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Somatisation Dr Eugene Cassidy.

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1 Somatisation Dr Eugene Cassidy

2 In Lithuania, where few drivers have insurance (at least in 1996), late Whiplash syndrome doesn’t exist. Schrader et al (1996) Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet 347(9010): A cohort of 202 individuals identified from traffic police records in Kaunas, Lithuania were interviewed 1-3 years after experiencing a rear-end collision. A control sample matched for age and sex who were randomly selected from the same region were also interviewed. Headache and neck pain did not differ between groups nor did the number of cases with chronic pain. Of those who did report chronic neck or head pain since the accident, the majority had similar symptoms before the accident. There was no relationship between impact severity and degree of pain. This finding may in part relate to a lack of expectation of chronicity (i.e anything other than acute neck sprain symptoms) which has been found in this population by comparison with a Canadian cohort (Ferrari et al (2002). 2) Symptom expectation and amplification influence victim’s behaviour in a detrimental way 3) In UK demographic factors and the presence of a compensation suit show strongest correlation with acute and chronic neck pain 4) Demolition derby drivers do not suffer from chronic neck pain (less than expected!) 5) Doctors’ behaviour influences patients’ behaviour 1,2) Ferrari R, Shrader H. J Neurol Neurosurg Psychiatry 2001;70:722-6. 3) Pobereskin L. J Neurol Neurosurg Psychiatry 2005;76: 4)Simotas A, Shen T. Arch Phys Med Rehabil 2005;86:693-6. 5) Ferrari R. Emerg Med J 2002;19:

3 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 Most somatic symptoms are not associated with a clear medical diagnosis or identifiable pathophysiology and are considered ‘functional’. Such functional somatic symptoms are common in the general population.

4 Overview of ‘functional’ illness
Symptoms Syndromes Disorders Feigned illness

5 Functional Somatic Symptoms
3.4 symptoms per person general population over previous 2 years (Rief et al, 2001) Pain and Fatigue most common Most somatic symptoms are not associated with a clear medical diagnosis or identifiable pathophysiology and are considered ‘functional’. Such functional somatic symptoms are common in the general population. In Germany, Rief et al (2001) reported an average of 3.4 symptoms per person over the previous two years for which no medical cause was found and which had a significant influence on well-being, pain symptoms (up to 30% - back pain) being especially prevalent. In an epidemiological study in Southeast London, Nimnuan et al (2001a) examined the prevalence of functional somatic symptoms in a large cohort (n=890) of all new outpatient attenders to seven different medical specialities. In 52% of those for whom complete data was available (n=582), the principle somatic complaint was found to be medically unexplained following appropriate examination and investigation. Patients with such symptoms were more likely to be female and younger, and more likely to endorse a physical rather than a lifestyle or psychological attribution for their symptoms. Medical OPD 52% presenting symptoms MUS (Nimnuan et al, 2001)

6 Functional somatic syndromes (1)
Gastroenterology IBS/ Functional dyspepsia Cardiology Non-Cardiac chest pain Neurology Chronic Headache / CFS Rheumatology Fibromyalgia / CRPS Gynaecology Chronic pelvic pain Orthopaedics Chronic back pain Dental TMJ dysfunction Immunology Multiple Chemical Sensitivity Functional syndromes (typically groups of unexplained somatic symptoms) have long been observed in patients attending different medical specialties. Indeed, almost every medical specialty has its own. Nimnuan et al (2001b) examined the prevalence of 13 different functional somatic syndromes. 56% of the sample had at least one functional somatic syndrome (FSS) and half of these had more than one. Functional syndromes (typically groups of unexplained somatic symptoms) have long been observed in patients attending different medical specialties. Indeed, almost every medical specialty has its own functional somatic syndrome as a discrete diagnostic entity (e.g. Fibromyalgia in Rheumatology, Irritable Bowel Syndrome in Gastroenterology etc.). These syndromes have been the subject of considerable research into possible aetiology & pathophysiology but in the absence of such explanations, they continue to be defined largely by groups of subjectively reported symptoms and associated disability. Despite the oft-posited co-occurrence of these syndromes in clinical practice, until recently there has been little by way of epidemiological data to support this. In the same cohort of medical outpatients described above, Nimnuan et al 5 (2001b) examined the prevalence of 13 different functional somatic syndromes (including Fibromyalgia, Chronic Fatigue Syndrome, Irritable Bowel Syndrome, Tension Headache, Atypical Facial Pain, Temporomandibular joint dysfunction, Hyperventilation syndrome, Non-Ulcer Dyspepsia, Globus Syndrome, Multiple Chemical Sensitivity, Chronic Pelvic Pain, Premenstrual Syndrome). 56% of the sample had at least one functional somatic syndrome (FSS) and half of these had more than one. 6 Aggarwal et al (2006) recently examined the prevalence and co-occurrence of 4 functional somatic syndromes (chronic widespread pain, chronic oro-facial pain, irritable bowel syndrome, and chronic fatigue) in a general population survey. 27% reported one or more syndromes and 1% reported all four. There were a number of common factors across syndromes including female gender, high levels of aspects of health anxiety, reporting of other somatic symptoms and reporting of recent adverse life events. This finding is in keeping with the observation that among individuals who consult with such unexplained somatic symptoms, psychosocial factors play a major role in maintaining symptoms and disability. Both female gender and having a history of early life trauma (including sexual abuse) are well-established risk factors for adult anxiety and depression. It is perhaps not surprising therefore that somatic symptom reporting is more common in females and among those with a history of childhood abuse 9 (Newman et al, 2000). This effect however persists after depression has been controlled suggesting common trait vulnerability to both depression and somatic symptom reporting.

