1. Professor George Ikkos Liaison Psychiatry Consultant MRCPsych MRCP
Somatisation & Somatoform Disorders What are they, What to tell patients and How?
Professor George Ikkos
Liaison Psychiatry Consultant
MRCPsych MRCP

2. “And, poets, your brain is in your body.”
Mind Body and Psychosomatic Problems Useful websites for professionals recommended by Professor George Ikkos
Mind and Body A Psychiatric Summary by
Prof George Ikkos and Dr Susie Lingwood

3. Background (1) 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
Depression can exacerbate the pain and distress associated with physical illnesses and adversely affect outcomes
NOTES 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.

4. Basic Emotions Joseph E
Basic Emotions Joseph E. LeDoux, Emotion Memory and the Brain Scientific American, 2002
Fear
Panic (and Care)
Rage
Seeking (and Lust)
Play
(Disgust)
(Joy)
Copyright: Scientific American

5. Brain, Autonomic Nervous System

6. Integrative/ Psychosomatic Medicine

7. Stress, Brain and Body Wilkinson and Pickett, “The Spirit Level”, Allen Lane/ Penguin
Acute Stress
Chronic Stress
Brain: acute alertness
Less perception of pain
Immune tissues:
Readied for possible injury
Circulatory system:
Heart beats fast and blood vessels constrict: more oxygen to muscles
Adrenal glands:
Secrete hormones to mobilise energy supplies
Reproductive organs:
reproductive functions temporarily suppressed
Brain: impaired memory
Increased risk of depression
Immune tissues:
Deteriorated response
Circulatory system:
Elevated blood pressure and higher risk of cardiovascular disease
Adrenal glands:
High hormone levels and slow recovery from acute stress
Reproductive organs:
Higher risk of infertility and miscarriage

8. Subcortical Emotion

10. Thalamus Septum Hypothalamic Nuclei Tectum Amygdala Dorsal dACC
Emotions/
Motor
Responses
Tectum
Amygdala
Interoceptive
Awareness
Dorsal
Tegmental
Area
dACC
Body
Experience
THA
Hypothalamus
Basal
Forebrain
Body
Map
Re-
Map
Raphe
Nucleus
Interoceptive
Input
Amygdala
Hippocampus
Locus
Coeruleus
S.E.L.F.

11. (23) Insula

12. Medically Unexplained Symptoms

13. Medically Unexplained Symptoms
Mental Disorder
Not Mental Disorder
Medically Unexplained Symptoms

14. Medically Unexplained Symptoms
Functional Mental Disorders
Functional and Dissociative Neurological Symptoms
Functional Somatic Syndromes
Including Various Pain Syndromes
Somatoform Disorders (including Somatoform Pain)
Clinical Somatisation

15. Medically Unexplained Symptoms
Organic Physical + Mental Disorders
Functional Mental Disorders
Functional and Dissociative Neurological Symptoms
Functional Somatic Syndromes
Including Various Pain Syndromes
Somatoform Disorders (including Somatoform Pain)
Clinical Somatisation

16. Organic Mental Disorders

17. Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Medically Unexplained Symptoms

18. Organic Mental Disorders
Iatrogenic conditions
Psychotropic side effects of medication
Other side effects medication
Which may be misunderstood for somatisation

19. Functional Mental Disorders www.rcpsych.ac.uk/expertadvice.aspx

20. Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Functional Mental Disorders
Medically Unexplained Symptoms

21. Functional Mental Disorders www.rcpsych.ac.uk/expertadvice.aspx
Mood and anxiety disorders
Schizophrenia and non-affective psychoses
Eating, Body Dysmorphic and Hypochondriacal Disorders
Autism Spectrum Disorders!!

22. Functional and Dissociative Neurological Symptoms www. neurosymptoms
Functional and Dissociative Neurological Symptoms

23. Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Functional Mental Disorders
Functional Neurological Symptoms
Functional Dissociative Symptoms
Medically Unexplained Symptoms

24. Functional and Dissociative Neurological Symptoms www. neurosymptoms
Functional and Dissociative Neurological Symptoms
This website is about symptoms which are:
Neurological (such as numbness, blindness and blackouts)
Real (and not imagined)
But not due to neurological disease
Symptoms like these are surprisingly common but are difficult for patients and health professionals to understand
Its like having a software problem rather than a hardware problem

25. Functional and dissociative neurological symptoms have been given many different names over the years: e.g. conversion, hysteria
Many 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.

