Download Somatization Patients with multiple symptoms

“Unexplained illness”
Managing somatization:
art & evidence
Norman Jensen MD MS
Professor, General Internal Medicine
University of Wisconsin - Madison
[email protected]
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Workshop Schedule
1:00
1:15
2:00
2:50
3:00
3:45
4:15
4:30
Intro & Learning Objectives
Case Talk
Didactic
Break
Skills demonstration
Skills work - small groups
Summary & assessment
Adjourn
Somatization ILO s

Enhancement of
– Clinical concept of somatization
`definitions
 pathophysiology
 epidemiology
 diagnosis

– Medical management

The practical and the evidence
– Communication with patient
Unexplained Illness
 How
can it be explained?
 How can I be a good doctor when
I can’t explain my patient’s
symptoms?
 What is the evidence for effective
management?
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
Somatization, a definition

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
Somatization Disorder 300.81

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
Somatization Disorder 300.81

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.
Somatization Disorder 300.81

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.

D. Not intentionally produced / feigned.
Undifferentiated
Somatoform Disorder 300.81
AKA, sub-threshold or abridged SD, or
somatization syndrome
 One or more symptom
– medically unexplained, or
– beyond expectation from known
pathology
Causing distress or dysfunction
 Duration => 6 months

Suffering in somatoform illness
Disease
Sickness
Illness
“By golly, you ARE crying on the inside!”
Theoretical Mechanisms: Neurobiologic

Variable CNS modulation of incoming
sensory information, e.g.,
– conversion = excessive inhibition
– somatization = inadequate inhibition.


Melzack R & Wall P. Pain mechanisms: A new theory. Science.
1965;150:971-979
Wall P. The gate control theory of pain mechanisms: a reexamination and re-statement. Brain. 1978;101:1-18.
Attention, emotion,
memories of prior
experience
Central
Control
L
+
SG
SG
-
-+
T
- +
Action
System
s
Gate Control System - Melzack & Wall, Science 1965
SG = Substantia Gelatinosa in dorsal horn
Harrison’s Textbook of Internal Medicine
1962 (4th) & 1970 (6th)
1983 (10th)
Harrison’s Textbook of Internal Medicine
Afferent
Efferent
1987 (11th) & 1991 (12th)
1994 (13th) & 1998 (14th)
The
“Pain
Matrix”
“Pain sensitivity linked to gene”
Wisconsin State Journal 1999
muOR: thalamus and spinal cord
 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.
NMDA – Receptor
N-methyl-D-aspartate

Hypotheses
– Involved in neuropathic pain
– Antagonists block “Opioid insensitive”
component


Dextromethorphan
d-methadone
– NMDA antagonist & Opioid agonists



(dl) Methadone
Dextropropoyphene
ketobemidone
Theoretical Mechanisms: Neurobiologic

Alexithymia, a cognitive-affective disturbance
characterized by difficulties in verbally
expressing moods, symbols, and feelings.

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

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”
Theoretical Mechanisms:
Social-psychological

Psychological
(nature)
– needs for nurturance & support
– “defense mechanisms” that resolve conflict

Social-cultural
(nurture)
– SICK ROLE (1° gain)
– CULTURAL CORRECTNESS



parents (“big kids don’t cry”)
CLINICIANS - “Balint agreement”, “this won’t hurt”
teachers, clergy, peers, etc.
Contexts of Somatization
normal daily experience
 highly situational
 marked individual differences
 marked cultural differences
 associated with ΨS stress
 associated with DSM disorders

SD: Epidemiology

Community prevalence
DSM IV
– 0.2 - 2.0% for women
– ~ < 0.2% for men

Primary care prevalence
– Somatization
– Somatization disorder
– Hypochondriasis
25 - 75%
?
~3%
Impact on Personal Health

Illness behavior
– Social function

Role function
– Mental functioning

Sense of well being
– Physical functioning

Bed days
slide in development
Impact on Health Services

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.
Impact on Physicians’ Attitudes
Gorlin: helplessness, loss of control,
inadequacy, impotence, frustration,
threatened authority, anger, and
guild.
 Groves: aversion, fear / counterattack, guilt, inadequacy, malice,
wish that patients would “die and get
it over with”.