7 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) Functional syndromes (typically groups of unexplained somatic symptoms) have long been observed in patients attending different medical specialties. Indeed, almost every medical specialty has its own. Nimnuan et al (2001b) examined the prevalence of 13 different functional somatic syndromes. 56% of the sample had at least one functional somatic syndrome (FSS) and half of these had more than one. Functional syndromes (typically groups of unexplained somatic symptoms) have long been observed in patients attending different medical specialties. Indeed, almost every medical specialty has its own functional somatic syndrome as a discrete diagnostic entity (e.g. Fibromyalgia in Rheumatology, Irritable Bowel Syndrome in Gastroenterology etc.). These syndromes have been the subject of considerable research into possible aetiology & pathophysiology but in the absence of such explanations, they continue to be defined largely by groups of subjectively reported symptoms and associated disability. Despite the oft-posited co-occurrence of these syndromes in clinical practice, until recently there has been little by way of epidemiological data to support this. In the same cohort of medical outpatients described above, Nimnuan et al 5 (2001b) examined the prevalence of 13 different functional somatic syndromes (including Fibromyalgia, Chronic Fatigue Syndrome, Irritable Bowel Syndrome, Tension Headache, Atypical Facial Pain, Temporomandibular joint dysfunction, Hyperventilation syndrome, Non-Ulcer Dyspepsia, Globus Syndrome, Multiple Chemical Sensitivity, Chronic Pelvic Pain, Premenstrual Syndrome). 56% of the sample had at least one functional somatic syndrome (FSS) and half of these had more than one. 6 Aggarwal et al (2006) recently examined the prevalence and co-occurrence of 4 functional somatic syndromes (chronic widespread pain, chronic oro-facial pain, irritable bowel syndrome, and chronic fatigue) in a general population survey. 27% reported one or more syndromes and 1% reported all four. There were a number of common factors across syndromes including female gender, high levels of aspects of health anxiety, reporting of other somatic symptoms and reporting of recent adverse life events. This finding is in keeping with the observation that among individuals who consult with such unexplained somatic symptoms, psychosocial factors play a major role in maintaining symptoms and disability. Both female gender and having a history of early life trauma (including sexual abuse) are well-established risk factors for adult anxiety and depression. It is perhaps not surprising therefore that somatic symptom reporting is more common in females and among those with a history of childhood abuse 9 (Newman et al, 2000). This effect however persists after depression has been controlled suggesting common trait vulnerability to both depression and somatic symptom reporting. - There is only one …….. (Wessely, 1999)

8 Disorders Mood disorders Somatoform disorders
Somatoform-like disorders

9 Somatoform-like disorders
Malingering feigned illness; conscious gain Factitious disorder (Personal / By proxy) feigned illness; no conscious gain

10 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 Some patients have multiple medically unexplained symptoms that affect many different bodily systems, are of long duration and are associated with considerable disability (Bass, 1996). Such patients may meet criteria for ‘Somatisation disorder’ as operationally defined by DSM-IV (American Psychiatric Association, 1994). This disorder is reported rarely (<0.5%) in the general population (Escobar et al, 1989; Rief et al, 2001) possibly because of the very restrictive diagnostic criteria.

11 Somatoform disorders Categorical Classification unhelpful
Somatisation disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder Dissociative / Conversion disorders Syndromes overlap Chronic Fatigue syndrome FMS Some patients have multiple medically unexplained symptoms that affect many different bodily systems, are of long duration and are associated with considerable disability (Bass, 1996). Such patients may meet criteria for ‘Somatisation disorder’ as operationally defined by DSM-IV (American Psychiatric Association, 1994). This disorder is reported rarely (<0.5%) in the general population (Escobar et al, 1989; Rief et al, 2001) possibly because of the very restrictive diagnostic criteria.

12 Somatisation is typically not consciously elaborated
Medical Model doesn’t Help Training Define disease in terms of pathology Cure disease by reversing pathology No identifiable pathology Feel cheated Angry towards patients For misleading us Behaving as if they have pathology when they do not Frustrated Our usual treatments will not work - cannot cure them And worse - some do not even want to be cured But…. isn’t it human nature to exaggerate/make ourselves heard?

13 The Cost of Somatisation (1)
More visits More admission days More ED attendances More procedures Annual US healthcare costs doubled (Barsky et al, 2005) Context: Somatoform disorders are an important determinant of medical care utilization, but their independent effect on utilization is difficult to determine because somatizing patients frequently have psychiatric and medical comorbidity. Objectives: To assess the extent of the overlap of somatization with other psychiatric disorders; to compare the medical utilization of somatizing and nonsomatizing patients; and to determine the independent contribution of somatization alone to utilization. Design: Patients were surveyed with self-report questionnaires assessing somatization and psychiatric disorder. Medical care utilization was obtained from automated encounter data for the year preceding the index visit. Medical morbidity was indexed with a computerized medical record audit. Setting: Two hospital-affiliated primary care practices. Participants: Consecutive adults making scheduled visits to their primary care physicians on randomly chosen days. In all, 2668 questionnaires were distributed, and 1914 (71.7%) were returned. Of these, 1546 (80.8%) contained complete data and met eligibility criteria. Main Outcome Measures: Medical care utilization and costs within our hospital system in the preceding 12 months. Results: Two hundred ninety-nine patients (20.5%) received a provisional diagnosis of somatization; 42.3% of these patients had no comorbid depressive or anxiety disorder. Somatizing patients, when compared with nonsomatizing patients, had more primary care visits (mean [SE], 4.90 [0.32] vs 3.43 [0.11]; P.001); more specialty visits (mean [SE], 8.13 [0.55] vs 4.90 [0.21]; P.001); more emergency department visits (mean [SE], 1.29 [0.15] vs 0.52 [0.036]; P.001); more hospital admissions (mean [SE], 0.32 [0.051] vs 0.13 [0.014]; P.001); higher inpatient costs (mean [SE], $3146 [$380] vs $991 [$193]; P.001); and higher outpatient costs (mean [SE], $3208 [$180] vs $1771 [$91]; P.001). When these results were adjusted for the presence of comorbid anxiety and depressive disorders, major medical morbidity, and sociodemographic characteristics, patients with somatoform disorder still had more primary care visits (P=.04), more specialist visits (P=.002), more emergency department visits (P.001), more hospital admissions (P.001), more ambulatory procedures (P.001), higher inpatient costs (P.001), and higher outpatient costs (P.001). When these findings are extrapolated to the national level, an estimated $256 billion a year in medical care costs are attributable to the incremental effect of somatization alone. Conclusions: Patients with somatization had approximately twice the outpatient and inpatient medical care utilization and twice the annual medical care costs of nonsomatizing patients. Adjusting the findings for the presence of psychiatric and medical comorbidity had relatively little effect on this association. Arch Gen Psychiatry. 2005;62: Severe somatoform disorders are at least as common (and as disabling) as schizophrenia 19, 20, 21, (Escobar et al, 1989; Spitzer et al, 1995; Hiller et al, 1997). Smith et al 22 (1986) found that their cohort of subjects with somatization disorder (a somatoform disorder characterized by multiple medically unexplained symptoms, including pseudoneurological symptoms, of long duration) spent an average of seven days ill in bed each month and in another cohort 23 (Bass & Murphy, 1991), 10% were wheelchair-bound. Acute general hospitals with their biomedical emphasis are ill-equipped to deal with such individuals. Not surprisingly, patients with somatoform disorders incur a disproportionate amount of healthcare costs. In a recent US study, the annual healthcare costs (including inpatient, outpatient, emergency department, specialty and primary care) were doubled in patients with probable somatoform disorder 24 (Barsky et al, 2005). These costs were solely due to medical service utilization as there was no increase in mental health service use by patients with somatoform disorder. This is no surprise as Psychiatry, with its growing emphasis on psychotic illnesses, has inevitably neglected this group of patients 25 (Bass et al, 2001).

