1. Medically unexplained symptoms 1 (MUS, Somatoform Disorders) Medically unexplained Symptoms H.Afshar Psychosomatic research center IUMS

2. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Importance for the Health System (Western countries) High prevalence in primary care (30 %) and secondary care (20 %) High use of medical service Treatment costs up to 9 times higher (Work disability time due to sick leave and retirement) Ineffective therapeutic measures in ca. half of the patients; e.g. non-indicated surgical procedures are performed in 20 % of hospitalized „somatisers‘ Frequent change of doctors, emergency admission to hospital and dissatisfaction with treatment Diagnosis

3. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  1.Definition 2.Classification 3.Etiology Overview

4. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Medically unexplained symptoms (MUS) General term, very broad Functional syndroms Disturbance of bodily function rather than structure Somatization A psychological problem or emotional disorder is expressed somatically Somatoform disorders Diagnostic category in the psychiatric classification of DSM and ICD Definition and Terminology

5. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Overlapping of MUS, Functional Syndroms, Somatization and Somatoform Disorders

6. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Definition of somatoform disorders Repeated presentation of physical symptoms Stubborn demand for medical examination despite negative organic findings (dysfunctional illness behavior). Emotional problems denied, although there is close relationship with psychosocial life events or conflicts (somatic fixation). Symptoms are not feigned or aggravated Disappointing doctor-patient relationship (interpersonal disorder) Definition

7. Patient experiences physical symptoms and seeks help The doctor focuses on organically-caused symptoms and prescribes organ-medical diagnostic tests prescribes medications Patient feels misunderstood and demands further diagnostic measures The doctor is irritated Doctor retreats or refers to Specialist or the patient breaks off contact; doctor shopping Doctor looks for psychosocial stress; Patient denies and becomes enraged Patient sees no improvement; the findings are negative; Patient doesn´t know where to turn Disruption of the Doctor-Patient Relationship

8. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms 

9. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  1.Definition 2.Classification 3.Etiology Overview

10. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  ICD – 10 classification F 45.0 Somatization disorders F 45.2 Hypochondrial disorders F 45.3 Somatoform autonomic dysfunction F 45.4 Persistent somatoform pain disorders F 44 Dissociative (conversion) disorders F 48.0 Neurasthenia Classification

11. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Subgroups of somatization Initial somatizers Part somatizers Facultativ somatizers True somatizers Functional somatizers Classification

12. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Common Symptoms Symptoms of pain backache (73%) headache(67%) bellyache(56%) Symptoms in the gastrointestinal tract feeling of pressure(54%) flatulence(56%) Symptoms in the cardiovascular tract heart palpitation(55%) sweating(62%) Rief et al. 1997 Classification

13. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Somatisation Depressive disorder Anxiety disorder Classification

14. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Physical symptoms in anxiety disorders Classification

15. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  1.Definition 2.Classification 3.Etiology Overview

16. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Elicitor e.g. Minor injury Psychosocial stress Sudden cardiac death of a close person Physical Changes Physical reactions Malaise Symptoms Maintain Factors „Checking the body“ Excessive worries about health „Doctor shopping“ – many medical examinations Taking medications Protective behaviour Somatic concept of illness Symptom potentiation Increased attention to one’s own body Physiological arousal Anxiety, depressive symptoms Perception Misinterpretation as asign of threatening disease Vicious circle of somatoform symptoms Etiology (Based on Rief 2000)

17. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  My hair stood on end Get cold feet Have butterflies in the stomach lBody related idioms

18. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  What can the medical doctor do? Avoid insults, recognize the illness as an attempt at solution, legitimization of the symptoms Take the physical symptoms seriously Pay attention to difficulties in the doctor- patient relationship (e.g. Negative feelings) Avoid premature coupling of the symptoms to psychosocial stress

19. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Approach to patients: disease or illness oriented Cognition: content, styles Emotion Function Expectation Concerns: questions

20. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  The reattribution model - how to talk to somatizating patients and how to deal - 1.Take a full history of the symptoms 2.Explore emotional cues 3.Explore social and family factors 4.Explore health beliefs 5.Brief focused physical examination Stage 1: Feeling understood

21. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  The reattribution model 1.Feed back the results of the examination 2.Acknowledge the reality of the symptoms 3.Reframe the complaints: link physical, psychological, and life events Stage 2: broadening the agenda

22. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  The reattribution model 1.Simple explanation Three-stage explanation for anxiety How depression lowers the pain threshold 2.Demonstration Practical Link to life events „Here and Now“ Stage 3: making the link

23. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Extra systoles Palpitations Shortness of breath Tingling Muscle pains, esp. shoulder and neck Blood pressure increase Heart rate increase Rapid breathing Tensed muscles Anxiety Excitation Inner restlessness Tension Three Stage explanation for “Anxiety and physical complaints” EmotionsPhysical Reactions Symptoms

24. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Headache Aching joints Stomache Back pain Susceptibility to infections Neglect of preventive health measures Reduced pain threshold Increased sinsitivity to physical discomfort Weakened immune system Feeling blue Lack of energy Lack of interest Withdrawal Three Stage explanation for “Depression“ EmotionsPhysical Reactions Symptoms

25. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Viscious circle model of anxiety and panic attacks (Margraf & Schneider, 1990)

26. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Symptom Diary Record of thoughts and feelings during physical complaints

27. UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms  Potentially acutely serious? (< 5 %) Expedited diagnostic evaluation Yes No Likely minor and self-limited (70-75 %) 1.Adress patient expectations 2.Symptom-specific therapy 3.Follow-up in 2-6 weeks Yes No Persistent unexplained somatic symptoms (20-25 %) Depressive or anxiety disorder? Yes Functional somatic syndrome? Yes Regular time-limited clinic visits Psychological assesment (e.g. somatoform disorders, personality disorders, history of trauma/abuse) Individual or group chronic symptom management programs Complementary medicine treatments when evidence-based Rehabiltative rather than disability approach Yes No Antidepressant and / or cognitive- behavioral therapy Syndrom-specific therapy if evidence-based Kroenke 2003 Ineffective