Medical Management
Principle components
Patient education
 Risk of a missed “organic” diagnosis
 Medical resource conservation
 Protect patient from medical injury
 Use of consultants
 Care for the doctor

Management:
Patient Education

Give the illness a name
– abnormal nervous system
– leaky gates, weak editing / noise filtering
– give examples from ordinary experience

Postpone psychological interpretation
– resistance prone by nature or nurture
– hypersensitive to doubt of sx reality
– expect slow or no insight
Management:
RISK of MISSED DX

Share the diagnostic risk with patient
– Document discussion in medical record

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
Management:
Resource conservation
Limit: ER, urgent care, walk-ins,
and phone calls - contract if needed.
 Raised threshold for tests, images,
drugs, surgery, procedures
 Substitute old-fashioned doctoring

– empathic listening / witnessing
– liberal physical exam
– reliable, accepting, helping relationship
Management:
Protect the patient

Marginal tests
– especially invasive tests

Marginal treatments
– toxicity
– polypharmacy
Excess expense
 Assert your primary care role

Management:
Use of Consultants




Carefully explain purpose.
Assure your ongoing commitment -“expert advice helps me be the best
possible doctor for you”.
Psychiatry consultant helps diagnose comorbid DSM disorders.
Prepare consultants so they too will
judiciously use tests, procedures, drugs.
Management:
Caring for the doctor


These patients consume energy
Confront and cope with negative responses
– learn professional emotion handling skills



Seek support of colleagues, formal or informal
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.
Management that WORKS
What is the Evidence ?
 Consult-advice
CBT for patient
CBT training for MD
Drug Therapy
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.
Intervention

Psychiatric consultation letter
– described somatization disorder
– MD encouraged to serve as primary
– management suggestions
regular visits, q 4-6 weeks
 physical exam at each visit
 avoid hosp., procedures, surgery, tests
 avoid, “it’s all in your head”

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
 physical
3 51 58 SD 33
 physical
12
Evidence that CBT works
Kroenke, Psychother Psychosom 2000;69(4):205-215.
All
Somatic
Distress
Psych
Distress
Function
N
% All Studies
31
Improve Improve
Definite
Possible
28
71
11
26
38
8
19
47
26
Rx: Training 1 Physicians

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.

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,  patientinitiated consultations,  cost variation
per patient. 1/3 pts  mental function,
disqualifying as “mental”.
Drug Therapy
Insufficient evidence to recommend.
 Small trials show interest for

–
–
–
–
tricyclic antidepressants
fluvoxamine
gabapentin
anti-psychotics (if psychosis)
The abstract ends here!
Questions?
Answers
$0.25
Answers requiring thought $1.00
Correct answers
$2.50
Comments?
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
Skills
Demonstrations
Discussion to Follow
Skills Demonstration
46 y/o woman who has had multiple
waxing and waning sx for > 15 years.
 We’ve done a complete hx & pe and
reviewed large stack of tests and
images. Everything we’d have wanted
has been done.
 Her diagnosis is very clearly
Somatoform Disorder, 300.81.
 We must now inform & motivate this
patient for management.

Skills Practice - evaluation
There are lots of good ways to communicate
 Take
time out anytime
– For reflection
– Ask for help
 How
well did it work?
– Well enough? Why & how?
– Less well? Alternative actions?
 Feedback:
Ask - Tell - Ask
Skills Practice

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.
Summary & Assessment
 Take-home
 Please
learning?
complete evaluations.
 Thanks
for coming!
END of WORKSHOP

Additional information slides follow
Usual symptoms

Gastrointestinal (other than pain)
– nausea & bloating most common
– vomiting, diarrhea, food intolerance

Sexual - reproductive
– women: metrorrhagia, menorrhagia,
vomiting throughout pregnancy, sexual
indifference
– men: “E D”, ejaculatory dysfunction,
sexual indifference
Usual symptoms

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
DSM disorders associated
with somatization
 Mood
 Anxiety
 AODA
 Adjustment
SD: Epidemiology, cont.