14 Normal Inflamed 456 appendicectomies followed for at least 15 years
(Dummett et al, 2002) Normal Inflamed Attendance 6.5/100 yrs 3.4/100yrs DSH % 2.2% Psych attendance 10.5% 4.0% BRITISH JOURNAL OF P SYCHIATRY (2002) Long-term hospital attendance of children and adults who have undergone removal of normal or inflamed appendices NICOLA J. DUMMETT, NICOLA J. MAUGHAN and ANNE WORRALL-DAVIES Aims To test the hypothesis that such presentations are followed by higher long term utilisation rates of secondary health care even excluding further abdominal symptoms, and particularly for self-harm, than presentations with acute appendicitis. Results Attendance rates of all kinds were significantly higher for normal appendix patients than for appendicitis patients, with equal strengths of finding for males and females.

15 ‘PSEUDO-STATUS’ 54% Status Epilepticus 23% Encephalopathy
Walker et al, 1996 54% Status Epilepticus 23% Encephalopathy 23% ‘Pseudostatus’ (majority intubated) The basic premise is: Somatoform disorders are common They are neglected They are treatable LP services need to expend

16 ‘PSEUDO-STATUS’ 54% Status Epilepticus 23% Encephalopathy
Walker et al, 1996 54% Status Epilepticus 23% Encephalopathy 23% ‘Pseudostatus’ (majority intubated)

17

18 The Cost of Somatisation (2)
Somatization Disorder 7 days per month in bed (Smith et al, 1986) 10% wheelchair-bound (Bass & Murphy, 1991) Severe somatoform disorders are at least as common (and as disabling) as schizophrenia 19, 20, 21, (Escobar et al, 1989; Spitzer et al, 1995; Hiller et al, 1997). Smith et al 22 (1986) found that their cohort of subjects with somatization disorder (a somatoform disorder characterized by multiple medically unexplained symptoms, including pseudoneurological symptoms, of long duration) spent an average of seven days ill in bed each month and in another cohort 23 (Bass & Murphy, 1991), 10% were wheelchair-bound. Acute general hospitals with their biomedical emphasis are ill-equipped to deal with such individuals. Not surprisingly, patients with somatoform disorders incur a disproportionate amount of healthcare costs. In a recent US study, the annual healthcare costs (including inpatient, outpatient, emergency department, specialty and primary care) were doubled in patients with probable somatoform disorder 24 (Barsky et al, 2005). These costs were solely due to medical service utilization as there was no increase in mental health service use by patients with somatoform disorder. This is no surprise as Psychiatry, with its growing emphasis on psychotic illnesses, has inevitably neglected this group of patients 25 (Bass et al, 2001).

19 Somatisation is associated with
Gender Childhood adversity Parenting Cultural factors Gain Life events / dilemmas Depression Litigation Iatrogenic factors Physical deconditioning

20 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) Gender Differences in the Reporting of Physical and Somatoform Symptoms KURT KROENKE, MD AND ROBERT L. SPITZER, MD Objective: Women have consistently been shown to report greater numbers of physical symptoms. Our aim in this study was to assess gender differences for specific symptoms and to assess how much of these differences were attributable to psychiatric comorbidity. Method: Data from the PRIME-MD 1000 study (1000 patients from four primary care sites evaluated with the Primary Care Evaluation of Mental Disorders interview) were analyzed to determine gender differences in the reporting of 13 common physical symptoms. The effect of gender on symptom reporting was assessed by multivariate analysis, adjusting for depressive and anxiety disorders as well as age, race, education, and medical comorbidity. Results: All symptoms except one were reported more commonly by women, with the adjusted odds ratios (typically in the range) showing statistically significant differences for 10 of 13 symptoms. Somatoform (ie, physically unexplained) symptoms were also more frequent in women. Although depressive and anxiety disorders were the strongest correlate of symptom reporting, gender had an independent effect that persisted even after adjusting for psychiatric comorbidity. Gender was the most important demographic factor associated with symptom reporting, followed by education. Conclusions: Most physical symptoms are typically reported at least 50% more often by women than by men. Although mental disorders are also more prevalent in women, gender influences symptom reporting in patient independently.

