Table of Contents

1. Overview

  • symptoms are culturally dependent
  • "idiopathic" is preferred terminology for somatic symptoms
  • What is common in both situations is that patients’ lives are shadowed by disproportionate and excessive thoughts, feelings, and behaviors that center on the perceived somatic sensations
  • regardless of medical explanations, multiple physical symptoms predict disability and psychopathology

1.1. Diagnostic changes

  • no longer needs to be medically unexplainable
  • suffices if it's disproportionate
  • pain disorder has been removed
  • hypochondriasis has been removed as its pejorative

2. Etiology and Risk

2.1. Bio

  • increased sensitivity to pain
  • proprioceptive acuity
  • abnormality of autonomic and proprioceptive responses
  • pituitary-hypothalamic axis
  • e.g. imaging has shown hypoperfusion of the non-dominant hemisphere in functional GI syndromes
  • TRAIL study: association of cortisol responses and clusters of functional somatic symptoms
  • no clear genetics

2.2. Psycho

  • hx of violence, abuse, deprivations
  • traits: suggestability, dramatic demeanor, flair, flamboyance
  • alexithymia - associated with tendency to somatize
  • learned behaviour for gain

2.3. Social

  • attention obtained from having an illness
  • lack of reinforcement of nonsomatic expressions of distress
  • generally higher in lower socioeconomic strata, developing countries
  • in US, certain ethnic groups
  • cultural factors

3. Comorbidities

  • >90% depression and/or anxiety
  • substance use d/o - especially Rx'd

4. DDx

  • very very large: cross section of psychiatric and medical

4.1. Features

  • The symptoms coexist with major psychiatric disorders such as

depression or panic.

  • The symptoms closely follow traumatic events.
  • The symptoms lead to psychological “gratification” or “secondary gain.”
  • The symptoms represent predictable personality traits (coping mechanisms).
  • The symptoms become persistent, join a conglomerate of other symptoms, and convey such attitudes as overuse of medical services and dissatisfaction with medical care.

4.2. Somatic Sx in psychiatric issues

  • depression: pain
  • anxiety: cardioresp and GI symptoms
  • psychosis: somatic delusions

5. Course and prognosis

  • mostly chronic
  • closely associated with personality and cognitive styles
  • number and type of symptoms change: some inconsistency in presentation
  • disability proportional to number and severity of symptoms
  • depression and anxiety become more disabling if associated with medically unexplained symptoms

6. Treatment

6.1. Alliance

  • Pts approach medical encounters with a mixture of magical, unrealistic expectations, pessimism, and distrust of the profession
  • respect for the patient’s symptoms and an acknowledgement of their validity.
  • Active, receptive listening, tolerance for repetition, and a “neutral” approach (avoiding being dismissive, confrontational, or overly reassuring)

6.2. History

  • often "thick charts"
  • keep an open mind, despite forewarnings in the medical records, and perform an independent assessment of the patient
  • emphasis on psychological questioning and interpretations should be avoided at this stage
  • Premature reassurance, although seemingly appropriate from the physician’s perspective, may be perceived by the patient as disinterest or dismissiveness.

6.3. Reassurance

  • traditional practice of medicine gave high importance to bedside manner and interpersonal issues
  • “to comfort,” meaning “to give strength and hope; to ease the grief or trouble; to cheer,”
  • new meaning: “to reassure,” simply meaning “to assure anew; or restore to confidence.”
    • doesn't work

6.4. Physical vs Psychological focus

  • many patients do not readily acknowledge or recognize “emotional” issues
  • As the history taking moves along, attitudes, beliefs, and attributions should become clearer and patterns of interaction and illness behavior discernible

6.5. General approach

  • "caring" than "curing"
  • restraint in the use of medication
  • infrequent but regular appointments (x1/mo) is preferable than random ones based on fluctuations
  • clearly spelled out treatment plan
  • true insight may never develop, some awareness of psychosocial stressors helps
  • should continue to see primary care physician even if seeing a psychiatrist
  • Therapeutic goals should be modest at first and be limited to small, attainable gains such as a decrease in medical visits, a commitment to a single primary care physician, and the avoidance of unnecessary tests and procedures.

7. DSM

7.1. Somatic Symptom disorder

7.1.1. Dx

  • 1+ distressing symptom
  • excessive thoughts/feelings/behaviours
  • >6mo

7.1.2. Epidemiology

  • unknown; much higher than somatization disorder in DSM-IV
  • 0.1%-0.8% "full" somatization disorder

7.1.3. Treatment

  • CBT; brief psychodynamic
    • CBT has a pivotal study (Allen, 2006) at 15 mo "very much improved"
  • exercise, yoga, relaxation, meditation, and massage
  • Medications should be generally avoided
  • Smith's consultation letter
    • The letter urged the physicians to see these patients during regularly scheduled appointments, perform brief physical examinations focusing on the area of discomfort at each visit, avoid unnecessary diagnostic procedures, invasive treatments, and hospitalizations, avoid using statements such as “symptoms are all in your head,” and briefly allow/encourage patients to talk about “stressors.”

7.2. Illness anxiety disorder

7.2.1. Dx

  • preoccupation with having/acquiring an illness
  • no/mild symptoms, or excessive preoccupation
  • high anxiety
  • excessive health-related behaviours
  • >6mo

7.2.2. Epidemiology

  • 4-6%
  • comorbidities: depression (40%), panic disorder (20%), OCD and GAD (5%)
  • 60% show symptoms after years of follow up

7.2.3. Treatment

  • CBT: first line
    • (barsky, 2004)
  • fluoxetine: moderately effective and well-tolerated (Fallon et al)
  • no superiority for pharm

7.3. Conversion disorder

7.3.1. Dx

  • voluntary motor or sensory
  • incompatibility between symptom and neuro conditions

7.3.2. Epidemiology

  • 5-14% among hospital referrals to CL Psych
  • 5-25% among psychiatric outpatients

7.3.3. Treatment

  • special attention given to history of trauma, sexual and physical abuse, and family history of conversion symptoms
  • early intervention can reduce chronicity
  • Psychological interpretations or explanations do not work well early in the process, but reassuring patients that critical tests are normal and that symptoms will eventually improve may be helpful
  • Behavioral interventions should focus on improving self-esteem, the capacity for emotional expression and assertiveness, and PSYCHOTHERAPY.the ability to communicate comfortably with others.
  • pharm: comorbidities

7.4. Psychological factors affecting other medical conditions (PFAOMC)

7.4.1. Dx

  • medical condition/symptom
  • psych/behavioural factors adversely affect the condition: course, treatment, risk

7.4.2. Treatment

  • psychoeducational: patient's medical team and family

7.5. Factitious disorder

7.5.1. Dx

  • falsification
  • presents as ill/impaired/injured
  • deception is evident

7.5.2. Epidemiology

  • unknown

7.5.3. Treatment

  • conservative, aimed at preventing further complications

7.6. Other specified and unspecified somatic symptom and related disorders

8. Instruments

  • Present State Examination (PSE)
  • Whitley Scale
  • Pain Catastrophizing Scale

Author: Armin

Created: 2022-07-19 Tue 15:28