Download Somatoform Disorder or Medically Unexplained Symptoms

Somatoform Disorder
or
Medically Unexplained Symptoms
Bruce Slater, MD, MPH
Associate Professor (CHS)
University of Wisconsin
School of Medicine
May 25, 2005
Learning Objectives
• Discuss Several Theories of Somatoform
Disorder
• List Techniques for Recognizing
Somatoform Disorder
• Review Treatment Approaches for Patients
With Medically Unexplained Symptoms
May 25, 2005
Financial Disclosure
• No Financial Support
May 25, 2005
Case Presentation
• 12 Visits Over 9 Months for Abdominal
Pain
• Apparently Unnecessary Treatment for
Presumed Disease
• Extensive Diagnostic Evaluation
• Several Consultants
May 25, 2005
Clinical Features of Case
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Slowly Evolving Nature of Symptoms
Contradictory Symptomatology
Minimal Secondary Gain
Underlying Anxiety Uncovered
May 25, 2005
Historical Origins
• Dark Ages Organ Based Explanations of
Disease
• Uterus Frequently Blamed for MUS
• Hysterical Symptoms
• 1667 Thomas Willis - ? Brain Involvement
• 1889 Charcot ?Nervous Center Lesion
• Babinski/Freud Psychological Explanations
May 25, 2005
(Loose) Diagnostic Criteria
• Several Non-specific Symptoms in
Different Organ Systems
• Chronic Course
• Frequently Co-morbid for Psychiatric
Disease
• Ten Times More Common in Women
• Fully Developed by Age 30
May 25, 2005
Diagnostic Criteria
• Diagnostic and Statistical Manual (DSM IV)
– Multiple Recurring Pains and Symptoms
• Gastrointestinal
• Sexual
• Pseudoneurological
– Occurring Over a Period of Years
– Not Intentionally Induced
– Significance
• Result in Medical Attention
• Functional Impairment
May 25, 2005
Therapeutic Approach
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Empathy
Rational Reassurance
Evaluation of Equivocal Symptoms
Symptom Based Care
Emphasize Return to Normal Activities
Approach Psychiatric Disease Separately
Treat Psychiatric Disease Actively
May 25, 2005
Therapeutic Approach (Details)
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Step 1 Set Stage, Intro, Ensure Comfort
Step 2 Agenda (Constraints, the List, Negotiate)
Step 3 HPI Open Ended, Non-focused, Gather Data
Step 4 Focus on Symptoms, Context, Emotion,
Address Emotion
• Step 5 Transition – Summary, Check, Assess
Readiness to Change Focus to Physician Centered
May 25, 2005
From RC Smith, et al. JGIM 2003
Interesting Findings and Theories
• Patients With Irritable Bowel Are Sensitive
to Distention in the Gut, but Not As
Sensitive to Pain From Skin.
• Increased Anxiety Is Associated With
Increased Pain (Battlefield Versus Mva)
• Adrenaline Released at Sympathetic Nerve
Endings May Sensitize Nociceptors and
Trigger Somatic Muscle Tension Reflexes
May 25, 2005
May 25, 2005
From Wilhelmsen, Gut 2000;47
(Suppl 4);iv5-iv7(December)
More Interesting Theories
• Amplification of Bodily Sensations
– Panic Attacks
– Somatisation
• Family Dynamics and the Identified Patient
• The Need to Be Sick
• Dissociation
– (Sensory Experience in the Absence of Sensory
Stimulation)
May 25, 2005
From D Servan-Schreiber AFP 2000
Summary
• Evolving Concepts
• Frequent in Minor Incomplete “Form Frust”
• Rule Out Disease for Rational And/or
Potentially Serious Symptoms
• Understand the Patient With the Disease
• Care Not Cure
May 25, 2005
Questions for Me?
Questions for You
• Do You Enjoy Seeing Patients With Mus?
• What Diagnostic Clues Can You Add?
• What Have You Tried Therapeutically?
May 25, 2005
References
• Brain-gut Axis As an Example of the Bio-psycho-social
Model. I Wilhelmsen, Gut 2000;47(Suppl IV):Iv5-iv7
(December)
• Treating Patients With Medically Unexplained Symptoms
in Primary Care. RC Smith. J Gen Intern Med 18:478-488.
June 2003
• Somatizing Patients: Part I. Practical Diagnosis.
D Servan-Schreiber, et al. Am Fam Physician 61/4;
pp. 1073-1079 2/15/2000.
May 25, 2005