21 1: Br J Psychiatry. 2004 May;184:416-21. Links
Comment in: Br J Psychiatry Oct;185:353. Br J Psychiatry Jan;186:76; author reply 76. Impact of child sexual abuse on mental health: prospective study in males and females.Spataro J, Mullen PE, Burgess PM, Wells DL, Moss SA. Victorian Institute of Forensic Mental Health, Department of Psychological Medicine, Monash University, Victoria, Australia. BACKGROUND: The lack of prospective studies and data on male victims leaves major questions regarding associations between child sexual abuse and subsequent psychopathology. AIMS: To examine the association between child sexual abuse in both boys and girls and subsequent treatment for mental disorder using a prospective cohort design. METHOD: Children (n=1612; 1327 female) ascertained as sexually abused at the time had their histories of mental health treatment established by data linkage and compared with the general population of the same age over a specified period. RESULTS: Both male and female victims of abuse had significantly higher rates of psychiatric treatment during the study period than general population controls (12.4% v. 3.6%). Rates were higher for childhood mental disorders, personality disorders, anxiety disorders and major affective disorders, but not for schizophrenia. Male victims were significantly more likely to have had treatment than females (22.8% v.10.2%). CONCLUSIONS: This prospective study demonstrates an association between child sexual abuse validated at the time and a subsequent increase in rates of childhood and adult mental disorders.

22 Pain & Childhood Trauma (McBeth et al, 1999)
Adult general population Distress (GHQ>1) High Tender point count (1/3) related to: Abuse (OR 6.9) Parental loss (OR 2.1) Female (OR 3.5) Illness behaviour (OR 2.3) McBeth et al (1999) A population sample of adults with psychological distress (GHQ>1) had a tender point examination, psychological evaluation and interview about childhood experiences. Those with a high tender point count (>4; n=99) were compared to those without (n=190). Those with high tender points were more likely to report parental loss (OR 2.1) and abuse (OR 6.9). This effect was independent of the presence of chronic pain. Other associations with tender points were: female sex (OR 3.5, illness behaviour (OR 2.3) and fatigue (OR 1.9).

23 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) 1: Arch Gen Psychiatry Nov;63(11): Links Early adverse experience and risk for chronic fatigue syndrome: results from a population-based study. Heim C, Wagner D, Maloney E, Papanicolaou DA, Solomon L, Jones JF, Unger ER, Reeves WC. CONTEXT: Chronic fatigue syndrome (CFS) is an important public health problem. The causes of CFS are unknown and effective prevention strategies remain elusive. A growing literature suggests that early adverse experience increases the risk for a range of negative health outcomes, including fatiguing illnesses. Identification of developmental risk factors for CFS is critical to inform pathophysiological research and devise targets for primary prevention. OBJECTIVE: To examine the relationship between early adverse experience and risk for CFS in a population-based sample of clinically confirmed CFS cases and nonfatigued control subjects. DESIGN, SETTING, AND PARTICIPANTS: A case-control study of 43 cases with current CFS and 60 nonfatigued controls identified from a general population sample of adult residents from Wichita, Kan. MAIN OUTCOME MEASURES: Self- reported childhood trauma (sexual, physical, and emotional abuse and emotional and physical neglect) and psychopathology (depression, anxiety, and posttraumatic stress disorder) by CFS status. RESULTS: The CFS cases reported significantly higher levels of childhood trauma and psychopathology compared with the controls. Exposure to childhood trauma was associated with a 3- to 8-fold increased risk for CFS across different trauma types. There was a graded relationship between the degree of trauma exposure and CFS risk. Childhood trauma was associated with greater CFS symptom severity and with symptoms of depression, anxiety, and posttraumatic stress disorder. The risk for CFS conveyed by childhood trauma increased with the presence of concurrent psychopathology. CONCLUSIONS: This study provides evidence of increased levels of multiple types of childhood trauma in a population-based sample of clinically confirmed CFS cases compared with nonfatigued controls. Our results suggest that childhood trauma is an important risk factor for CFS. This risk was in part associated with altered emotional state. Studies scrutinizing the psychological and neurobiological mechanisms that translate childhood adversity into CFS risk may provide direct targets for the early prevention of CFS. PMID: [PubMed - indexed for MEDLINE]

24 Parenting (Craig et al, 2004)
Parental focus on health Maternal somatisation Parental Illness 1: Psychol Med Jul;32(5): Links Comment in: Psychol Med Feb;34(2):195-8. Intergenerational transmission of somatization behaviour: a study of chronic somatizers and their children.Craig TK, Cox AD, Klein K. Department of Psychiatry and Psychology, St Thomas Hospital, London. BACKGROUND: Exposure to an ill parent in childhood may be a risk factor for adult somatization. This study examines the hypothesis that somatizing adults are more likely to have been exposed to illness as a child and that in turn, their children are more likely to report ill health and to have more contact with medical services than children of other mothers. METHOD: A cross-sectional comparative investigation of three groups of mothers and their children of 4-8 years of age: (i) 48 mothers suffering from chronic somatization; (ii) 51 mothers with chronic 'organic' illness; and (iii) 52 healthy mothers was carried out. RESULTS: Somatizing mothers were more likely than other women to report exposure to childhood neglect and to physical illness in a parent (OR 2.9; 95% CI ). The children of these somatizing mothers were more likely to have health problems than were the children of organically ill or healthy women and had more consultations with family doctors (average annual rates: somatizers 4.9 (S.D. 3.8), organic 3.0 (S.D. 3.5) and healthy 2.8 (S.D. 2.6)). Multivariate modelling of consultation rates among children found significant main effects for maternal somatization, maternal childhood adversity, the child's tendency to worry about health and a two-way interaction of maternal childhood adversity and her somatization status. CONCLUSIONS: The hypotheses are broadly supported. However, it is important to emphasize the extent to which these findings are based on maternal reports. 1: Psychol Med Feb;34(2): Links Intergenerational transmission of somatization behaviour: 2. Observations of joint attention and bids for attention.Craig TK, Bialas I, Hodson S, Cox AD. Department of Psychiatry & Psychology, St Thomas's Hospital, London. BACKGROUND: Somatoform disorders may have their roots in childhood through processes that involve an enhanced parental focus on health. The aim of this study was to test the hypothesis that somatizing mothers will show less joint involvement than other mothers during play but greater responsiveness when this play involves a 'medical' theme. METHOD: Cross-sectional observational study of 42 chronic somatizers, 44 organically ill and 50 healthy mothers and their 4-8 year-old children during structured play and a meal. Tasks comprised boxes containing tea-set items, 'medical' items and a light snack. RESULTS: Somatizing mothers were emotionally flatter and showed lower rates of joint attention than other mothers during both play tasks. While the three groups had similar rate of bids for attention, somatizing mothers were more responsive to their child's bids during play with the medical box than at other times. In contrast, the children of somatizing mothers ignored a greater proportion of their mother's bids during play with the medical box than did children of other mothers or during play with a non-medical theme. CONCLUSION: The study has demonstrated tentative evidence in support of the hypothesis.

