Download Psychiatry—Chronic Pain and Somatoform Disorders

Psychiatry—Chronic Pain and Somatoform Disorders
Chronic Pain Syndrome
Chronic pain syndrome is a poorly-defined medical condition consisting of pain that is of a complex natural
history and unknown etiology. This syndrome is considered when pain persists for at least 3 months, or when its
duration continues beyond the expected healing time for the involved tissue.
While the chronic pain syndrome usually results from an initial organic pain condition (any noxious stimulus that
causes pain via myelinated alpha and unmyelinated delta and C-fibers), the continued, unrelieved pain characterizes this
syndrome. There are two purported factors thought to be associated with this syndrome:
Internal Reinforcers – emotions of guilt, or fear of work, sex, or responsibilities
External Reinforcers – increased attention from family and friends, increased socialization from physician/PA,
medication, compensation, and time off from work
Epidemiology
1) Prevalence – 35% have chronic pain
2) 49 million Americans are partially or totally disabled
3) Females >Males
4) Groups with disproportionately greater disability – ethnic distribution, elderly, lower socioeconomic group,
children living in poverty, and female headed households
Associated Contributory History and Risk Factors
1) History of loss – death or divorce
2) Prior traumatic life events
3) Increased stressors – financial, emotional
4) Physical or sexual abuse history
5) Concurrent and worsening psychiatric illness – major depression, anxiety disorder, somatoform disorders,
alcoholism or drug abuse
6) Termination of prior physician-patient contracts – history of “doctor shopping”, frustration and anger of previous
“ineffective care”, and high expectations for help from the new provider
7) Hidden agendas – narcotic seeking, disability, sick-role privilege, and legitimize illness to family and coworkers
Sternbach’s 6 D’s of Chronic Pain Syndrome
1) Dramatization of complaints
4) Dependency
2) Drug misuse
5) Depression
3) Dysfunction/disuse
6) Disability
History
Pain
1) A thorough history is necessary to direct further evaluation and appropriate consultations, and to avoid repeating
invasive and expensive procedures
2) Descriptors – OPPQRST
Past Medical History
1) Adult illnesses
2) Psychosocial history – occupational, family and marital problems, stressors, recreational/hobbies, religious
affiliation, sleep patterns/diet/exercise, drug/alcohol abuse, physical abuse, and social support systems
3) Sexual history
Physical
Waddell signs – used to indicated non-organic or psychological components of pain
1) Superficial tenderness – skin discomfort on light palpation
2) Non-anatomic tenderness – tenderness crossing multiple anatomic boundaries
3) Axial loading – eliciting pain when pressing down on the top of the patient’s head
4) Pain on stimulated rotation – rotating the shoulders and pelvis together should not be painful as it does not
stretch the structures of the back
5) Distracted straight leg raise – if a patient complains of pain on straight leg raise, but if the examiner extends the
knee with the patient seated (e.g. when checking Babinski reflex)
6) Regional sensory change – stocking sensory loss, or loss in an entire extremity or side of the body
7) Regional weakness – weakness that can be overpowered smoothly. Organic weakness will be jerky, with
intermittent resistance
8) Overreaction – exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is
given later
9) Detailed physical examination of the musculoskeletal, cardiovascular, GI, GU, reproductive, and neurological
systems are warranted
Diagnosis
6) UA
1) Review of prior studies
7) Urine toxicology
2) Utilize necessary diagnostics to confirm
8) Plain films
suspected diagnosis
9) CT scan
3) R/O life threatening illnesses
4) CBC and differential
10) MRI
5) Comprehensive/basic metabolic panel
11) EMG/NCV
Treatment
1) Underlying cause
2) Rehabilitation – physical therapy and exercise, hot and cold applications, TENS, massage, trigger point
injections, occupational therapy, recreational therapy, acupuncture, and chiropractic therapy
3) Surgery – nerve blocks, spinal cord stimulation, external or internal intrathecal morphine pumps
4) Pharmacological – OTCs, non-opiod, opiod, and BDZ
5) Psychophysiological – reassurance, counseling, relaxation therapy, stress management programs, biofeedback
6) Other – hypnosis
7) Appropriate referrals
Strategies
1) Do no suggest “it’s all in your head”
2) Do no order endless testing without indication – avoid unnecessary invasive tests or medications, avoid over
referring to specialists
3) Do not focus on symptoms (focus on function instead)
4) Establish long-term empathetic relationship
5) Schedule frequent visits
Prognosis
Poor Prognostic Factors
1) High frequency of physical complaints – somatization
2) Long history of frequent healthcare visits
Good Prognostic Factors Suggestive of Recovery
1) Brief history of chronic pain (<2 years)
3) Followed by primary care physicians
2) No underlying psychiatric disorder
SEE CHART!!!
