Presentation on theme: "Professor George Ikkos Liaison Psychiatry Consultant MRCPsych MRCP"— Presentation transcript:
1Professor George Ikkos Liaison Psychiatry Consultant MRCPsych MRCP Somatisation & Somatoform Disorders What are they, What to tell patients and How?Professor George IkkosLiaison Psychiatry ConsultantMRCPsych MRCP
2“And, poets, your brain is in your body.” Mind Body and Psychosomatic Problems Useful websites for professionals recommended by Professor George IkkosMind and Body A Psychiatric Summary byProf George Ikkos and Dr Susie Lingwood
3Background (1) Depression is a broad and heterogeneous diagnosis Central to it is depressed mood and/or loss of pleasure in most activitiesA chronic physical health problem can both cause and exacerbate depressionDepression can exacerbate the pain and distress associated with physical illnesses and adversely affect outcomesNOTES FOR PRESENTERS:Key points to raise:This guideline makes recommendations on the identification, treatment and management of depression in adults aged 18 years and older who also have a chronic physical health problem (such as cancer, heart disease, diabetes, or a musculoskeletal, respiratory or neurological disorder).Depression is a broad and heterogeneous diagnosis. Central to it is depressed mood and/or loss of pleasure in most activities.A chronic physical health problem can both cause and exacerbate depression: pain, functional impairment and disability associated with chronic physical health problems can greatly increase the risk of depression in people with physical illness, and depression can also exacerbate the pain and distress associated with physical illnesses and adversely affect outcomes, including shortening life expectancy.
4Basic Emotions Joseph E Basic Emotions Joseph E. LeDoux, Emotion Memory and the Brain Scientific American, 2002FearPanic (and Care)RageSeeking (and Lust)Play(Disgust)(Joy)Copyright: Scientific American
7Stress, Brain and Body Wilkinson and Pickett, “The Spirit Level”, Allen Lane/ Penguin Acute StressChronic StressBrain: acute alertnessLess perception of painImmune tissues:Readied for possible injuryCirculatory system:Heart beats fast and blood vessels constrict: more oxygen to musclesAdrenal glands:Secrete hormones to mobilise energy suppliesReproductive organs:reproductive functions temporarily suppressedBrain: impaired memoryIncreased risk of depressionImmune tissues:Deteriorated responseCirculatory system:Elevated blood pressure and higher risk of cardiovascular diseaseAdrenal glands:High hormone levels and slow recovery from acute stressReproductive organs:Higher risk of infertility and miscarriage
21Functional Mental Disorders www.rcpsych.ac.uk/expertadvice.aspx Mood and anxiety disordersSchizophrenia and non-affective psychosesEating, Body Dysmorphic and Hypochondriacal DisordersAutism Spectrum Disorders!!
22Functional and Dissociative Neurological Symptoms www. neurosymptoms Functional and Dissociative Neurological Symptoms
24Functional and Dissociative Neurological Symptoms www. neurosymptoms Functional and Dissociative Neurological SymptomsThis website is about symptoms which are:Neurological (such as numbness, blindness and blackouts)Real (and not imagined)But not due to neurological diseaseSymptoms like these are surprisingly common but are difficult for patients and health professionals to understandIts like having a software problem rather than a hardware problem
25Functional and dissociative neurological symptoms have been given many different names over the years: e.g. conversion, hysteriaMany of these labels are 'psychiatric' and are based on the idea that the symptoms are 'all in the mind'.Psychological factors are often important to look at in relation to functional and dissociative neurological symptoms but the symptoms are not 'made up'.Most experts believe that these symptoms exist at the interface between the brain and mind, between neurology and psychiatry, which is why it is difficult when people (and patients) ask "is it neurological or psychological?".The evidence suggests it is both, and that actually this question doesn’t really make sense given what we know about how movement and emotion pathways work in the brain.
