) and neuroticism (Emotional Stability Scale) showed
that high levels of neuroticism was associated with higher levels of
somatic complaints.
– BUT cause or effect?
Hypochondriasis
• Common (and normal!) in society as short-lived ideas
• A frequently missed diagnosis
• ? Associated with profession?
• Primary (existing independently)
• Secondary:
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Depression
Anxiety disorders
Delusional disorders
Schizophrenia
Dysthymic disorder
Organic brain disease
Hypochondriasis
• Very difficult to assess and diagnose, no
negative/positive or pass/fail test available.
• A POSITIVE diagnosis – rather than continuing to
exclude other diagnoses
• Methods have been introduced to identify traits
leading to increased probability of presence of
hypochondriasis:
– Minnesota Multiphasic Personality Inventory (MMPI) uses
10 scales and specifically looks at hypochondriasis, also
depression and hysteria among others.
– Whitely Index
Hypochondriasis
• Despite being a stable chronic condition, there
is an increased morbidity associated with it:
– risks of complications from investigations (3 times
more likely to be referred for further investigation)
– side-effects from inappropriate treatments
Management
• Explain to the patient and family relationship
between psych and somatic
• Empathic attitude
• Avoid unnecessary investigation
• Treat underlying depression and anxiety
• Symptom variation provides teaching moments.
• “Goal of treatment is to figure out how you can
control symptoms.”
• Describe the potential for stress to affect
symptoms.
– Normal stress reaction in terms of sympathetic
arousal—the body’s “emergency mode.”
– For example, digestive functions are “turned off”
when stressed. If prolonged, results in digestive
distress (e.g., pain, constipation, diarrhea).
Behavioral Techniques
• Increased Activity Involvement
– Combats stress (minimize functioning in emergency
mode)
– Improves overall mood (as we see in dep treatment)
– Provides Distraction from somatic symptoms
– Pain perception has a subjective component—
improved mood and distraction reduce the experience
of pain
– Exercise has physiological effects that combat
somatization and stress
• Do they get their daily dose of meaningful
activity, productivity, and exercise?
• Assertiveness Techniques
– What kinds of needs are asserted?
– What kinds of needs are not?
– Do they engage in combative communication
patterns?
• Activity strategies and assertiveness help
patients obtain reinforcement by behaviors
other than illness behaviors.
Relaxation Techniques
• Directly acts on physical symptoms, given its effects on
breathing, heart rate, muscle tension, etc.
• Patients report benefit soon upon learning the
technique
• Helps with stress management
• Includes Diaphragmatic Breathing, Progressive Muscle
Relaxation, Biofeedback
• Practice, Practice, Practice.
– Practiced in session with patient, consecutively for a period
of weeks (combined with practice at home).
Sleep Strategies
– Establish consistent sleep patterns (same bedtime and
waketime everyday)
– Go to bed only when sleepy (stimulus control)
– If not asleep within 20-30 minutes leave bed and return
when sleep again (stimulus control)
– Bed is only for sleep and sex. No TV, reading, etc.
(stimulus control)
– Comfortable sleep environment
– Avoid alcohol/caffeine during 6 hours before bedtime
– Exercise regularly, but not within 4 hours of bedtime
Woolfolk and Allen (2007)
Cognitive Strategies
• Much like CBT for depression
– Looking for adaptability of thoughts
– Eliminating distortions
• Use somatic symptoms as anchors for examining
thoughts
• Look for variations in adaptability of thoughts and
discuss their effect
• Patients are likely to have difficulty identifying
thoughts/emotions.
• Likely to have schemas that include health concern