25 Enhanced parental focus on health Maternal somatisation
Parental Illness 1: Psychol Med Jul;32(5): Links Comment in: Psychol Med Feb;34(2):195-8. Intergenerational transmission of somatization behaviour: a study of chronic somatizers and their children.Craig TK, Cox AD, Klein K. Department of Psychiatry and Psychology, St Thomas Hospital, London. BACKGROUND: Exposure to an ill parent in childhood may be a risk factor for adult somatization. This study examines the hypothesis that somatizing adults are more likely to have been exposed to illness as a child and that in turn, their children are more likely to report ill health and to have more contact with medical services than children of other mothers. METHOD: A cross-sectional comparative investigation of three groups of mothers and their children of 4-8 years of age: (i) 48 mothers suffering from chronic somatization; (ii) 51 mothers with chronic 'organic' illness; and (iii) 52 healthy mothers was carried out. RESULTS: Somatizing mothers were more likely than other women to report exposure to childhood neglect and to physical illness in a parent (OR 2.9; 95% CI ). The children of these somatizing mothers were more likely to have health problems than were the children of organically ill or healthy women and had more consultations with family doctors (average annual rates: somatizers 4.9 (S.D. 3.8), organic 3.0 (S.D. 3.5) and healthy 2.8 (S.D. 2.6)). Multivariate modelling of consultation rates among children found significant main effects for maternal somatization, maternal childhood adversity, the child's tendency to worry about health and a two-way interaction of maternal childhood adversity and her somatization status. CONCLUSIONS: The hypotheses are broadly supported. However, it is important to emphasize the extent to which these findings are based on maternal reports. 1: Psychol Med Feb;34(2): Links Intergenerational transmission of somatization behaviour: 2. Observations of joint attention and bids for attention.Craig TK, Bialas I, Hodson S, Cox AD. Department of Psychiatry & Psychology, St Thomas's Hospital, London. BACKGROUND: Somatoform disorders may have their roots in childhood through processes that involve an enhanced parental focus on health. The aim of this study was to test the hypothesis that somatizing mothers will show less joint involvement than other mothers during play but greater responsiveness when this play involves a 'medical' theme. METHOD: Cross-sectional observational study of 42 chronic somatizers, 44 organically ill and 50 healthy mothers and their 4-8 year-old children during structured play and a meal. Tasks comprised boxes containing tea-set items, 'medical' items and a light snack. RESULTS: Somatizing mothers were emotionally flatter and showed lower rates of joint attention than other mothers during both play tasks. While the three groups had similar rate of bids for attention, somatizing mothers were more responsive to their child's bids during play with the medical box than at other times. In contrast, the children of somatizing mothers ignored a greater proportion of their mother's bids during play with the medical box than did children of other mothers or during play with a non-medical theme. CONCLUSION: The study has demonstrated tentative evidence in support of the hypothesis.

26 Parental Illness Predictors of adult somatisation:
National birth cohort study (n=5362) followed from 1946 until 1989 Predictors of adult somatisation: 1: Br J Psychiatry Mar;176: Links Childhood predictors of adult medically unexplained hospitalisations. Results from a national birth cohort study.Hotopf M, Wilson-Jones C, Mayou R, Wadsworth M, Wessely S. Guy's School of Medicine, London. BACKGROUND: It has been suggested that adults with medically unexplained physical symptoms experienced greater ill-health then others (either in themselves or their families) during childhood. AIMS: To test these hypotheses. METHOD: We used data from the Medical Research Council (MRC) National Survey of Health and Development, a population-based cohort study established in 1946 (n = 5362). Subjects were followed from birth in 1946 until 1989 (age 43 years). As outcome, we used operationally defined medically unexplained hospital admissions at age years. Exposure variables included childhood illness, and illness in parents during the childhood of the subjects. RESULTS: The risk set (n = 4603) comprised individuals still in the Survey at age 15. Ninety-five unexplained hospital admissions were identified. Subjects whose mothers reported below-average health in the father were at increased risk of subsequent unexplained admissions. Below average reported health in the mother was not associated with this increased risk. Defined physical diseases in childhood were not associated, but persistent abdominal pain at age 7-15 years was. CONCLUSIONS: Unexplained hospital admissions are associated with certain childhood experiences of illness, but defined physical illness in childhood is not a risk factor. Childhood MUS Maternal reports of below average health in father

27 ‘Even ill-health, though it has annihilated several years of my life, has saved me from the distractions of society and amusement’ Father a well-respeceted doctor Mother died when he was 8 22 opportunity to travel on HMS Beagle Chronic somatic symptoms: Fatigue, abdominal pain, nausea, vomiting Social avoidance Ailments endeared him to his father with him he had otherwise communicated poorly In the Darwin family tradition: another look at Charles Darwin's ill health (Katz-Sidlow, J Royal Soc Med, 1998)

28 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 Harkness et al (2005) compared 2 detailed population surveys of pain prevalence in Manchester, UK, 4 decades apart ( & ) The point prevalence of low back, shoulder and widespread pain was found to be 2-4 times higher now than 40 years ago. Increased reporting & awareness x 7-11 sickness benefit rate x 3 number of solicitors

