Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Somatisation & Somatoform Disorders What are they, What to tell patients and How? Professor George Ikkos Liaison Psychiatry Consultant MRCPsych MRCP."— Presentation transcript:

1 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 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 Background (1)

4 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 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 Chronic Stress 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

9

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

11 (23) Insula

12 Medically Unexplained Symptoms gphysicalandmh/medicallyunexplainedsymptoms. aspx gphysicalandmh/medicallyunexplainedsymptoms. aspx

13 Medically Unexplained Symptoms Mental DisorderNot Mental Disorder

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 Medically Unexplained Symptoms Mental DisorderNot Mental Disorder Organic Mental Disorders

18  Iatrogenic conditions  Psychotropic side effects of medication  Other side effects medication Which may be misunderstood for somatisation

19 Functional Mental Disorders px px

20 Functional Mental Disorders Medically Unexplained Symptoms Mental DisorderNot Mental Disorder Organic Mental Disorders

21 Functional Mental Disorders px px  Mood and anxiety disorders  Schizophrenia and non-affective psychoses  Eating, Body Dysmorphic and Hypochondriacal Disorders  Autism Spectrum Disorders!!

22 Functional and Dissociative Neurological Symptoms

23 Organic Mental Disorders Functional Mental Disorders Functional Neurological Symptoms Functional Dissociative Symptoms Medically Unexplained Symptoms Mental DisorderNot Mental Disorder

24 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 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

28 Organic Mental Disorders Functional Mental Disorders Functional Neurological Symptoms Functional Dissociative Symptoms Functional Somatic Syndromes Pain Syndromes Medically Unexplained Symptoms Mental DisorderNot Mental Disorder

29 Functional Somatic Syndromes 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? 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).White et al, 1998Rea et al, 1999  The risk factor of childhood sexual abuse varies six-fold across different functional somatic syndromes (Romans et al, 2002).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).Allen et al, 2002Donta et al, 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 Functional Somatic Syndromes- Same? Functional Pain Disorders: Time for a Paradigm Shift Ch 25; E A Mayer and M C Bushnel 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) 2009

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

33 Integration of Interoceptive Information Interoceptive Input THApINS mIN S aINS

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

35 ICD 10 F45 Somatoform disorders

36 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 Mental DisorderNot Mental Disorder

37 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. ICD 10 F45 Somatoform disorders

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  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

41

42 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 Mental DisorderNot Mental Disorder Organic Physical + Functional Mental Disorders Organic Physical + Somatoform Mental Disorders Organic Physical + Mental Disorders Organic Physical + Medically Unexplained Symptoms


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

Similar presentations


Ads by Google