26. www. 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’.

27. Functional Somatic Syndromes http://www.nhs.uk/Conditions

28. Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Functional Mental Disorders
Functional Neurological Symptoms
Functional Dissociative Symptoms
Functional Somatic Syndromes
Pain Syndromes
Medically Unexplained Symptoms

29. Functional Somatic Syndromes http://www.nhs.uk/Conditions
Atypical Facial Pain
TMJ Pain + Burning Mouth Syndrome
Migraine
Hyperventilation
Non-cardiac/ atypical chest pain
Functional Dyspepsia
Irritable Bowel Syndrome
Irritable Bladder
Chronic Pelvic Pain
Multiple Chemical Sensitivity
Chronic Fatigue Syndrome
Fibromyalgia
Non-specific lower back pain
Joint Hypermobility Syndrome (Ehler-Danlos)

30. Functional Somatic Syndromes - Different
Functional Somatic Syndromes - Different? The British Journal of Psychiatry (2004) 185: Peter White
There 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.

31. Ch 25; E A Mayer and M C Bushnel
Functional Somatic Syndromes- Same? Functional Pain Disorders: Time for a Paradigm Shift
Ch 25; E A Mayer and M C Bushnel
2009
Hypersensitivity to experimental stimuli
Compromised DNIC
Evidence of structural brain abnormalities
Evidence of altered neuro-cognitive function
Evidence of increased activity in central arousal circuits and sympathetic nervous system
Evidence of common genetic susceptibility (endophenotypes)

32. Thalamus Septum Hypothalamic Nuclei Tectum Amygdala Dorsal dACC
Emotions/
Motor
Responses
Tectum
Amygdala
Interoceptive
Awareness
Dorsal
Tegmental
Area
dACC
Body
Experience
THA
Hypothalamus
Basal
Forebrain
Body
Map
Re-
Map
Raphe
Nucleus
Interoceptive
Input
Amygdala
Hippocampus
Locus
Coeruleus
S.E.L.F.

33. Integration of Interoceptive Information
aINS
Interoceptive
Input
THA
pINS
mINS

34. Interoceptive awareness and emotional responses
Attention!!
Orbitofrontal
PFC
Interoceptive
Input
MIS-MATCH!!!
Insula:
Aversive Learning
Interoceptive
Awareness
pINS
mINS
aINS
THA
Interoceptive
Expectation
Cingulate Gyrus:
Limbic Motor Cortex
Emotions/
Motor
Responses
Amygdala
Hippocampus
dACC
Body Loops

35. ICD 10 F45 Somatoform disorders

36. Mental Disorder
Not Mental Disorder
Organic Mental Disorders
Functional Mental Disorders
Functional Neurological Symptoms
Functional Dissociative Symptoms
Functional Somatic Syndromes
Pain Syndromes
Somatoform Disorders
Somatoform Pain Disorder
Medically Unexplained Symptoms

37. ICD 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

38. ICD 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

39. ICD10 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 · headache
Somatoform pain disorder

40. Personal 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 harm
Analgesic Dependence and abuse
Analgesic exacerbated pain
Use pictures
Provide information
Refer to websites
“RE-ATTRIBUTION”- Target unhelpful cognitions;
Focus on unnecessary or unhelpful health anxiety
ACTIVITY SCHEDULING- with appropriate pacing and encourage fun
Follow-up
Consider further specific treatment:
rehabilitation, psychological and psychiatric approaches, including medication

42. Mental Disorder
Not Mental Disorder
Organic Physical Disorders
Organic Mental Disorders
Functional Mental Disorders
Functional Neurological Symptoms
Functional Dissociative Symptoms
Functional Somatic Syndromes
Somatoform Disorders
Pain Syndromes
Somatoform Pain Disorder
Medically Unexplained Symptoms
Organic Physical + Mental Disorders
Organic Physical + Functional Mental Disorders
Organic Physical + Somatoform
Mental Disorders
Organic Physical + Medically Unexplained Symptoms