1. “Unexplained illness” Managing somatization : art & evidence Norman Jensen MD MS Professor, General Internal Medicine University of Wisconsin - Madison nmj@medicine.wisc.edu

2. Take 1 minute to write 3 things you’d like to learn from this workshop

3. 3 things U’d like to learn from this workshop … 1. 2. 3. After the workshop, did U learn them? Y N ? What U learned that U didn’t expect …

4. Workshop Schedule 1:00Intro & Learning Objectives 1:15Case Talk 2:00Didactic 2:50Break 3:00Skills demonstration 3:45 Skills work - small groups 4:15Summary & assessment 4:30Adjourn

5. Somatization ILO s l Enhancement of – Clinical concept of somatization l `definitions l pathophysiology l epidemiology l diagnosis – Medical management l The practical and the evidence – Communication with patient

6. Unexplained Illness l l How can it be explained? l l How can I be a good doctor when I can’t explain my patient’s symptoms? l l What is the evidence for effective management?

7. 46 y/o woman from LaCrosse comes self-referred, as a new patient for the evaluation of multiple waxing and waning symptoms for more than 15 years. She comes with two bulging radiology folders and a 3 inch stack of medical records recording many normal physical exams and laboratory tests. She comes to the “U” to find out what’s wrong; “something is definitely wrong” and the other doctors “think it’s all in my head”. She is not worried about a specific condition. PMH = lots of illness; no disease. FH = not significant. Soc Hx = married twice, two young adult children, insurance office manager, “rough childhood”. ROS = very +, see following slide. PE = She looks healthy and worried. VS and full PE normal. Labs and Imaging = lots of them all normal

9. Somatization, a definition N Jensen The indirect, unconscious, unintentional expression (transduction) of psych. distress through illness, as an alternate to direct expressions of emotion, anxiety and depression; a dysfunction just beginning to be describable in terms of anatomy and chemistry; its reality is appreciated only via patient’s subjective experience. Described 1960s; DSM dx 1980. N Jensen

10. Somatization Disorder 300.81 l l A. Many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning. DSM IV

11. Somatization Disorder 300.81 B. B. Each of following required to have occurred at any time in course of illness: – –1. Pain in at at least four sites or functions – –2. Two GI symptoms other than pain – –3. One sexual symptom – –4. One neurological symptom.

12. Somatization Disorder 300.81 C C. Either of the following: – –1. Each of the symptoms ( in criterion B) cannot be fully explained by a known medical condition or direct effect of a substance. – –2. In presence of a known medical condition, the symptoms or impairment are in excess of what the disease stage would explain. l l D. Not intentionally produced / feigned.

13. Undifferentiated Somatoform Disorder 300.81 AKA, sub-threshold or abridged SD, or somatization syndrome l l One or more symptom – –medically unexplained, or – –beyond expectation from known pathology l l Causing distress or dysfunction Duration => 6 months

14. Suffering in somatoform illness l Disease l Sickness l Illness

15. “ By golly, you ARE crying on the inside! ”

16. Theoretical Mechanisms: Neurobiologic l l Variable CNS modulation of incoming sensory information, e.g., – –conversion = excessive inhibition – –somatization = inadequate inhibition. l l Melzack R & Wall P. Pain mechanisms: A new theory. Science. 1965;150:971-979 l l Wall P. The gate control theory of pain mechanisms: a re- examination and re-statement. Brain. 1978;101:1-18.

17. Action System T S G - + Central Control Gate Control System - Melzack & Wall, Science 1965 SG = Substantia Gelatinosa in dorsal horn + + - - s L Attention, emotion, memories of prior experience

18. 1962 (4th) & 1970 (6th)1983 (10th) Harrison’s Textbook of Internal Medicine

19. 1994 (13th) & 1998 (14th)1987 (11th) & 1991 (12th) Harrison’s Textbook of Internal Medicine AfferentEfferent

20. The “Pain Matrix”

21. “ Pain sensitivity linked to gene” Wisconsin State Journal 1999 l l muOR: thalamus and spinal cord l l muOR density – –:: 1/pain perception – –:: morphine analgesia – –varies by individual – –varies with stress conditions Uhl GR, et al. The mu opiate receptor as a candidate gene for pain: Polymorphisms, variations in expression, nociception, and opiate responses. Proc Natl Acad Sci U S A. 1999 Jul 6;96(14):7752-7755.