Somatoform Disorders
Somatoform disorders are a group of disorders characterized by physical complaints and symptoms that suggest
a medical condition, but cannot be explained by a medical disorder, substance abuse, or mental disorder. It is thus
difficult to differentiate between a true organic process and a psychiatric illness. In addition, there is an element of
enmeshment; a legitimate medical complaint may lead to a psychiatric somatoform disorder as a coping mechanism, or a
psychiatric disorder may contribute to an organic complaint. While the pathophysiology of somatoform disorders is
unknown, there is speculation that a heightened awareness of normal bodily sensations and autonomic arousal may elicit
a cognitive bias. The production of the symptoms of illness is not intentional, and the motivation for illness is
unconscious.
Epidemiology
1) There are no definitive incidence and prevalence rates
2) Slight female predominance
Risk Factors
1) Genetic and environmental influences
3) Physical and sexual abuse
2) Parents with somatoform disorder
4) Poor ability to express emotions (alexithymia)
Somatization Disorder
Somatization disorder is characterized by the presentation of many physical symptoms affecting many organ
symptoms without any medical explanation (physical examination and laboratory testing). There are multiple and
chronic complaints of unexplained physical symptoms. Major depression, anxiety, and panic disorder are often present.
Characteristics
1) Multiple pain symptoms involving multiple sites, such as the head, neck, back, stomach, and limbs
2) At least 2 or more unexplained GI symptoms, such as nausea and indigestion
3) At least 1 sexual complaint and/or menstrual complaint
4) At least 1 pseudoneurological symptoms, such as blindness or inability to walk, speak, or move
5) Onset – younger than 30 years old
6) Women >> men (10-20:1)
7) Manage with frequent appointment
Hypochondriasis
Hypochondriasis is characterized by the patient’s belief or fear that he or she has some specific disease,
usually >6m. Despite constant reassurance the patient’s belief remains the same. Symptoms are often consistent
with patient’s conception of specific illness.
Characteristics
1) Onset is 20-30
4) Often a history of prior physical disease
2) Men = women
5) Causes significant distress and impairment
3) AA > Caucasian
Conversion Disorder
Conversion disorder is characterized by one or two neurological symptoms (sudden loss of neurological
function) e.g. inability to walk, sudden blindness, limb weakness, or paralysis, aphonia) affecting voluntary or sensory
function that cannot be explained by any known neurological disorder. Must have psychological factors
(Stressors) associated with the onset or exacerbation of the neurological symptoms
Characteristics
1) Onset – adolescents and young adults
2) Women – 2:1
3) More common among lower SES, rural populations, low IQ’s, and military personnel
4) Associated features – often a history of conversion or somatization disorder, modeling the symptom after
someone else with a similar presentation, a serious preceding emotional event, or underlying history of
depression, schizophrenia, or personality disorder
Pain Disorder
Pain disorder is characterized by the presence of pain in one or more bodily sites. Psychological factors
must be present in the onset, exacerbation, or continuation of the pain. Complaints of pain are inconsistent with
anatomic and clinical signs.
