1. Dr. Marwan A. Bakarman Consultant Family & Community Medicine SOMATOFORM DISORDER

2. Case study Ahmed 35 years old present to PHC complaing of dizziness, backache and indigestion. His file show: for the last 7 month, he presented with the following: abdominal pain, nausea, intolerance to 13 different foods, backache, shortness of breath at rest, chest pain, dizziness, difficulty swallowing, palpitation. Investigation: Blood test 5 times chest x-ray 3 times, ECG ( 6 times), ultrasound abdomin (2 times), CT scan abdomin( 2 times), upper Gi endoscopy (2 times), colonoscopy once ALL investigations were NORMAL HOW YOU WILL MANAGE AHMED ?

3. Both conditions are defined in both ICD-10 and DSM-IV Both disorders have stigma attached Symptoms are very real for the patients and often their families and the condition needs to be taken seriously Lack of physical diagnosis can be very frustrating for patients Never underestimate the effect it can have on you, the doctor Also a huge financial burden on health services But it really hurts Doctor....

4. Presentation of physical symptoms that are: unexplained after medical/physical examination (i.e., medically unexplained symptom). associated with significant concern, distress or impairment as a manifestation of psychological distress. Somatization: Definition

5. Up to a quarter of all new OPA are related to somatic symptoms More common in females than males (10X) Symptoms tend to manifest themselves by adolescence, established by age of 30 Incidence does not increase with age (Costa and McCrae) Established link with child abuse (Bowman 2000) Often fail to respond to treatment, show passive interest in finding a cure High co-morbidity with: – Depression (55%) – Anxiety Disorders (34%) – Personality Disorders (61%) – Panic Disorders (26%) Somatization Disorder

6. Somatization Disorder Exercise How many symptoms can you list?

7. symptoms VomitingAbdominal pain NauseaBloating DiarrhoeaPain in arms and legs Back painJoint pain DysuriaHeadaches Shortness of breathPalpitations Chest painDizziness AmnesiaDifficulty in swallowing Visual changesParalysis/muscle weakness Sexual apathyDyspareunia ImpotenceDysmenorrhoea Irregular menstruationMennorrhagia DeafnessSeizures Lump in the throatLoss of voice Basically a minefield!!!

8. The way we react to a patients somatic complaints can relieve them OR exacerbate them Study (Salmon 1999) on patients perspective on medical explanations showed 3 categories of doctors explanation with varying degrees of success: – Rejecting – Colluding التآمر – Involving The key is EMPOWERMENT

9. Somatization Disorder (Briquet’s Syndrome) ICD-10 45.0 Appearance of physical symptoms NOT accounted for by physical pathology or autonomic arousal Chronic course, often fluctuating Frequently consult with many different doctors seeking treatment, often with vague, inconsistent and disorganised medial histories. Has impaired social/work/personal functioning Symptoms may be exacerbated by stress No element of feigning symptoms to occupy sick role (Facititious Disorder) or for material gain (Malingerer)

10. Hypochondriasis DSM-IV 300.7 and ICD-10 45.2 Criteria: – Persistent belief in the presence of one or more serious illness underlying a presenting symptoms – Unable to accept reassurance from multiple doctors that there is no physical illness – Persistant for more than 6 months – Causing significant impairment/distress – Not delusional in intensity

11. Hypochondriasis Prevalence of 4.2-13.8% in general medical clinics Equal prevalence amongst men and women No increasing prevalence with age No geographical factors No evidence of genetic factors Maladaptive behaviour can contribute May be associated with childhood experiences (chronic/serious illness in pt or family members/missing school/traumatic experiences) May be associated with parental characteristics i.e. overprotectiveness Chronic stable condition

12. Hypochondriasis Kendall (1974) proposed that it could be explained by learned abnormal illness behaviour. Costa and McCrae (1985) demonstrated a link between hypochondriasis and neuroticism (emotional maladjustment) defined as – “ a broad dimension of NORMAL personality that encompasses a variety of specific traits, including self-consciousness, inability to inhibit cravings, and vulnerability to stress as well as the tendency to experience anxiety....” – Study consisting of 1000 pts looking at somatic complaints (Cornell Medical Index) and neuroticism (Emotional Stability Scale) showed that high levels of neuroticism was associated with higher levels of somatic complaints. – BUT cause or effect?

13. Hypochondriasis Common (and normal!) in society as short-lived ideas A frequently missed diagnosis ? Associated with profession? Primary (existing independently) Secondary: – Depression – Anxiety disorders – Delusional disorders – Schizophrenia – Dysthymic disorder – Organic brain disease

14. Hypochondriasis Very difficult to assess and diagnose, no negative/positive or pass/fail test available. A POSITIVE diagnosis – rather than continuing to exclude other diagnoses Methods have been introduced to identify traits leading to increased probability of presence of hypochondriasis: – Minnesota Multiphasic Personality Inventory (MMPI) uses 10 scales and specifically looks at hypochondriasis, also depression and hysteria among others. – Whitely Index

15. Hypochondriasis Despite being a stable chronic condition, there is an increased morbidity associated with it: – risks of complications from investigations (3 times more likely to be referred for further investigation) – side-effects from inappropriate treatments

16. Management Explain to the patient and family relationship between psych and somatic Empathic attitude Avoid unnecessary investigation Treat underlying depression and anxiety

17. Symptom variation provides teaching moments. “Goal of treatment is to figure out how you can control symptoms.” Describe the potential for stress to affect symptoms. – Normal stress reaction in terms of sympathetic arousal—the body’s “emergency mode.” – For example, digestive functions are “turned off” when stressed. If prolonged, results in digestive distress (e.g., pain, constipation, diarrhea).

18. Increased Activity Involvement – Combats stress (minimize functioning in emergency mode) – Improves overall mood (as we see in dep treatment) – Provides Distraction from somatic symptoms – Pain perception has a subjective component— improved mood and distraction reduce the experience of pain – Exercise has physiological effects that combat somatization and stress Do they get their daily dose of meaningful activity, productivity, and exercise? Behavioral Techniques

19. Assertiveness Techniques – What kinds of needs are asserted? – What kinds of needs are not? – Do they engage in combative communication patterns? Activity strategies and assertiveness help patients obtain reinforcement by behaviors other than illness behaviors.

20. Relaxation Techniques Directly acts on physical symptoms, given its effects on breathing, heart rate, muscle tension, etc. Patients report benefit soon upon learning the technique Helps with stress management Includes Diaphragmatic Breathing, Progressive Muscle Relaxation, Biofeedback Practice, Practice, Practice. – Practiced in session with patient, consecutively for a period of weeks (combined with practice at home).

21. Sleep Strategies – Establish consistent sleep patterns (same bedtime and waketime everyday) – Go to bed only when sleepy (stimulus control) – If not asleep within 20-30 minutes leave bed and return when sleep again (stimulus control) – Bed is only for sleep and sex. No TV, reading, etc. (stimulus control) – Comfortable sleep environment – Avoid alcohol/caffeine during 6 hours before bedtime – Exercise regularly, but not within 4 hours of bedtime Woolfolk and Allen (2007)

22. Cognitive Strategies Much like CBT for depression – Looking for adaptability of thoughts – Eliminating distortions Use somatic symptoms as anchors for examining thoughts Look for variations in adaptability of thoughts and discuss their effect Patients are likely to have difficulty identifying thoughts/emotions. Likely to have schemas that include health concern