29 The late whiplash syndrome is influenced by cultural expectation
In Lithuania, where few drivers have insurance (at least in 1996), late Whiplash syndrome doesn’t exist. Schrader et al (1996) Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet 347(9010): A cohort of 202 individuals identified from traffic police records in Kaunas, Lithuania were interviewed 1-3 years after experiencing a rear-end collision. A control sample matched for age and sex who were randomly selected from the same region were also interviewed. Headache and neck pain did not differ between groups nor did the number of cases with chronic pain. Of those who did report chronic neck or head pain since the accident, the majority had similar symptoms before the accident. There was no relationship between impact severity and degree of pain. This finding may in part relate to a lack of expectation of chronicity (i.e anything other than acute neck sprain symptoms) which has been found in this population by comparison with a Canadian cohort (Ferrari et al (2002). 2) Symptom expectation and amplification influence victim’s behaviour in a detrimental way 3) In UK demographic factors and the presence of a compensation suit show strongest correlation with acute and chronic neck pain 4) Demolition derby drivers do not suffer from chronic neck pain (less than expected!) 5) Doctors’ behaviour influences patients’ behaviour 1,2) Ferrari R, Shrader H. J Neurol Neurosurg Psychiatry 2001;70:722-6. 3) Pobereskin L. J Neurol Neurosurg Psychiatry 2005;76: 4)Simotas A, Shen T. Arch Phys Med Rehabil 2005;86:693-6. 5) Ferrari R. Emerg Med J 2002;19: Schrader et al, 1996

30 Look for ‘diagnosis’ not ‘cure’
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’

31 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 Ellen MacArthur is a remarkable woman. The first woman, youngest and fastest to single-handedly circumnavigate the world. Born to 2 teachers in rural landlocked derbyshire, the middle of 3 and only girl. Studying for A levels – any alternative to taking the sensible correct path forward was inconceivable Advised not even to apply for vetinary school. My bedroom light was still on at 3 in the morning 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. Perversely glandular fever was one of the best things that ever happened to me. 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 ‘Taking on the World’

32 ‘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.’ Jean Van de Velde suffering from unknown illness Jean Van de Velde would have preferred to be at Carnoustie this week, staring down his golfing demons in person. Instead, the guy who threw away the 1999 British Open is tackling a much more frightening adversary: a mysterious ailment that has his doctors puzzled and Van de Velde fretting about whether he's got some sort of dire disease. On Monday, he went in for an exam that will hopefully rule out any signs of bone cancer. Later this week, he's scheduled for another major test in hopes of determining what's been causing all his pain and nausea. He's looking to get a full medical report within 10 days. "To be really honest, I think my health is more important than playing in a golf tournament," said Van de Velde, his career on hold. The dashing Frenchman will forever be linked with this devilish links course along the Scottish coast, where he squandered a three-stroke lead on the 72nd hole. The most lasting -- some might say pitiable -- image was Van de Velde standing barefooted in the Barry Burn, his pant legs rolled up as he considered whether to try to hit the ball from the chilly water. He wound up making triple bogey, forcing a playoff, and lost the claret jug to Paul Lawrie, whose record 10-stroke comeback in the final round is largely obscured by Van de Velde's follies (and who even remembers there was a third player for those four extra holes, Justin Leonard?). Van de Velde graciously accepted his stunning defeat, an attitude that has endured over the years even as it became more and more apparent that he had blown his one and only chance to win a major championship. He's only qualified for one major over the last five years, missing the cut at St. Andrews in There was talk of giving him an exemption into this week's Open, but he would have been in no condition to play. Over the past few months, Van de Velde's declining health has sapped his will to tee it up. Only 41, he was initially diagnosed with a form of glandular fever. But the aching in his shoulder and joints won't let up, so doctors ordered up additional tests to ensure that nothing more sinister is going on. Van de Velde is eager to get all this poking and prodding behind him so he can return to the course. Despite that one devastating hole eight years ago, it remains the place where he feels most comfortable. "I still want to play golf. I still want to compete," he said during a phone interview that was piped in to Carnoustie. "Right now, it's just a little bit of a (setback)." Until his health took a turn for the worse, Van de Velde had every intention of being in Scotland this week. If he didn't earn a spot in the Open field, there surely would have been offers to work as a television analyst. He wanted to come back. He longed to come back. Much like someone who turns off the lights to deal with their fear of the dark, he planned to deal with this lingering ghost on his terms, right out in the open for everyone to see. Right up until the last minute -- which, in golfing terms, would be a week ago -- he was determined to qualify. His ailing body just wouldn't allow it. "I am very sad that that I'm not there this week," Van de Velde said. "I have respect for the place and the tournament as well, and for all the people that are going to be there. Yes, I would have liked to have come." He's still asked about Carnoustie at just about every event he plays. Sure, it's gets old, but he rarely shows signs of being frustrated with his infamous place in the sport. Immediately after his loss, he said that no one would remember what happened in, oh, 200 years or so. But eight years later? No one has forgotten. "I think it's going to last at least a good 15 to 20 years before people stop asking me questions," Van de Velde said. "So, there's probably another 12 to go." Even those who don't bring it up -- Van de Velde's fellow golfers -- are keenly aware of what happened the last time the Open was played at Carnoustie. "When I was walking up the fairway," Graeme McDowell said after getting in a few practice holes, "absolutely you're reminiscing. It's one of the more notable golf moments of the last 10 years, for all the wrong reasons. It's one of those where you remember exactly where you were when it happened." McDowell was still a teenager, camped out in front of his television after his family had its Sunday dinner. "I remember feeling sick for the guy," he said. "It was a painful to watch. You never want to see that happen to any golfer." Right after his meltdown, Van de Velde insisted that he had no regrets about the way he played the 18th hole. Eight years later, he largely sticks to that way of thinking -- even though he was, and still is, roundly condemned for the swashbuckling way that he attacked the hole with such a comfortable lead. The driver off the tee, which veered off into a peninsula carved out by the burn. The 2-iron that struck a grandstand and ricocheted straight back into knee-high rough. Instead of chopping out into the fairway with his third shot, he went for the green.He wound up in the creek instead. "It's one shot I would have played differently," Van de Velde conceded. "You know, people say we learn from experiences. That's life." He rarely watches others playing golf on television, but he'll be tuned in this week. And, if everything goes according to plan, Van de Velde will get well, qualify for next year's British Open at Royal Birkdale -- and not make a mess of the 72nd hole. "That's a date," he said, just before hanging up the phone. "I'll see you in Birkdale." 27/06/07 - Pro-Am INTERVIEW : Jean Van de Velde (FRA) Jean Van de Velde: “Beware of the wounded animal!” How are you feeling before the start of the Open de France tomorrow? After a good start to the season with good performances in Thailand, I’m physically out of shape. Since Portugal, 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. They thought it was due to iron deficiency in my body but that apparently is not the case. I hit balls for half an hour and then have to stop because I’m just too tired. It certainly isn’t the best way to prepare the Open de France Alstom? I have no expectations. I’m obviously not in the best of shape. All I can hope for is to be physically OK. It’s very frustrating but its part of life and its part of the life of a traveller when you change countries, hotels and food every week. Before that I had my knee injury in mind, now I have to cope with this illness. On the other hand technically I feel fine. You never know. One must be careful with a wounded animal. What are the plans after this Open de France Alstom? I had decided not to change "It's thought that he'd been suffering from ME (myalgic encephalomyelitis)," said manager Jamie Cunningham. "To be really honest, I think my health is more important than playing in a golf tournament,"

