Transcript Somatizing patients: an approach for family physicians

An Approach to the Somatizing Patient for Family
Physicians
Dr. Katharine Gillis FRCPC
Shared Care Mental Health Team, Ottawa Hospital
University of Ottawa
Disclosure
• No conflicts to declare
• Relationships with commercial interests:
– Grants/Research Support: Non applicable
– Speakers Bureau/Honoraria: Non applicable
– Consulting Fees: Non applicable
– Other: Non applicable
Learning Objectives
• Understand changes to DSM-5 for somatization and
implications for your practice
• Understand principles of assessment for diagnosis and
prognosis of somatization
• Utilize management strategies to assist your patients
functioning and reduce your stress
DSM 5 changes-Somatic Symptom Disorder
• Somatoform Disorders simplified to Somatic Symptom
Disorder
• Somatic symptoms persistent 6 months or more
• Very distressing or significant disruption of function
• Excessive and disproportionate thoughts, feelings and
behaviours regarding somatic sx
• Somatic sx do not need to be medically unexplained
• Somatic symptoms are not intentionally produced
Somatoform Disorders used to include
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Somatization Disorder
Conversion Disorder
Somatoform Pain Disorder
Undifferentiated Somatoform Disorder
Hypochondriasis
Body Dysmorphic Disorder (BBD)
** for all of the above the symptoms are not intentionally
produced by patients
** none but BDD are in DSM-5 instead are symptoms of Somatic
Symptom Disorder
** BDD is under Obsessive-Compulsive Spectrum Disorder
Why is somatization important?
• e.g. one study(Ford,1983) estimated that Somatization
accounted for about 10% of direct health care costs
• May account for 25-50% of primary care visits
• Can have an adverse impact on the clinician-patient
relationship if no cause found for the somatic symptom.
• They also incur increase health risk to themselves from potential
adverse effects of investigations.
Classification of somatization by time course
1.
2.
3.
4.
Acute-usually associated with a stressor
Sub acute- often associated with a depressive or
anxiety disorder
Chronic- pervasive and enduring pattern of
somatization
Not all patients who somatize have a disorder (1 and
2)
Etiology of Somatization
Stress
• There is increasing evidence of abnormalities in the
stress systems (SNS and HPA axis) in patients with
somatization
• Protracted activation of the stress response creates
wear and tear on the body (“allostatic load”)
• Stress can produce or exacerbate many prototypical
somatization syndromes including headaches, noncardiac chest pain and GI symptoms as well as
causing muscular tension
Emotion
• Emotions are properly conceived as brain
processes, some conscious and some unconscious,
at times affecting the body just as stress does
• Negative emotion and moods have been linked to
various forms of disease whereas positive moods
are linked to longevity and favourable health
outcomes
• Evidence suggests that somatization can result from
blocked, partially expressed, or unexperienced
emotions
• Alexithymia is seen in some somatizing patients and
refers to an inability to identify feelings
Exploring Emotional Repertoire
• When you ask questions about emotions do they have
trouble answering?
• Are they aware they have difficulty identifying or
expressing emotions
• Explore if the patient has a need to “please others”
• Can they set personal limits
• Do they need to feel physically unwell in order to say
no
• Do they doubt their own value and likeability
• Is there an all or nothing pattern of behaviour and
inability to pace self
Cognitions and Behaviour
• Somatizing patient tend to have distorted beliefs about
their health
• Thoughts of possible illness rise to feelings of anxiety,
dysphoria and frustration, which are likely to generate
and maintain physiological arousal and physical
symptomatology and hence be interpreted as further
evidence of serious illness
• Medical help-seeking can be negatively reinforced
through the reduction of anxiety and distress
The Sick Role
• Described by Talcott Parsons 1951; Role theory suggests
we become the roles that we play
• Those who chronically inhabit the sick role grow more
disabled over time, and their impairment is genuine
• Some somatizers come from families in which it was
normal for someone to be sick
• However there are many rewards and exemptions
attached to illness, not all of which the patient are
conscious of
Somatization and Secondary Gain
1.
2.
3.
4.
5.
6.
7.
8.
9.
