Presentation on theme: "Identifying and Treating Somatic Symptom Disorder in the Primary Care Setting Presented by: Ruth Tadesse, MS, RN Date: 4/02/2015 1 1."— Presentation transcript:
1Identifying and Treating Somatic Symptom Disorder in the Primary Care Setting Presented by: Ruth Tadesse, MS, RNDate: 4/02/201511
2Learning Objectives: Disclosures and Learning Objectives Identify 3 common types of somatization seen in primary care settingKnow DSM 5 criteria used to diagnose Somatic Symptom DisorderIdentify at least 2 assessment tools used to diagnose somatic symptom disorderList at least 4 treatment methods used to manage somatic symptom disorder.Disclosures: Ruth Tadesse has nothing to disclose.22
3Historical Background and Changes from DSM III to DSM 5 (Dimsdale, J. E., et al. 2013) Somatoform Disorder Somatic Symptom DisorderFirst introduced 30yrs ago in DSM-III as Somatoform Disorder.Somatoform didn’t translate to another language wellDSM-IV – concept of medically unexplained symptoms were introduced.Is it unexplained or unexamined medical condition?DSM-5 replaced Somatoform Disorder with Somatic Symptom Disorder and Related DisordersThe symptoms may or may not be medically unexplained. If the patient primarily had anxiety but not somatic complaints, the diagnosis would be Illness Anxiety Disorder.Somatic Symptom Disorder Fact Sheet.pdf
4Differences from DSM IV to DSM 5 (Dimsdale, J. E., et al. 2013) DSM IV Somatoform DisorderDSM 5 - Somatic Symptom Disorder and related disordersSomatic Symptom DisorderIllness Anxiety DisorderConversion DisorderPsychological factors affecting a medical conditionFactitious DisorderOther specific and nonspecific somatic symptom disordersSomatization DisorderUndifferentiated Somatoform DisorderConversion DisorderPain DisorderHypochondriasisBody Dysmorphic DisorderSomatoform Disorder NOS
5Somatic Symptom Disorders and Other Related Disorders
6Somatic Symptom Disorder vs Illness Anxiety Disorder (Croicu, C Somatic Symptom Disorder vs Illness Anxiety Disorder (Croicu, C., et al. 2014) Approach to the patient with multiple somatic symptoms.pdf
7DSM 5 Criteria for Somatic Symptom Disorder A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.B. Excessive thoughts, feelings, behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:1) Disproportionate and persistent thoughts about the seriousness ofone's symptoms.2) Persistently high level of anxiety about health or symptoms.3) Excessive time and energy devoted to these symptoms or healthconcerns.C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent - more than 6 months.American Psychiatric Association ((APA) (2013). Diagnostic and Statistical Manual of MentalDisorders. (5th ed.) Washington, DC: American Psychiatric Association Press. p. 309–27.
8Case Study – Ms. BMs. B is a 37-year-old woman who presents to the ED with abdominal pain. She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple abdominal surgeries, the most recent was for pain felt due to adhesions. These operations have failed to reduce her complaints of pain. Her physical examination, vital signs, and labs, including CBC, urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician for further examination.
9Case Study – Ms. BIf you are her PCP, what more would you like to know?What additional tests/screenings would you like to do?What will you include under your differential diagnosis?What do you think her full mental status examination would look like?What will you prescribe to treat Ms. B’s chronic pain?
10Somatic Symptom Disorder - Pathophysiology Pathophysiology is unknownAssociated with a heightened awareness of normal bodily sensations which maybe paired with a cognitive bias to interpret any physical symptom as indicative of medical illnessSome tend to have autonomic arousalBrain imaging shows reduced volume of amygdalaComorbidity – depressive disorders, anxiety disorders, substance use, and personality disordersSomatic complaints epidemiology and psychiatric co-morbidity.pdf
11Somatic Symptom Disorder - Epidemiology Somatic Symptom Disorder PrevalenceCommunity sample – 0.1%Medical chart review show prevalence rate in womenas high as 2%Liberal criteria rates as high as 11.6%Hypochondriasis in primary care 4-6%50% of patients presents in primary care with physical symptoms has no diagnosable diseaseFemale-to-Male ratio is 10:1Symptoms usually begin in childhood, adolescence or early adulthoodSomatic complaints epidemiology and psychiatric co-morbidity.pdf
12Common types of somatization seen in primary care (Croicu, C. , et al Acute somatization- Temporary production of physical symptoms associated withtransient stressors2. Relapsing somatization- Repeated episodes of physical symptoms associated withrepetitive stressors & anxiety or depressive episodes3. Chronic somatization- Nearly continuous somatic focus, perception of ill health,development of disabilityApproach to the patient with multiple somatic symptoms.pdf
13Assessing for Somatic Symptom Disorder Using the 3-Ps (Croicu C, et al PredisposingChronic childhood illnesses, childhood adversities, comorbid medical illness, lifetime psychiatric diagnosis, poor coping ability- PrecipitatingMedical illness, psychiatric disorder, social & occupation stress, and changes in social supportPerpetuatingChronic stressors, maladaptive coping skills, negative health habits, and disability paymentsApproach to the patient with multiple somatic symptoms.pdf
14Assessing Mental Health in Patients with SSD using S4 Model (Jackson, et al., 2003) Stress recently (last week) (yes/no)Symptom count (checklist of 15 somatic symptoms; scored as positive if more than 5 symptoms)Self-rated overall health poor or fair on a 5-point-scale (excellent, very good, good, fair, poor); scored as positive for fair or poor responses.)Self-rated severity of symptoms from 0 (none at all) to 10 (unbearable) scale, scored as positive for responses greater than 5Clinical predictors of mental disorders among medical outpatients.pdfValidation of the S4 Model.pdf