33 It is no surprise therefore that this book is so widely bought

34 Physician know thyself
Veysman, B. BMJ 2005;331:1529 DOCTORS DIFFER Medical Model doesn’t Help Training Define disease in terms of pathology Cure disease by reversing pathology No identifiable pathology Feel cheated Angry towards patients For misleading us Behaving as if they have pathology when they do not Frustrated Our usual treatments will not work - cannot cure them And worse - some do not even want to be cured

35 Likes / Hates adults & children equally
DOCTORS DIFFER Medical Model doesn’t Help Training Define disease in terms of pathology Cure disease by reversing pathology No identifiable pathology Feel cheated Angry towards patients For misleading us Behaving as if they have pathology when they do not Frustrated Our usual treatments will not work - cannot cure them And worse - some do not even want to be cured This algorithm looks very useful, but needs to be extended. Under the not crazy>very hard working area, there needs to be an extra branching point - the choice is not just "hates adults" or "hates children" but also there needs to be a "likes adults and children" or perhaps "hates adults and hates children equally", which lead to family medicine. I notice Ob/Gyn is also absent so perhaps a "hates men, likes women" or "likes babies but only for 2 minutes" choice point needs to be added too? Perhaps some refinements regarding income requirements or medical student debt or reluctance to be woken up at night should be added too? And an exit to a nonmedical career for those who just don't fit in at all? Competing interests: I am a family doctor Likes / Hates adults & children equally GP?

36 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) Somatic symptoms more common in those with pain Guilt and loneliness less common Females more somatic symptoms Depression more likely x 3 if CWP DSM-IV criteria and Depression Rating scales do no take this into account.

37 Depression and somatic symptoms
Large WHO study in primary care (n=25,916) 10.1 percent had major depression. 45-95% of depressed patients reported only somatic symptoms Half the depressed patients reported multiple unexplained somatic symptoms WHO study of psychological problems in general health care Screened 25,916 pts at 15 primary care centers in 14 countries on 5 continents. Interviewed 5447 of these patients. Results: 10.1 percent met the criteria for major depression. 45-95% of depressed patients reported reported only somatic symptoms of depression Half the depressed patients reported multiple unexplained somatic symptoms 11 percent denied psychological symptoms of depression on direct questioning.

38 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 As in the earlier analysis of the National Comorbidity Survey, female respondents had twice the prevalence of somatic depression as male respondents (2.8% versus 1.4%) but a much smaller difference in prevalence in pure depression (2.3% versus 1.7%) (overall 2=48.30, df=2, p<0.001). Among women, those with somatic depression were more likely than those with pure depression to have had an anxiety disorder (31.4% versus 22.9%) (2=4.52, df=1, p=0.03), to have had pain (60.9% versus 48.6%) (2=6.39, df=1, p=0.01), and to have had chronic depression (49.2% versus 36.8%) (2=8.08, df=1, p=0.004). Men with somatic depression were more likely than those with pure depression to have had pain (48.9% versus 28.6%) (2=8.20, df=1, p=0.004), but they were not more likely to have had an anxiety disorder (39.3% versus 31.9%) (2=1.22, df=1, n.s.) or chronic dysphoria (37.8% versus 33.3%) (2=0.39, df=1, n.s.). No significant differences between respondents with somatic versus pure depression were found in the age respondents first exhibited depressive symptoms among either women (mean somatic=27.75 years, pure=27.75) (t=0.003, df=549, n.s.) or men (mean somatic=26.64 years, pure=24.72) (t=1.2, df=255, n.s.) Silverstein, 2002

39 DENIAL Culture did not effect the likelihood of a somatic presentation
WHO study of psychological problems in general health care Only 11 percent denied psychological symptoms of depression on direct questioning. 1: J Psychosom Res Mar;50(3): Links Is "somatisation" a defense against the acknowledgment of psychiatric disorder?Hotopf M, Wadsworth M, Wessely S. Department of Psychological Medicine, Institute of Psychiatry, Guy's King's and St. Thomas' School of Medicine, King's College London, 103 Denmark Hill, London SE5 8AZ, UK. OBJECTIVE: To determine whether experiencing physical symptoms is associated with a denial of psychological distress in individuals with probable psychiatric disorder. METHODS: A nested case-control study was performed using data from a national birth cohort study. All subjects who scored above threshold on a case-finding questionnaire of psychiatric disorder were identified. Those who in a separate question endorsed the presence of psychiatric disorder ("acknowledgers") were compared with those who did not. RESULTS: Acknowledgers were more likely to be female, better educated and have more severe current and past psychiatric disorder. They were also more likely to report multiple physical symptoms, even when potential confounders and severity of psychiatric disorder were controlled. CONCLUSION: There is no evidence that experiencing multiple physical symptoms helps the individual deny the presence of psychiatric disorder. Culture did not effect the likelihood of a somatic presentation Only 11 percent denied psychological symptoms of depression

40 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) McBeth et al (2001) 1480 / 1658 subjects free from CWP at baseline were re-evaluated 12 months later. 5.8% developed new CWP at follow-up Baseline predictors of CWP at follow-up were: female sex; psychological distress (OR 2.0); non-pain somatic symptoms (OR 3.8); illness behaviour (OR 8.7) Majority of somatisers did not develop CWP. However, if no features of somatisation, then CWP prevalence negligable.