22. NMDA – Receptor N-methyl-D-aspartate l Hypotheses – Involved in neuropathic pain – Antagonists block “Opioid insensitive” component l Dextromethorphan l d-methadone – NMDA antagonist & Opioid agonists l (dl) Methadone l Dextropropoyphene l ketobemidone

23. Theoretical Mechanisms: Neurobiologic l l Alexithymia, a cognitive-affective disturbance characterized by difficulties in verbally expressing moods, symbols, and feelings. l l Kooiman CG. The status of alexithymia as a risk factor in medically unexplained physical symptoms. Comprehensive Psychiatry. 1998;39:152-159. – –Corpus callosum defects prevent symbolic & affective information in the right hemisphere from reaching the left hemisphere so as to be expressed in language l l TenHouten W, et.al. Alexithymia: an experimental study of cerebral commissurotomy patients and normal control subjects. Am J Psychiatry 1986;143:312-316. – –“Emotional IQ”

24. Theoretical Mechanisms: Social-psychological l l Psychological (nature) – –needs for nurturance & support – –“defense mechanisms” that resolve conflict l l Social-cultural (nurture) – –SICK ROLE (1° gain) – –CULTURAL CORRECTNESS l l parents (“big kids don’t cry”) l l CLINICIANS - “Balint agreement”, “this won’t hurt” l l teachers, clergy, peers, etc.

25. Contexts of Somatization l l normal daily experience l l highly situational l l marked individual differences l l marked cultural differences l l associated with ΨS stress associated with DSM disorders

26. SD: Epidemiology l l Community prevalence DSM IV – –0.2 - 2.0% for women – –~ < 0.2% for men l l Primary care prevalence – –Somatization 25 - 75% – –Somatization disorder ? – –Hypochondriasis ~3%

27. Impact on Personal Health l Illness behavior – Social function l Role function – Mental functioning l Sense of well being – Physical functioning l Bed days slide in development

28. Impact on Health Services l l 60% of primary care patients recurrently present with unexplained somatic sx. “ … the failure to provide mental health service [had] the potential of bankrupting the health care financing system due to over-utilization of primary care physicians by somatizing patients.” Rand / Permanente Study Cummings. Health Policy Quarterly 1981;1159-1175.

29. Impact on Physicians’ Attitudes l l Gorlin: helplessness, loss of control, inadequacy, impotence, frustration, threatened authority, anger, and guild. l l Groves: aversion, fear / counter- attack, guilt, inadequacy, malice, wish that patients would “die and get it over with”.

30. Rx

31. Medical Management Principle components l Patient education l Risk of a missed “organic” diagnosis l Medical resource conservation l Protect patient from medical injury l Use of consultants l Care for the doctor

32. Management: Patient Education l l Give the illness a name – –abnormal nervous system – –leaky gates, weak editing / noise filtering – –give examples from ordinary experience l l Postpone psychological interpretation – –resistance prone by nature or nurture – –hypersensitive to doubt of sx reality – –expect slow or no insight

33. Management: RISK of MISSED DX l l Share the diagnostic risk with patient – –Document discussion in medical record l l Systematic surveillance – –regular visits, longer duration – –careful listening for change in sx – –liberal physical exam of symptomatic parts (somatoform relationship) – –parsimonious use of tests, drugs, & surgery

34. Management: Resource conservation l l Limit: ER, urgent care, walk-ins, and phone calls - contract if needed. l l Raised threshold for tests, images, drugs, surgery, procedures l l Substitute old-fashioned doctoring – –empathic listening / witnessing – –liberal physical exam – –reliable, accepting, helping relationship

35. Management: Protect the patient l l Marginal tests – –especially invasive tests l l Marginal treatments – –toxicity – –polypharmacy l l Excess expense l l Assert your primary care role

36. Management: Use of Consultants l Carefully explain purpose. l Assure your ongoing commitment -- “expert advice helps me be the best possible doctor for you”. l Psychiatry consultant helps diagnose co- morbid DSM disorders. Prepare consultants so they too will judiciously use tests, procedures, drugs. Prepare consultants so they too will judiciously use tests, procedures, drugs.

37. Management: Caring for the doctor l These patients consume energy l Confront and cope with negative responses –learn professional emotion handling skills l Seek support of colleagues, formal or informal l Credit yourself with hard work done well with your fair share of these patients Refer to another doctor if you cannot provide state-of-the-art care for this patient. Refer to another doctor if you cannot provide state-of-the-art care for this patient.

38. Management that WORKS What is the Evidence ?  Consult-advice CBT for patient CBT training for MD Drug Therapy

39. 3 Randomized Controlled Studies of Psychiatric Consultation 1. Smith RG, NEJM 1986;314:1407-13 2. Rost K. General Hospital Psychiatry 1994;16:381-7. 3. Smith GR. Arch Gen Psychiatry 1995;52:238-43.