15Identifying Somatic Symptom Disorder (Croicu C, et al. 2014) Do a thorough history and detailed physical assessmentRule out medical illnessConsider medication side effectsIdentify ability to meet basic needsIdentify secondary gainsIdentify ability to communicate emotional needsDetermine substance useBuild therapeutic alliance with the patientUse screening tools appropriate for somatic symptom disorder: SSS-8 and PHQ-15Approach to the patient with multiple somatic symptoms.pdf
16The BATHE TechniqueB: Background - What is going on in your life? And What brings you in here today?A: Affect – How do you feel about that?T: Trouble – What bothers you the most about this situation?H:Handling - How are you handling that?E: Empathy – That must be very difficult for you.The BATHE Method.pdfApproach to the patient with multiple somatic symptoms.pdf
17PHQ-15 - Screening for Somatic Symptom Presence and Severity Not bothered at all(0)Bothered alittle (1)lot (2)a.Stomach painb.Back painc.Pain in your arms, legs, or joints (knees, hips, etc.)d.Menstrual cramps or other problems with your periodsWOMEN ONLYe.Headachesf.Chest paing.Dizzinessh.Fainting spellsi.Feeling your heart pound or racej.Shortness of breathk.Pain or problems during sexual intercoursel.Constipation, loose bowels, or diarrheam.Nausea, gas, or indigestionn.Feeling tired or having low energyo.Trouble sleepingScores 0-2 for each item, making the total 0-30; 5 = low; 10=moderate; and 15 = high somatic symptom severity
18Somatic Symptom Scale – 8 [SSS-8] (Table is hyperlinked)
19Essential Treatment Approaches for Patients with Somatic Symptom Disorder (Croicu, C., et al. 2014) Schedule time-limited regular appointments (e.g weeks) to address complaintsExplain that although there may not be a reason for their symptoms, you will work together to improve their functioning as much as possibleEducate patients how psychosocial stressors and symptoms interactAvoid comments like “Your symptoms are all psychological.” or “There is nothing wrong with you medically.”Approach to the patient with multiple somatic symptoms.pdf
20Essential Treatment Approaches for Patients with Somatic Symptom Disorder (Croicu, C., et al. 2014) Avoid the temptation to order unnecessary, repetitive, or invasive investigationsEducate the patient on how to cope with their symptoms instead of focusing on a cureEvaluate somatic symptom burdenCollaborate with the patient in setting treatment goalsScreen for common psychiatric conditions associated with somatic complaints such as depression and anxietyTreat identified comorbid psychiatric disordersApproach to the patient with multiple somatic symptoms.pdf
21Essential Treatment Approaches for Patients with Somatic Symptom Disorder (Croicu, C., et al. 2014) Case management to minimize economic impactMedications to treat anxiety and depression (SSRIs)Short term use of anxiety meds (dependence is a risk)Non-pharmacological treatments*CBT – Shows promising evidencePsychodynamic therapyIntegrative therapyApproach to the patient with multiple somatic symptoms.pdf
22SummaryScheduling a regular visit with the patient reduces or eliminates unnecessary ED visits.Identifying risks such as childhood trauma can suggest screening for somatic symptom disorders using appropriate assessment tools (PHQ-15 & SSS-8).Identifying, screening for and treating common psychiatric comorbidities such as depression (PHQ-9) and anxiety (GAD-7) can decrease somatic symptom burden.Non-pharmacological interventions such as CBT has shown evidence in decreasing somatic symptom disorder.Therapeutic alliance with the patient with somaticcomplaints improves outcomes.
23ReferencesAmerican Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. 5th edition. American Psychiatric Association Press. Croicu, C., Chwastiak, L., & Katon, W. (2014). Approach to the patient with multiple somatic symptoms. Medical Clinics of North America. 98(5): Dimsdale, J. E., Creed F., Escobar, J., …Levenson, J. (2013). Somatic symptom disorder: An important change in DSM. Journal of Pscyhosomatic Research. 75(3): DSM V Somatic Symptom Disorder Fact Sheet available online Glerk,B., Kohlmann,S., Kroenke, K., …Lowe, B. (2014). The Somatic Symptom Scale-8 (SSS- 8). A Brief Measure of somatic symptom burden. JAMA Internal Medicine. 174(3): Gierk, B., Kohlmann, S., Toussaint, A. …Lowe, B. (2014). Assessing somatic symptom burden. A psychometric comparison of the Patient Health Questionnaire – 15 (PHQ-15) and the Somatic Symptom Scale- 8(SSS-8)
24References Cont.Jackson, J.L., O’Malley, P., & Kroenke, K. (1998). Clinical Predictors of Mental Disorders Among Medical Outpatients: Validation of the S4 Model. The Journal of Consultation and Liaison Psychiatry. 39(5): 431–436. Kroenke K., (2003). Patients presenting with somatic complaints epidemiology, psychiatric comorbidity and management. International journal of methods in psychiatric research .12(1): Kroenke, K., Jackson, J.L., & Chamberlin, J. (1997). Depressive and anxiety disorders in patients presenting with physical complaints. The American Journal of Medicine. 103(5): 339–347. Martin, A., Rauh, E., Fichter, M., & Rief, W. (2007). A One-session treatment for patients suffering from medically unexplained symptoms in primary care: A randomized clinical trial. Psychosomatics. 48(4): Ravesteign, H., Wittkampf, K., Lucassen, P., …,Weel, C. (2009). Detecting somatoform disorders in primary care with the PHQ-15. Annals of Family Medicine. 7: Van Dessel, N., den Boeft, van der Wouden, J.C. …van Marwijk, H. (2014). Non- pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane Database Systematic Review.11(1): Vol.11, p.CD CD011142