Dr. Marwan A. BakarmanConsultant Family & Community Medicine

SOMATOFORM DISORDER

Case studyAhmed 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 onceALL investigations were NORMAL

HOW YOU WILL MANAGE AHMED?

• 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

But it really hurts Doctor. . . .

• 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: Definition

• 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:

– Depression (55%)– Anxiety Disorders (34%)– Personality Disorders (61%)– Panic Disorders (26%)

Somatization Disorder

Somatization DisorderExercise

• How many symptoms can you list?

symptomsVomiting Abdominal painNausea BloatingDiarrhoea Pain in arms and legsBack pain Joint painDysuria HeadachesShortness of breath PalpitationsChest pain DizzinessAmnesia Difficulty in swallowingVisual changes Paralysis/muscle weaknessSexual apathy DyspareuniaImpotence DysmenorrhoeaIrregular menstruation MennorrhagiaDeafness SeizuresLump in the throat Loss of voice

• Basically a minefield!!!

• 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 – InvolvingThe 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• 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:

– 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).

• 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?

Behavioral Techniques

• 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