40. Intervention l Psychiatric consultation letter – described somatization disorder – MD encouraged to serve as primary – management suggestions l regular visits, q 4-6 weeks l physical exam at each visit l avoid hosp., procedures, surgery, tests l avoid, “it’s all in your head”

41. Results S MDs PTs %  $ Function F/U mo. 1 35 38 SD 50 h  dis. day 18 2 59 73 S 21 (12)  mental  role 12  role 12  physical  physical 3 51 58 SD 33  physical 12

42. Evidence that CBT works Kroenke, Psychother Psychosom 2000;69(4):205-215.

43. Rx: Training 1  Physicians l l Moriss R, Gask L, Ronalds C, et.al.et.al. Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs. Family Practice 1998;15:119-25. l l Before-after GP CBT 8hr. group training. 8 GPs. 102+112 patients with somatization & mental disorder. At 3 mo., 23.1%  cost of referrals outside practice,  patient- initiated consultations,  cost variation per patient. 1/3 pts  mental function, disqualifying as “mental”.

44. Drug Therapy l Insufficient evidence to recommend. l Small trials show interest for – tricyclic antidepressants – fluvoxamine – gabapentin – anti-psychotics (if psychosis)

45. The abstract ends here! Questions? Answers $0.25 Answers requiring thought $1.00 Correct answers $2.50 Comments?

46. Skills Work is Next Goal 1: Increase personal awareness Goal 2: Reduce instinctive responses Goal 3: Enhance trained responses Learning Method: Reflection on action Observed action Participatory action

47. Skills Demonstrations Discussion to Follow

48. Skills Demonstration l 46 y/o woman who has had multiple waxing and waning sx for > 15 years. l We’ve done a complete hx & pe and reviewed large stack of tests and images. Everything we’d have wanted has been done. l Her diagnosis is very clearly Somatoform Disorder, 300.81. l We must now inform & motivate this patient for management.

49. Skills Practice - evaluation There are lots of good ways to communicate l Take time out anytime – For reflection – Ask for help l How well did it work? – Well enough? Why & how? – Less well? Alternative actions? l Feedback: Ask - Tell - Ask

50. Skills Practice l Role play is – voluntary; no one is required to do it – not real; it is simulation, practice – a rare opportunity; try something new – confidential; take some risk – play; have some fun.

51. Summary & Assessment l Take-home learning? l Please complete evaluations. l Thanks for coming!

52. END of WORKSHOP l Additional information slides follow

53. Usual symptoms l l Gastrointestinal (other than pain) – –nausea & bloating most common – –vomiting, diarrhea, food intolerance l l Sexual - reproductive – –women: metrorrhagia, menorrhagia, vomiting throughout pregnancy, sexual indifference – –men: “E D”, ejaculatory dysfunction, sexual indifference

54. Usual symptoms l l Neurological – –impaired coordination or balance – –paralysis or localized weakness – –loss of touch or pain sensation – –double vision or blindness – –deafness – –seizures – –Dissociative, e.g., amnesia – –loss of consciousness other than fainting

55. DSM disorders associated with somatization l Mood l Anxiety l AODA l Adjustment

56. SD: Epidemiology, cont. l l Family coincidence ( 1° rel.) DSM IV – –women, 10-20% S D – –men,  antisocial and AODA

57. Impact on Health Services II l l Collyer 1979, FP: 28% visits involved emotional illness, taking 48% of his time; 3.6% families too 32% his time. l l Katon 1984: 25-75% 1° care visits were caused by somatized Ψ-S stress; these patients take time 2-4 X non-somatizing patients. l l Burnum 1985, IM: Over 3 mos. 98/909 pts. had major Ψ-S problems, 65 combined with physical disease.

58. Impact on Health Services III l l Regier 1984, citizens with any of 13 DSM disorders, 58% had seen their 1°MD in prior 6 mos -- used medical care 2X normal. l l NAMCS 1978 & 1985: 70% pts with DX’d DSM disorders gave a somatic complaint as CC for MD visits. l l (Regier 1978, Schurman 1985)

59. Impact on Physicians’ Attitude l l Katon, et.al: physicians found somatizing patients to be signif. more frustrating than other high utilizing HMO patients.

