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Transcript
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 • • • • 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 • • • • • • • 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) • • • • 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