Avoidance of unpleasant life role or activity
Sympathy and concern from others
Importance within the family
Gratification of dependency needs
Financial awards associated with disability
Retaining the spouse in the marriage
Avoidance of sex
Procuring of drugs
Punishment of others or revenge
Management of Somatization and of
Somatic Symptom Disorder DSM-5
• Focus on “caring not curing”
A Caveat
• Although you do not want to over investigate and treat
a patient suspected of somatizing you also do not want
to miss an underlying medical illness
• Certain illnesses can present with symptoms in different
systems including SLE, MS, HIV, hyperparathyroidism
and paraneoplastic syndromes in various cancers to
name a few
Therapeutic approach
• Focus on doctor-patient relationship is critical
• Attitude is empathic and interested
• Doctor’s efforts to validate the patient’s discomfort and
distress are critical to developing therapeutic rapport
• Listen carefully to patient’s report of his or her
symptoms and the impact they have on his or her life
Approach to Acute Somatization
•
Important to inquire about the patient’s fears about
their illness
• May respond to:
1. Provision of information about symptoms
2. Reassurance
3. Problem-solving regarding stressors
4. Patient activation
5. Bolstering of existing support systems
Likely chronic somatization if:
1.
2.
3.
4.
5.
Patient reports a lifetime history of multiple physical
symptoms with unclear or no diagnosis
Patient reports seeing many doctors and receiving
many diagnostic procedures with inconsistent
findings for more than one symptom
Patient reports a pattern of physicians, family
members and/or friends being “unable to
understand” or “fed up” with the patient’s physical
symptoms
Symptoms are described graphically or dramatically
There is strong evidence of secondary gain
Management of chronic somatization
1.
Patient should have one primary care physician
2.
Appointments should be at regular time-contingent
intervals
3.
Brief physical examination should be performed at
each visit to address new health concerns
(Remember: somatizing patients can develop
organic medical conditions)
Management of chronic somatization
(contd.)
4.
Judicious diagnostic evaluations are initiated
conservatively based on new physical findings or
symptoms
5.
Once a rapport has developed begin to shift focus to
current functioning, stressors and available support
systems
6.
Corroborate history, disability, treatment adherence,
substance use and health care use by integrating
family and other supports into the care plan
Management of chronic somatization appointments
• Draw up a plan for regular check ups.
• Increase the space between check ups as time goes
on.
• In between scheduled appointments, encourage
patients to write new worries that develop on a list as
opposed to making an early appointment
• Make sure you address the items on the list at the next
scheduled appointment.
Management of chronic somatization (contd.)
• Goal is to help patient to develop tolerance for delaying
having their symptoms checked out. But also to reassure
them that there is an adequate monitoring schedule
arranged so that any serious illness is not overlooked
• Overall goal is to help patient become less hyper vigilant of
their body sensations
• These patients can be frustrating to deal with, but they suffer.
Encourage them to continue their follow up with you
Management of chronic somatization mind/body connection
• Encourage patient to use “log book” or calendar for
tracking illness or pain symptoms.
• Use log book to look at emotionally significant events
occurring prior to symptoms getting worse.
• Goal is to help patient make the link between life
stressors/emotional events with worsening physical
symptoms
• If can become more assertive may not need to rely on
illness as a way of communicating.
Relaxation Training
•
Includes diaphragmatic breathing and progressive
muscle relaxation
• Benefits include:
1. Interrupt muscle tension-pain cycle
2. May reduce generalized physiologic arousal or
reactivity
3. Patient may feel less like a helpless victim of
symptoms
(resource app calm.com )
Behavioural Management
•
Increased Activities focused on 3 categories
1. Meaningful activities (e.g. paid or volunteer work,
household projects, education)
2. Pleasurable activities (social activities, hobbies)
3. Exercise
*Encourage patient to pace themselves. To not over
do it on “good days”
Psychotherapy
• In general, psycho-educational and supportive
techniques predominate, although insight-oriented
therapy may be indicated in some patients
• Group therapy may be particularly useful in enhancing
interpersonal skills e.g. assertiveness skills
• Cognitive-behavioural therapy well studied in
hypochondriasis and may be the treatment of choice
for many somatoform disorders
• Assertiveness training
Pharmacotherapy
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Very few studies done
Use Tricyclic antidepressants or SNRIs for chronic pain
Identify and treat associated Axis I disorders
Treatment of Body Dysmorphic Disorder with SSRI’s
Symptoms of Hypochondriasis shown to improve with
Fluoxetine in one small open-label study
Pharmacotherapy-narcotics
• Patients with Somatic Symptom Disorder and
Chronic Pain: Caution Narcotics can be a trap
• Narcotics mellow out/numb angry feelings
• A positive response to narcotics may not be
evidence of pain and pain relief rather can be a
psychological relief (or both). Tolerance to this
psychological effect develops easily resulting in
request for escalating doses.
• Try to avoid narcotics in this group of patients.
• Questions