Download Somatisation medical students

Somatisation
Dr Eugene Cassidy
Somatisation
• The expression of personal and social distress in an
idiom of bodily complaints with medical help seeking
• A culturally determined mechanism of expressing
psychological problems in a more socially acceptable
form
• A process rather than a diagnosis
• Classification of ‘disorders’ currently unhelpful
Overview of ‘functional’ illness
• Symptoms
• Syndromes
• Disorders
• Feigned illness
Functional Somatic Symptoms
• 3.4 symptoms per person general population
over previous 2 years (Rief et al, 2001)
• Pain and Fatigue most common
• Medical OPD 52% presenting symptoms MUS
(Nimnuan et al, 2001)
Functional somatic syndromes (1)
Gastroenterology
IBS/ Functional dyspepsia
Cardiology
Non-Cardiac chest pain
Neurology
Chronic Headache / CFS
Rheumatology
Fibromyalgia / CRPS
Gynaecology
Chronic pelvic pain
Orthopaedics
Chronic back pain
Dental
TMJ dysfunction
Immunology
Multiple Chemical Sensitivity
Functional somatic syndromes (2)
General Population:
•27% have CFS, IBS, CWP or CO-FP
•1% all 4 (Aggarwal et al, 2006)
Medical OPD:
•56% (Nimnuan et al, 2001)
- There is only one …….. (Wessely, 1999)
Disorders
• Mood disorders
• Somatoform disorders
• Somatoform-like disorders
Somatoform-like disorders
• Malingering
– feigned illness; conscious gain
• Factitious disorder (Personal / By proxy)
– feigned illness; no conscious gain
Somatoform disorders
• Symptoms suggestive of a medical disorder
but are medically unexplained
• Disabling
• May be severe, of long duration and involve multiple
symptoms
– ie Somatisation disorder
Somatoform disorders
• Categorical Classification unhelpful
–
–
–
–
–
–
Somatisation disorder
Pain Disorder
Hypochondriasis
Body Dysmorphic Disorder
Dissociative / Conversion disorders
Syndromes overlap
• Chronic Fatigue syndrome
• FMS
Somatisation is typically
not
consciously elaborated
But…. isn’t it human nature to
exaggerate/make ourselves heard?
The Cost of Somatisation (1)
•More visits
•More admission days
•More ED attendances
•More procedures
•Annual US healthcare
costs doubled
(Barsky et al, 2005)
• 456
appendicectomies
• followed for at least
15 years
(Dummett et al, 2002)
Normal
Inflamed
•Attendance
6.5/100 yrs
3.4/100yrs
•DSH
7.9%
2.2%
•Psych attendance
10.5%
4.0%
‘PSEUDO-STATUS’
Walker et al, 1996
• 54% Status Epilepticus
• 23% Encephalopathy
• 23% ‘Pseudostatus’
(majority intubated)
‘PSEUDO-STATUS’
Walker et al, 1996
54% Status Epilepticus
23% Encephalopathy
23% ‘Pseudostatus’ (majority intubated)
The Cost of Somatisation (2)
Somatization Disorder
•7 days per month in bed
(Smith et al, 1986)
•10% wheelchair-bound
(Bass & Murphy, 1991)
Somatisation is associated with
•
•
•
•
•
•
•
•
•
•
Gender
Childhood adversity
Parenting
Cultural factors
Gain
Life events / dilemmas
Depression
Litigation
Iatrogenic factors
Physical deconditioning
Women report more somatic symptoms
(Kroenke & Spitzer, 1998)
•1000 patients PRIME-MD interview
•13 common symptoms
•10/13 common symptoms more common in women
•OR (adjusted for anxiety, depression) 1.5-2.5
Pain & Childhood Trauma
(McBeth et al, 1999)
• Adult general population
• Distress (GHQ>1)
• High Tender point count (1/3) related to:
•Abuse
(OR 6.9)
•Parental
loss (OR 2.1)
•Female
(OR 3.5)
•Illness
behaviour (OR 2.3)
Fatigue and Childhood trauma
• Population based study (n=56146)
• 43 CFS V 60 controls
• Childhood trauma
– Increased CFS (OR 3-8)
– More severe CFS
(Heim et al, 2006)
Parenting (Craig et al, 2004)
•Parental focus on health
•Maternal somatisation
•Parental Illness
•Enhanced parental focus on
health
•Maternal somatisation
•Parental Illness
Parental Illness
• National birth cohort study (n=5362) followed from 1946
until 1989
• Predictors of adult somatisation:

Childhood MUS

Maternal reports of below average health in father
‘Even ill-health, though it has
annihilated several years of my life,
has saved me from the distractions of
society and amusement’
In the Darwin family tradition: another look at Charles Darwin's ill
health (Katz-Sidlow, J Royal Soc Med, 1998)
Pain is increasing
Harkness et al, 2005
• low back, shoulder and widespread pain now
2-4 times higher in the UK than 40 years ago
•True increase?
• Increased psychological distress
• Increased reporting & awareness
• x 7-11 sickness benefit rate
• x 3 number of solicitors
The late whiplash
syndrome is influenced
by cultural expectation
Schrader et al, 1996
Secondary gain
• Part of their strategy for dealing with life
• Disability may hold advantages
–Material
–Care and attention
–Excuse for avoidance
–Social mystique
• Look for ‘diagnosis’ not ‘cure’
Any alternative to taking the sensible correct path
forward was inconceivable
I remember the day when I knew I was going down
with some kind of illness.
I talked to Mum about it..realising that although I
didn’t feel too ill at the time, it was on its way.
I don’t know why I was so sure I was going to be ill.
It was a month before I set foot outside the front door
again. I would gaze outside and worry tormenting
myself about recovering the energy to complete those
final weeks at school before the A-levels
(Watching Whitbread Cup on TV).
With a feeling of most intense energy and clarity, I
suddenly realised that there was another way. In an
instant my exam pressures evaporated.
From then on my illness was somehow different
‘Taking on the World’
‘Jean Van de Velde suffering
from unknown illness’
‘A mysterious ailment that
has his doctors puzzled’
‘After a good start to the season with
good performances in Thailand, I’m
physically out of shape. I feel ill. I’m
basically very tired. I have muscle
pains and am frequently sick.’
‘There’s a big question mark on the
reason for this illness. I went through
several medical exams but the doctors
can’t quite seem to find a reason. I hit
balls for half an hour and then have to
stop because I’m just too tired.’
"To be really honest, I think my
health is more important than
playing in a golf tournament,"
Physician know thyself
Veysman, B. BMJ 2005;331:1529
Likes / Hates adults & children equally
GP?
Pain and Depression co-occur
92% of 150 patients about to be hospitalised with
major depression in France had at least one painful
symptom and 75% had several painful symptoms
(Corruble, 2000)
Depression and somatic symptoms
• Large WHO study in primary
care (n=25,916)
•10.1 percent had major depression.
 45-95% of depressed patients
reported only somatic symptoms
 Half the depressed patients reported
multiple unexplained somatic
symptoms
Gender and ‘Somatic’ Depression
• National Co-morbidity and ECA studies
• Pure (non-somatic) depression (m=f)
• Anxious somatic depression
– Female>male
– Earlier onset
– Pain
– Anxiety
Silverstein, 2002
DENIAL
Culture did not effect the likelihood of a somatic presentation
Only 11 percent denied psychological symptoms of depression
Predictors of Chronic Pain
• Clinic based studies
• Crossectional
• Population-based prospective study
–
–
–
–
• McBeth et al, 2001
Female
Non-pain somatic symptoms (OR 3.8)
Illness behaviour (OR 8.7)
Psychological Distress (OR 2.0)
Chronic Pain and Mental
Disorder
•
•
•
•
•
Clinic samples
Population samples (n=1953)
GHQ + were interviewed
22% CWP; 32% Mental disorder
OR 3.2 mood disorder in CWP v no CWP
Benjamin et al, 2000
Depression is a risk factor for pain
• Baltimore ECA Survey prospective community cohort (3
samples: 1981; 1982-3; 1993-1996)
• Depression doubles later risk of CLBP
– (Larson et al, 2004)
Litigation
Cassidy et al, 2000
Canadian Whiplash injuries
Change to no-fault
Reduced claims (417/100,000296/100,000)
Reduced time to closure of
claims (433 – 194 days)
Time to closure strongly
associated with:
•Pain severity,
•functioning,
•depression
Exercise cessation
& pain
Pain predicted by:
Lower basal cortisol
 Lower NK cell response
 HR variability
Medical Model doesn’t Help
(Stokes)
• Trained to define disease in terms of
pathology
• No identifiable pathology?
– Feel cheated
– Angry towards patients
– Frustrated
Cognitive-behavioural model
Cognitions - somatic focus,
misinterpretation of symptoms,
catastrophic / depressive thinking
Emotion
Anticipatory anxiety,
mood change,
symptom increase,
Attributions of
cause / condition
worsening,
loss of control
Behaviour change- avoidance of
physical and social activity, Loss
of fitness, seeking reassurance
/cure, limited engagement with
treatment, Loss of function
and role
Bodily
Signals
Filter
System
Enhanced by:
Enhanced by:
Affected by:
•Visits doctor
•Selective
•Cultural/Family
attention
beliefs
•Avoids physical
deconditioning
•Depression
•Misinterpret
•Loss/Trauma
•Health anxiety
• Overarousal
• Physical
•Absence of
distractors
•Infection
Cortical
Perception
symptoms
•Catastrophic
thinking
•Attributions
•Depressive
cognitions
Illness
Behaviour
activity
•Adopts sick role
Key points
• Somatoform disorders are common but neglected.
This is unfortunate as they are disabling and
costly.
• ‘Somatisation’ is associated with inter alia female
gender, childhood experiences, cultural
expectations, social ‘gain’, depression, life stress,
litigation, iatrogenic factors and physical fitness
Treatment
Attitudes required to
treat
Unqualified acceptance of validity of pt illness
experience
Willing to listen to patients views
Positive attitude to therapy
Tolerate slow progress
Willing to let patient take credit for success
(don’t expect chocolates!)
Targets for treatment
Misinformation -- Education
Distress -- Antidepressants
Illness / safety behaviour -- Behaviour
Rx
Conflict - - Psychotherapy
Deconditioning -- Graded activity
Treatment