60. Managing Somatization l Dx: complete problem list l Doctor - patient relationship l Patient education l Cope: doctor anger, anxiety & fatigue l missed diagnosis l time & energy requirements l Conserve resources l Care for the doctor

61. Management First Principles l Observe adjustment responses. l DX and RX mood and anxiety disorders. l Doctor-Patient Relationship is central! –Commitment: chronic care & realistic goals –Rogerian helping relationship l accepting, empathic, congruent (Carl Rogers)

62. Treatment Effects I l l Smith RG, NEJM 1986;314:1407-13 l l RCT-xo with 35 1° MDs & 38 SD patients.  consult letter resulted in ~50% decrease in health care charges compared to patients of control doctors. Mostly hospitalization cost. Trend  disability days. 18 month follow-up.

63. Treatment Effects II l l Rost K, et.al. General Hospital Psychiatry 1994;16:381-7. l l A RCT-xo of MDs & somatizing patients, of  consultation letter to 59 1° MDs. 73 patients reported 17% [0%*] greater physical capacity and had 21% [12%*] reduction in health care charges. Trend  mental and role function. No change gen’l health or social functioning. One year follow-up.

64. Treatment Effects III l l Smith GR, et.al. Arch Gen Psychiatry 1995;52:238-43. l l A RCT-xo of 51 MDs and 56 Somatizing patients of  consult letter with management suggestions, resulted in 33% decrease in medical and psychiatric charges and significantly improved physical functioning up to one year after trial was finished.

65. Treatment Effects IV l l Hellman, C.J., Budd, M., Borysenko, J., McClelland, D.C., and Benson, H. A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behav.Med. 16(4):165-173, 1990. l l RCT 80 primary care patients, Boston HMO. COG-BEHAV RX vs information. At 6 months, subjects had reduced visits and less psych and somatic symptoms.

66. Treatment Effects V l Speckens AEM, van Hemert AM, Spinhoven P, et. al. Cognitive behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial. BMJ 1995;311:1328-1332. l RCT in NL GIM consultation clinic. 39 S & 40 C. 6-16 CBT vs. usual care. 6 & 12 mo. S =  “recovery”, sx intensity & frequency, sleep, social life, leisure activities, and illness behavior. Severity somatization unspecified.

67. Treatment Effects VI l l Hellman, C.J., Budd, M., Borysenko, J., McClelland, D.C., and Benson, H. A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behav.Med. 16(4):165-173, 1990. l l RCT 80 PC somatizing patients. At 6- mo. CBT subjects  HMO visits, Ψsx & somatic sx. Effective therapy =~ teaching pts about the relationship among thoughts, behaviors and sx.

68. Treatment Effects VII l RCT group therapy with 70 SD patients, 8 sessions + consultation to primary doctor l Better physical and mental health at 1yr l Improvement :: # sessions attended l 52% net savings in health care charges l Kashner, T.M., Rost, K. Enhancing the health of somatization disorder patients. Effectiveness of short-term group therapy. Psychosomatics. 36(5):462-470, 1995.

69. Hypochondriasis 300.7 l l Preoccupation with fears of having, or the idea that one has, a serious disease based on misinterpretation of symptoms. l l Despite medical evaluation and reassurance. l l Not delusional. l l Causes distress or impairment in function l l For at least 6 months l l Not better explained by another DSM disorder.

70. Conversion Disorder 300.11 l l A motor or sensory dysfunction that suggests neurological or medical disease l l Psychological factors precede onset or exacerbation. l l Not intentionally produced or feigned. l l Cannot be fully explained by a organic disease, direct effects of a substance, or culturally sanctioned behavior. l l Causes distress or impairment. l l Not limited to pain or sexual dysfunction, Not better explained by another DSM disorder.

71. Body Dysmorphic Disorder 300.7 l l A. Preoccupation with an imagined or exaggerated defect in appearance. l l B. Causes distress or impairment. l l C. Not better accounted for by another DSM disorder.

72. Somatoform Disorder, NOS 300.81 Does not meet criteria for any S D l l Pseudocyesis l l Hypochondriacal symptoms < 6 months Somatoform symptoms < 6 months

73. Somatoform Pain Disorder 307.80 with psychological factors 307.89 with both psych. factors and medical condition l l Pain in one or more sites as the main warrant for clinical consultation. l l Causes distress or impairment. l l Psychological factors judged to have important etiologic or mechanistic role l l Not intentionally produced or feigned. l l Not better accounted for by another DSM disorder

74. Skills Practice - evaluation There are lots of good ways to communicate l How well did it work? (score?) l If it worked well, what happened? l If it didn’t work as well as I’d like, what might I do differently next time? l You can take time out anytime. l You can ask the group for help.

75. Workshop Schedule - 105 min. 3:30Intro & Learning Objectives 3:35Case Talk 3:50Didactic 4:10 Skills demonstration 4:20 Skills work - small groups 5:00Summary & assessment 5:15Adjourn