somatisation dr eugene cassidy. somatisation the expression of personal and social distress in an...
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Somatisation
• The expression of personal and social distress in an idiom of bodily complaints with medical help seeking
• A culturally determined mechanism of expressing psychological problems in a more socially acceptable form
• A process rather than a diagnosis
• Classification of ‘disorders’ currently unhelpful
Functional Somatic Symptoms
• 3.4 symptoms per person general population over previous 2 years (Rief et al, 2001)
• PaiPain and Fatigue most common
• Medical OPD 52% presenting symptoms MUS (Nimnuan et al, 2001)
Functional somatic syndromes (1)
GastroenterologyGastroenterology IBS/IBS/ Functional dyspepsiaFunctional dyspepsia
CardiologyCardiology Non-Cardiac chest painNon-Cardiac chest pain
NeurologyNeurology Chronic Headache / CFSChronic Headache / CFS
RheumatologyRheumatology Fibromyalgia / CRPSFibromyalgia / CRPS
GynaecologyGynaecology Chronic pelvic painChronic pelvic pain
OrthopaedicsOrthopaedics Chronic back painChronic back pain
DentalDental TMJ dysfunctionTMJ dysfunction
ImmunologyImmunology Multiple Chemical SensitivityMultiple Chemical Sensitivity
Functional somatic syndromes (2)
General Population:
•27% have CFS, IBS, CWP or CO-FP•1% all 4 (Aggarwal et al, 2006)
Medical OPD:
•56% (Nimnuan et al, 2001)
- There is only one …….. (Wessely, 1999)
Somatoform-like disorders
• Malingering
– feigned illness; conscious gain
• Factitious disorder (Personal / By proxy)
– feigned illness; no conscious gain
Somatoform disorders
• Symptoms suggestive of a medical disorder but are medically unexplained
• Disabling
• May be severe, of long duration and involve multiple symptoms– ie Somatisation disorder
Somatoform disorders
• Categorical Classification unhelpful
– Somatisation disorder– Pain Disorder – Hypochondriasis– Body Dysmorphic Disorder– Dissociative / Conversion disorders– Syndromes overlap
• Chronic Fatigue syndrome• FMS
Somatisation is typically not
consciously elaborated
But…. isn’t it human nature to exaggerate/make ourselves heard?
The Cost of Somatisation (1)
•More visits
•More admission days
•More ED attendances
•More procedures
•Annual US healthcare costs doubled
(Barsky et al, 2005)
• 456 appendicectomies • followed for at least 15
years (Dummett et al, 2002)
Normal Inflamed
•Attendance 6.5/100 yrs 3.4/100yrs
•DSH 7.9% 2.2%
•Psych attendance 10.5% 4.0%
‘PSEUDO-STATUS’Walker et al, 1996
• 54% Status Epilepticus
• 23% Encephalopathy
• 23% ‘Pseudostatus’
(majority intubated)
‘PSEUDO-STATUS’Walker et al, 1996
54% Status Epilepticus23% Encephalopathy23% ‘Pseudostatus’ (majority intubated)
Somatization Disorder
•7 days per month in bed (Smith et al, 1986)
•10% wheelchair-bound (Bass & Murphy, 1991)
The Cost of Somatisation (2)
Somatisation is associated with• Gender• Childhood adversity• Parenting• Cultural factors• Gain• Life events / dilemmas• Depression• Litigation• Iatrogenic factors• Physical deconditioning
Women report more somatic symptoms
(Kroenke & Spitzer, 1998)
•1000 patients PRIME-MD interview
•13 common symptoms
•10/13 common symptoms more common in women
•OR (adjusted for anxiety, depression) 1.5-2.5
• High Tender point count (1/3) related to:
• Adult general population
• Distress (GHQ>1)
Pain & Childhood Trauma (McBeth et al, 1999)
•Abuse (OR 6.9)
•Parental loss (OR 2.1)
•Female (OR 3.5)
•Illness behaviour (OR 2.3)
Fatigue and Childhood trauma
• Population based study (n=56146)
• 43 CFS V 60 controls
• Childhood trauma
– Increased CFS (OR 3-8)
– More severe CFS
(Heim et al, 2006)
Parental Illness
• National birth cohort study (n=5362) followed from 1946 until 1989
Childhood MUS
Maternal reports of below average health in father
• Predictors of adult somatisation:
In the Darwin family tradition: another look at Charles Darwin's ill health (Katz-Sidlow, J Royal Soc Med, 1998)
‘Even ill-health, though it has annihilated several years of my life, has saved me from the distractions of society and amusement’
Pain is increasing Harkness et al, 2005
• low back, shoulder and widespread pain now 2-4 times higher in the UK than 40 years ago
•True increase?