41 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 Benjamin et al 2000 Population based case-control study 1953 subjects (75% of random sample age 18-65) completed Pain questionnaire and GHQ. 301 of 710 GHQ positive subjects had a detailed structured psychiatric interview and medical records assessment. 67/301 (22%) had CWP 97/301 (32%) had a mental disorder (mood and/or anxiety disorders). OR of mental illness was 3.2 in CWP compared to no CWP.

42 Depression is a risk factor for pain
Baltimore ECA Survey prospective community cohort (3 samples: 1981; ; ) Depression doubles later risk of CLBP (Larson et al, 2004)

43 Litigation Canadian Whiplash injuries Change to no-fault
Cassidy et al, 2000 Canadian Whiplash injuries Change to no-fault Reduced claims (417/100, /100,000) Reduced time to closure of claims (433 – 194 days) Time to closure strongly associated with: Pain severity, functioning, depression N Engl J Med Apr 20;342(16): Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. Cassidy JD, Carroll LJ, Cote P, Lemstra M, Berglund A, Nygren A. The incidence and prognosis of whiplash injury from motor vehicle collisions may be related to eligibility for compensation for pain and suffering. On January 1, 1995, the tort-compensation system for traffic injuries, which included payments for pain and suffering, in Saskatchewan, Canada, was changed to a no-fault system, which did not include such payments. To determine whether this change was associated with a decrease in claims and improved recovery after whiplash injury, we studied a population-based cohort of persons who filed insurance claims for traffic injuries between July 1, 1994, and December 31, RESULTS: Of 9006 potentially eligible claimants, 7462 (83 percent) met our criteria for whiplash injury. The six-month cumulative incidence of claims was 417 per 100,000 persons in the last six months of the tort system, as compared with 302 and 296 per 100,000, respectively, in the first and second six-month periods of the no-fault system. The incidence of claims was higher for women than for men in each period; the incidence decreased by 43 percent for men and by 15 percent for women between the tort period and the two no-fault periods combined. The median time from the date of injury to the closure of a claim decreased from 433 days (95 percent confidence interval, 409 to 457) to 194 days (95 percent confidence interval, 182 to 206) and 203 days (95 percent confidence interval, 193 to 213), respectively. The intensity of neck pain, the level of physical functioning, and the presence or absence of depressive symptoms were strongly associated with the time to claim closure in both systems. CONCLUSIONS: The elimination of compensation for pain and suffering is associated with a decreased incidence and improved prognosis of whiplash injury.

44 Exercise cessation & pain
Pain predicted by: Lower basal cortisol Lower NK cell response HR variability 1: J Psychosom Res Oct;57(4): Links Comment in: J Psychosom Res Apr;58(4): The effect of brief exercise cessation on pain, fatigue, and mood symptom development in healthy, fit individuals.Glass JM, Lyden AK, Petzke F, Stein P, Whalen G, Ambrose K, Chrousos G, Clauw DJ. Department of Psychiatry and Institute for Social Research, University of Michigan, Ann Arbor, MI, USA. OBJECTIVE: Abnormalities of the biological stress response (hypothalamic-pituitary-adrenal axis and the autonomic nervous system) have been identified in both fibromyalgia (FM) and chronic fatigue syndrome (CFS). Although these changes have been considered to be partly responsible for symptom expression, we examine an alternative hypothesis that these HPA and autonomic changes can be found in subsets of healthy individuals in the general population who may be at risk of developing these conditions. Exposure to "stressors" (e.g., infections, trauma, etc.) may lead to symptom expression (pain, fatigue, and other somatic symptoms) in part by precipitating lifestyle changes. In particular, we focus on the effect of deprivation of routine aerobic exercise on the development of somatic symptoms. METHODS: Eighteen regularly exercising (>/=4 h/week) asymptomatic, healthy adults refrained from physical activity for 1 week. We predicted that a subset of these individuals would develop symptoms of FM/CFS with exercise deprivation, and this manuscript focuses on the baseline HPA axis, immune, and autonomic function measures that may predict the development of symptoms. RESULTS: Eight of the subjects reported a 10% increase in one or more symptoms (pain, fatigue, mood) after 1 week of exercise deprivation. These symptomatic subjects had lower HPA axis (baseline cortisol prior to VO2max testing), immune (NK cell responsiveness to venipuncture), and autonomic function (measured by heart rate variability) at baseline (prior to cessation of exercise) when compared to the subjects who did not develop symptoms. CONCLUSIONS: A subset of subjects developed symptoms of pain, fatigue, or mood changes after exercise deprivation. This cohort was different from the individuals who did not develop symptoms in baseline measures of HPA axis, immune, and autonomic function. We speculate that a subset of healthy individuals who have hypoactive function of the biological stress response systems unknowingly exercise regularly to augment the function of these systems and thus suppress symptoms. These individuals may be at risk for developing chronic multisymptom illnesses (CMIs) (e.g., FM or CFS among others) when a "stressor" leads to lifestyle changes that disrupt regular exercise.

45 Medical Model doesn’t Help (Stokes)
Trained to define disease in terms of pathology No identifiable pathology? Feel cheated Angry towards patients Frustrated

46 Cognitive-behavioural model
Attributions of cause / condition worsening, loss of control 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 Emotion Anticipatory anxiety, mood change, symptom increase,

47 Filter System Bodily Signals Cortical Perception Illness Behaviour
Visits doctor Avoids physical activity Adopts sick role 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

48 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

49 Treatment

50 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!)

51 Targets for treatment Misinformation -- Education
Distress -- Antidepressants Illness / safety behaviour -- Behaviour Rx Conflict - - Psychotherapy Deconditioning -- Graded activity

52 Treatment


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