Identifying and Treating Somatic Symptom Disorder in the Primary Care Setting Presented by: Ruth Tadesse, MS, RN Date: 4/02/2015 1 1

Learning Objectives: Disclosures and Learning Objectives Identify 3 common types of somatization seen in primary care setting Know DSM 5 criteria used to diagnose Somatic Symptom Disorder Identify at least 2 assessment tools used to diagnose somatic symptom disorder List at least 4 treatment methods used to manage somatic symptom disorder. Disclosures: Ruth Tadesse has nothing to disclose. 2 2

Historical Background and Changes from DSM III to DSM 5 (Dimsdale, J. E., et al. 2013) Somatoform Disorder Somatic Symptom Disorder First introduced 30yrs ago in DSM-III as Somatoform Disorder. Somatoform didn’t translate to another language well DSM-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 Disorders The 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. http://www.dsm5.org/documents/somatic%20symptom%20disorder%20fact%20sheet.pdf Somatic Symptom Disorder Fact Sheet.pdf

Differences from DSM IV to DSM 5 (Dimsdale, J. E., et al. 2013) DSM IV Somatoform Disorder DSM 5 - Somatic Symptom Disorder and related disorders Somatic Symptom Disorder Illness Anxiety Disorder Conversion Disorder Psychological factors affecting a medical condition Factitious Disorder Other specific and nonspecific somatic symptom disorders Somatization Disorder Undifferentiated Somatoform Disorder Conversion Disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder Somatoform Disorder NOS

Somatic Symptom Disorders and Other Related Disorders http://emedicine.medscape.com/article/294908-overview

Somatic 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

DSM 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 of one's symptoms. 2) Persistently high level of anxiety about health or symptoms. 3) Excessive time and energy devoted to these symptoms or health concerns. 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 Mental Disorders. (5th ed.) Washington, DC: American Psychiatric Association Press. p. 309–27.  

Case Study – Ms. B Ms. 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.

Case Study – Ms. B If 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?

Somatic Symptom Disorder - Pathophysiology Pathophysiology is unknown Associated with a heightened awareness of normal bodily sensations which maybe paired with a cognitive bias to interpret any physical symptom as indicative of medical illness Some tend to have autonomic arousal Brain imaging shows reduced volume of amygdala Comorbidity – depressive disorders, anxiety disorders, substance use, and personality disorders Somatic complaints epidemiology and psychiatric co-morbidity.pdf http://emedicine.medscape.com/article/294908-overview#a0104

Somatic Symptom Disorder - Epidemiology Somatic Symptom Disorder Prevalence Community sample – 0.1% Medical chart review show prevalence rate in women as 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 disease Female-to-Male ratio is 10:1 Symptoms usually begin in childhood, adolescence or early adulthood Somatic complaints epidemiology and psychiatric co-morbidity.pdf http://emedicine.medscape.com/article/294908-overview#a0199

Common types of somatization seen in primary care (Croicu, C. , et al Acute somatization - Temporary production of physical symptoms associated with transient stressors 2. Relapsing somatization - Repeated episodes of physical symptoms associated with repetitive stressors & anxiety or depressive episodes 3. Chronic somatization - Nearly continuous somatic focus, perception of ill health, development of disability Approach to the patient with multiple somatic symptoms.pdf

Assessing for Somatic Symptom Disorder Using the 3-Ps (Croicu C, et al Predisposing Chronic childhood illnesses, childhood adversities, comorbid medical illness, lifetime psychiatric diagnosis, poor coping ability - Precipitating Medical illness, psychiatric disorder, social & occupation stress, and changes in social support Perpetuating Chronic stressors, maladaptive coping skills, negative health habits, and disability payments Approach to the patient with multiple somatic symptoms.pdf

Assessing 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 5 Clinical predictors of mental disorders among medical outpatients.pdf Validation of the S4 Model.pdf

Identifying Somatic Symptom Disorder (Croicu C, et al. 2014) Do a thorough history and detailed physical assessment Rule out medical illness Consider medication side effects Identify ability to meet basic needs Identify secondary gains Identify ability to communicate emotional needs Determine substance use Build therapeutic alliance with the patient Use screening tools appropriate for somatic symptom disorder: SSS-8 and PHQ-15 Approach to the patient with multiple somatic symptoms.pdf

The BATHE Technique B: 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.pdf Approach to the patient with multiple somatic symptoms.pdf

PHQ-15 - Screening for Somatic Symptom Presence and Severity   Not bothered at all (0) Bothered a little (1) lot (2) a. Stomach pain  b. Back pain c. Pain in your arms, legs, or joints (knees, hips, etc.) d. Menstrual cramps or other problems with your periods WOMEN ONLY e. Headaches f. Chest pain g. Dizziness h. Fainting spells i. Feeling your heart pound or race j. Shortness of breath k. Pain or problems during sexual intercourse l. Constipation, loose bowels, or diarrhea m. Nausea, gas, or indigestion n. Feeling tired or having low energy o. Trouble sleeping Scores 0-2 for each item, making the total 0-30; 5 = low; 10=moderate; and 15 = high somatic symptom severity http://www.phqscreeners.com/instructions/instructions.pdf http://www.phqscreeners.com/pdfs/04_PHQ-15/English.pdf

Somatic Symptom Scale – 8 [SSS-8] (Table is hyperlinked)

Essential Treatment Approaches for Patients with Somatic Symptom Disorder (Croicu, C., et al. 2014) Schedule time-limited regular appointments (e.g. 4-6 weeks) to address complaints Explain that although there may not be a reason for their symptoms, you will work together to improve their functioning as much as possible Educate patients how psychosocial stressors and symptoms interact Avoid comments like “Your symptoms are all psychological.” or “There is nothing wrong with you medically.” Approach to the patient with multiple somatic symptoms.pdf

Essential Treatment Approaches for Patients with Somatic Symptom Disorder (Croicu, C., et al. 2014) Avoid the temptation to order unnecessary, repetitive, or invasive investigations Educate the patient on how to cope with their symptoms instead of focusing on a cure Evaluate somatic symptom burden Collaborate with the patient in setting treatment goals Screen for common psychiatric conditions associated with somatic complaints such as depression and anxiety Treat identified comorbid psychiatric disorders Approach to the patient with multiple somatic symptoms.pdf

Essential Treatment Approaches for Patients with Somatic Symptom Disorder (Croicu, C., et al. 2014) Case management to minimize economic impact Medications to treat anxiety and depression (SSRIs) Short term use of anxiety meds (dependence is a risk) Non-pharmacological treatments *CBT – Shows promising evidence Psychodynamic therapy Integrative therapy Approach to the patient with multiple somatic symptoms.pdf http://www.sciencedirect.com.liboff.ohsu.edu/science/article/pii/S0025712514000959

Summary Scheduling 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 somatic complaints improves outcomes.

References American 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): 1079-1095. Dimsdale, J. E., Creed F., Escobar, J., …Levenson, J. (2013). Somatic symptom disorder: An important change in DSM. Journal of Pscyhosomatic Research. 75(3): 223-228. DSM V Somatic Symptom Disorder Fact Sheet available online http://www.dsm5.org/documents/somatic%20symptom%20disorder%20fact%20sheet.pdf 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): 399- 407. 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)

References 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): 34-43 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): 294-303. Ravesteign, H., Wittkampf, K., Lucassen, P., …,Weel, C. (2009). Detecting somatoform disorders in primary care with the PHQ-15. Annals of Family Medicine. 7: 232-238. 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.CD011142-CD011142

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