26www. neurosymptoms. org Does anyone make up these symptoms Does anyone make up these symptoms? The answer to this question is undoubtedly (and unfortunately) yes, but it seems to be rare.For example, one man was filmed playing football when he said he was in a wheelchair. Another was filmed lifting heavy bins when he said that he couldn’t carry anything. In another case, a man who claimed he was blind and was suing for damages was arrested for speeding on a motorway.When patients who are malingering like this are examined, they can have some of the same positive signs as patients with functional symptoms but there are important differences. They tend to have very inconsistent stories (because they are making up that too). They don’t have the same kind of stories to patients genuinely experiencing symptoms and there may be a legal case or other obvious reason for the symptoms. (although this does not mean that everyone with a legal case is making up their symptoms)There are also some people who make up symptoms in order to gain admission to hospital or have an operation. When this happens it is called factitious disorder and by general consensus, its also a rare condition. Its best thought of as a form of behaviour like deliberate self harm.So, occasionally, people do make up symptoms and it can be difficult to tell. Some doctors (and sometimes patients) make a terrible mistake in thinking that most patients with functional symptoms are ‘making up’ their symptoms or ‘swinging the lead’.
30Functional Somatic Syndromes - Different Functional Somatic Syndromes - Different? The British Journal of Psychiatry (2004) 185: Peter WhiteThere is a five-fold risk of chronic fatigue syndrome in patients suffering from infectious mononucleosis (White et al, 1998), whereas there is no evidence that fibromyalgia is caused by infections (Rea et al, 1999).The risk factor of childhood sexual abuse varies six-fold across different functional somatic syndromes (Romans et al, 2002).A recent systematic review showed that ‘... psychosocial treatments have not yet been shown to have a lasting and clinically meaningful influence on the physical complaints of polysymptomatic somatisers’ (Allen et al, 2002). A recent large trial of treatment of Gulf War syndrome found no significant differences between CBT and control treatments (Donta et al, 2003). An accompanying editorial by Hotopf (2003) correctly attributed this lack of efficacy of CBT to not using an illness-specific model for CBT. In contrast, CBT is effective when specifically designed to help improve the physical functioning of patients with chronic fatigue (Whiting et al, 2001).the concept of a general functional somatic syndrome does not predict prognosis, which varies by specific functional somatic syndrome. Fibromyalgia runs a persistent and chronic course, whereas irritable bowel syndrome runs an intermittent course with recovery being more common.
31Ch 25; E A Mayer and M C Bushnel Functional Somatic Syndromes- Same? Functional Pain Disorders: Time for a Paradigm ShiftCh 25; E A Mayer and M C Bushnel2009Hypersensitivity to experimental stimuliCompromised DNICEvidence of structural brain abnormalitiesEvidence of altered neuro-cognitive functionEvidence of increased activity in central arousal circuits and sympathetic nervous systemEvidence of common genetic susceptibility (endophenotypes)
37ICD 10 F45 Somatoform disorders The main feature is repeated presentation of physical symptoms together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis.If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient.37
38ICD 10 F45.0 Somatization disorder A definite diagnosis requires the presence of all of the following:(a) at least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found(b) persistent refusal to accept the advice or reassurance of several doctors that there is no physical explanation for the symptoms(c) some degree of impairment of social and family functioning attributable to the nature of the symptoms and resulting behaviour
39ICD10 F45. 4 Persistent somatoform pain disorder http://www The predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences.The result is usually a marked increase in support and attention, either personal or medical.Pain presumed to be of psychogenic origin occurring during the course of depressive disorders or schizophrenia should not be included here.Psychalgia Psychogenic: · backache · headacheSomatoform pain disorder
40Personal Tips on Clinician Behaviour Comprehensive psychosocial assessment; INCLUDE MEANING!Impeccable consultation skills; DON’T MAKE IT WORSE!Validate Patient Experience“Showing courage and resilience”/ “Body can’t keep up with the mind”“Sensitive body”/ “sensitive body + mind”Possible evolutionary advantage!!!Discuss risk of iatrogenic harmAnalgesic Dependence and abuseAnalgesic exacerbated painUse picturesProvide informationRefer to websites“RE-ATTRIBUTION”- Target unhelpful cognitions;Focus on unnecessary or unhelpful health anxietyACTIVITY SCHEDULING- with appropriate pacing and encourage funFollow-upConsider further specific treatment:rehabilitation, psychological and psychiatric approaches, including medication