Characteristics
1) Onset – 40-50
4) Coexisting depression, anxiety, and substance
2) Women > men
abuse may be present
3) More common among persons with blue-collar jobs
Body Dysmorphic Disorder
Body dysmorphic disorder is characterized by the belief that some body part is abnormal, defective, or
misshapen, and is not evident to other. There is a preoccupation with an imagined defect in appearance. If a
slight physical anomaly is present, the person’s concern is markedly excessive
Characteristics
1) Most common age of onset is between 15-20
2) Women > men, likely to be unmarried
3) Often a personal history of depression, anxiety, and psychotic disorders
4) Family history of depression and OCD
5) Associated with multiple, frantic, and unsuccessful attempts to correct imagined defect by cosmetic surgery
Diagnosis
1) Physical exam findings are either negative or incongruent to complaints
2) Initially, it must be accepted that the patient’s distress is real
3) Utilize laboratory and imaging testing as indicated
4) Avoid invasive diagnostic procedures and aggressive surgical assessment
5) Minnesota Multiphasic Personality Inventory (MMPI) testing
Approach to the Patient with Somatoform Disorders
1) Build trust with patient to facilitate a therapeutic relationship
2) Realize that not every problem not found to have an organic basis is NOT necessarily a mental disease
3) Patient reassurance
4) Schedule regular, frequent, but short appointments – drugs are not meant to replace visits. Avoid excessive
referrals; one primary physician/PA is the preferred route
5) Utilize patient diaries
6) Psychoeducation – physical complaints may be exacerbated by anxiety and emotional problems, related
symptoms to adverse developments in the patients life
7) Psychologic therapy – hypnosis, group therapy
8) Behavioral therapy – biofeedback
9) Social support – family and coworker involvement
10) Pharmacotherapy – pain and body dysmorphic disorders (analgesia, TCAs, SSRIs, and MAO-Is)
11) Referrals – psychiatry
12) Follow CPS strategies
13) Best prognosis with early intervention
Factitious Disorders
Factitious disorders are characterized by the conscious production of signs and symptoms of both medical
and mental disorders. The main objective is to assume the sick role, and possible eventual hospitalization. The
pathophysiology of FD is unclear, and symptoms are produced intentionally but for unconscious reasons.
DSM –IV Criteria
1) Intentional production or feigning of physical or psychological signs or symptoms
2) Motivation for the behavior is to assume the sick role (primary gain)
3) Absence of external incentives for the behavior (secondary gain: economic gain, avoiding legal responsibility,
improving physical well-being, as in malingering
Malingering is not a mental disorder, nor a factitious disorder. It is the intentional and conscious
production of signs and symptoms for an obvious gain. Symptom motivation is also conscious: money, avoid
work, evading the police, free bed and board.
Two well-known examples are Munchausen syndrome (chronic FD) and Munchausen syndrome by proxy (the
intentional production or feigning of physical or psychological signs or symptoms in another person who is under the
individual’s care, i.e. mother through her child).
Epidemiology
1) Reliable percentages are not available
2) Overall FD and Munchausen syndrome by proxy more common in women aged 20-40
3) Chronic FD (Munchausen syndrome) more common in middle-aged men
Risk Factors
1) Hospital and health care workers – knowledge of textbook descriptions of illness, an unusual grasp of medical
terminology
2) Underlying psychological illness
Manifestations, Mechanisms, and Course
1) Dramatic or atypical presentation
2) Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
3) Symptoms or behaviors only present when the patient is being observed
4) Fluctuating clinical course – rapid development of complications or a new pathology if the initial workup findings
prove negative
5) Long medical record with multiple admissions at various hospitals in different cities
6) Presentation in the ED during times when obtaining old medical records is hampered or when experienced staff
are less likely to be present (holidays, late Friday afternoons)
7) FD – self-mutilation, fever (injecting bacteria to produce infection), hematuria (adding exogenous blood to urine),
hemorrhage, hypoglycemia (exogenous administration of insulin), ingesting CNS-active medications to induce
psychiatric symptoms, seizures, nephrolithiasis, un-witnessed syncopal episodes
8) Munchausen syndrome by proxy – child apnea, evidence of suspected child abuse
Diagnosis
1) FD is often a late diagnosis, after extensive diagnostic modalities to r/o organic pathologies have been employed
2) Helpful diagnostic methods – hypoglycemia (increased serum insulin/C-peptide ration (>1.0) during a
hypoglycemic episode), tissue biopsy for suspected false lesions, or nephrolithiasis (urine filtration and
composition analysis)
Treatment
4) Gentle, supportive confrontation
1) Psychiatric referral
2) Psychotherapy/cognitive-behavioral therapy
5) Treat underlying psychiatric disorders
3) Patient and family education
Complications
1) Wasted resources, iatrogenic