• Increased psychological distress
• Increased reporting & awareness
• x 7-11 sickness benefit rate
• x 3 number of solicitors
Secondary gain
• Part of their strategy for dealing with life
• Disability may hold advantages
–Material
–Care and attention
–Excuse for avoidance
–Social mystique
• Look for ‘diagnosis’ not ‘cure’
‘Taking on the World’
Any alternative to taking the sensible correct path
forward was inconceivable
I remember the day when I knew I was going down
with some kind of illness.
I talked to Mum about it..realising that although I
didn’t feel too ill at the time, it was on its way.
I don’t know why I was so sure I was going to be ill.
It was a month before I set foot outside the front door
again. I would gaze outside and worry tormenting
myself about recovering the energy to complete those
final weeks at school before the A-levels
(Watching Whitbread Cup on TV).
With a feeling of most intense energy and clarity, I
suddenly realised that there was another way. In an
instant my exam pressures evaporated.
From then on my illness was somehow different
‘Jean Van de Velde suffering from unknown illness’
‘A mysterious ailment that has his doctors puzzled’
‘After a good start to the season with good performances in Thailand, I’m physically out of shape. I feel ill. I’m basically very tired. I have muscle pains and am frequently sick.’
‘There’s a big question mark on the reason for this illness. I went through several medical exams but the doctors can’t quite seem to find a reason. I hit balls for half an hour and then have to stop because I’m just too tired.’
"To be really honest, I think my health is more important than playing in a golf tournament,"
Pain and Depression co-occur
92% of 150 patients about to be hospitalised with major depression in France had at least one painful symptom and 75% had several painful symptoms (Corruble, 2000)
• Large WHO study in primary care (n=25,916)
Depression and somatic symptoms
•10.1 percent had major depression.
45-95% of depressed patients reported only somatic symptoms
Half the depressed patients reported multiple unexplained somatic symptoms
Gender and ‘Somatic’ Depression
• National Co-morbidity and ECA studies• Pure (non-somatic) depression (m=f)• Anxious somatic depression
– Female>male– Earlier onset– Pain– Anxiety
Silverstein, 2002
Only 11 percent denied psychological symptoms of depression
DENIAL
Culture did not effect the likelihood of a somatic presentation
Predictors of Chronic Pain
• Clinic based studies
• Crossectional
• Population-based prospective study• McBeth et al, 2001
– Female
– Non-pain somatic symptoms (OR 3.8)
– Illness behaviour (OR 8.7)
– Psychological Distress (OR 2.0)
Chronic Pain and Mental Disorder
• Clinic samples• Population samples (n=1953)
• GHQ + were interviewed• 22% CWP; 32% Mental disorder• OR 3.2 mood disorder in CWP v no CWP
Benjamin et al, 2000
Depression is a risk factor for pain
• Baltimore ECA Survey prospective community cohort (3
samples: 1981; 1982-3; 1993-1996)
• Depression doubles later risk of CLBP– (Larson et al, 2004)
LitigationCassidy et al, 2000
Canadian Whiplash injuries
Change to no-fault
Reduced claims (417/100,000-
296/100,000)
Reduced time to closure of claims (433 – 194 days)
Time to closure strongly associated with:•Pain severity,
•functioning,
•depression
Exercise cessation & pain
Pain predicted by:
Lower basal cortisol
Lower NK cell response
HR variability
Medical Model doesn’t Help (Stokes)
• Trained to define disease in terms of pathology
• No identifiable pathology? – Feel cheated– Angry towards patients– Frustrated
Cognitive-behavioural model
Cognitions - somatic focus, misinterpretation of symptoms, catastrophic / depressive thinking
Behaviour change- avoidance of physical and social activity, Loss of fitness, seeking reassurance /cure, limited engagement with treatment, Loss of function and role
Attributions of cause / condition worsening,
loss of control
Emotion Anticipatory anxiety, mood change, symptom increase,
Filter
System
Cortical
Perception
Illness
Behaviour
Bodily
Signals
Enhanced by:
• Overarousal
• Physical deconditioning
•Loss/Trauma
Enhanced by:
•Selective attention
•Depression
•Health anxiety
•Absence of distractors
•Infection
Affected by:
•Cultural/Family beliefs
•Misinterpret symptoms
•Catastrophic thinking
•Attributions
•Depressive cognitions
•Visits doctor
•Avoids physical activity
•Adopts sick role
Key points
• Somatoform disorders are common but neglected. This is unfortunate as they are disabling and costly.
• ‘Somatisation’ is associated with inter alia female gender, childhood experiences, cultural expectations, social ‘gain’, depression, life stress, litigation, iatrogenic factors and physical fitness
Attitudes required to treat
Unqualified acceptance of validity of pt illness experience
Willing to listen to patients views
Positive attitude to therapy
Tolerate slow progress
Willing to let patient take credit for success(don’t expect chocolates!)
Targets for treatment
Misinformation -- Education
Distress -- Antidepressants
Illness / safety behaviour -- Behaviour Rx
Conflict - - Psychotherapy
Deconditioning -- Graded activity
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