Family coincidence ( 1° rel.) DSM IV
– women, 10-20% S D
– men,  antisocial and AODA
Impact on Health Services II



Collyer 1979, FP: 28% visits involved
emotional illness, taking 48% of his time;
3.6% families too 32% his time.
Katon 1984: 25-75% 1° care visits were
caused by somatized Ψ-S stress; these
patients take time 2-4 X non-somatizing
patients.
Burnum 1985, IM: Over 3 mos. 98/909 pts.
had major Ψ-S problems, 65 combined
with physical disease.
Impact on Health Services III

Regier 1984, citizens with any of 13
DSM disorders, 58% had seen their
1°MD in prior 6 mos -- used medical
care 2X normal.

NAMCS 1978 & 1985: 70% pts with
DX’d DSM disorders gave a somatic
complaint as CC for MD visits.

(Regier 1978, Schurman 1985)
Impact on
Physicians’ Attitude

Katon, et.al: physicians found
somatizing patients to be signif.
more frustrating than other high
utilizing HMO patients.
Managing Somatization
Dx: complete problem list
 Doctor - patient relationship
 Patient education
 Cope: doctor anger, anxiety & fatigue

missed diagnosis
 time & energy requirements

Conserve resources
 Care for the doctor

Management
First Principles



Observe adjustment responses.
DX and RX mood and anxiety disorders.
Doctor-Patient Relationship is central!
– Commitment: chronic care & realistic goals
– Rogerian helping relationship

accepting, empathic, congruent
(Carl Rogers)
Treatment Effects I

Smith RG, NEJM 1986;314:1407-13

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.
Treatment Effects II


Rost K, et.al. General Hospital Psychiatry 1994;16:381-7.
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.
Treatment Effects III

Smith GR, et.al. Arch Gen Psychiatry 1995;52:238-43.

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.
Treatment Effects IV

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.

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.
Treatment Effects V

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.

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.
Treatment Effects VI

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.

RCT 80 PC somatizing patients. At 6mo. CBT subjects  HMO visits, Ψsx &
somatic sx. Effective therapy =~
teaching pts about the relationship
among thoughts, behaviors and sx.
Treatment Effects VII
RCT group therapy with 70 SD patients, 8
sessions + consultation to primary doctor
 Better physical and mental health at 1yr
 Improvement :: # sessions attended
 52% net savings in health care charges


Kashner, T.M., Rost, K. Enhancing the health of
somatization disorder patients. Effectiveness of
short-term group therapy. Psychosomatics.
36(5):462-470, 1995.
Hypochondriasis 300.7






Preoccupation with fears of having, or the
idea that one has, a serious disease based
on misinterpretation of symptoms.
Despite medical evaluation and
reassurance.
Not delusional.
Causes distress or impairment in function
For at least 6 months
Not better explained by another DSM
disorder.
Conversion Disorder 300.11

A motor or sensory dysfunction that suggests
neurological or medical disease
Psychological factors precede onset or
exacerbation.
Not intentionally produced or feigned.
Cannot be fully explained by a organic disease,
direct effects of a substance, or culturally
sanctioned behavior.
Causes distress or impairment.
Not limited to pain or sexual dysfunction,

Not better explained by another DSM disorder.





Body Dysmorphic Disorder
300.7
 A.
Preoccupation with an
imagined or exaggerated defect
in appearance.
 B. Causes distress or
impairment.
 C. Not better accounted for by
another DSM disorder.
Somatoform Disorder, NOS
300.81
Does not meet criteria for any S D
Pseudocyesis
 Hypochondriacal symptoms < 6
months
 Somatoform symptoms < 6 months

Somatoform Pain Disorder
307.80 with psychological factors
307.89 with both psych. factors and medical condition





Pain in one or more sites as the main
warrant for clinical consultation.
Causes distress or impairment.
Psychological factors judged to have
important etiologic or mechanistic role
Not intentionally produced or feigned.
Not better accounted for by another DSM
disorder
Skills Practice - evaluation
There are lots of good ways to communicate
How well did it work? (score?)
 If it worked well, what happened?
 If it didn’t work as well as I’d like,
what might I do differently next time?
 You can take time out anytime.
 You can ask the group for help.

Workshop Schedule - 105 min.
3:30 Intro & Learning Objectives
3:35 Case Talk
3:50 Didactic
4:10 Skills demonstration
4:20 Skills work - small groups
5:00 Summary & assessment
5:15 Adjourn