* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Kein Folientitel
Depersonalization disorder wikipedia , lookup
Sluggish cognitive tempo wikipedia , lookup
Panic disorder wikipedia , lookup
Treatments for combat-related PTSD wikipedia , lookup
Bipolar II disorder wikipedia , lookup
Death anxiety (psychology) wikipedia , lookup
Asperger syndrome wikipedia , lookup
Factitious disorder imposed on another wikipedia , lookup
History of mental disorders wikipedia , lookup
Rumination syndrome wikipedia , lookup
Combat stress reaction wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Child psychopathology wikipedia , lookup
Spectrum disorder wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Depression in childhood and adolescence wikipedia , lookup
Alcohol withdrawal syndrome wikipedia , lookup
Symptoms of victimization wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Post-concussion syndrome wikipedia , lookup
Medically unexplained symptoms 1 Medically unexplained Symptoms (MUS, Somatoform Disorders) H.Afshar Psychosomatic research center IUMS ASIA LINK VN009 Importance for the Health System (Western countries) Medically unexplained Symptoms High prevalence in primary care (30 %) and secondary care (20 %) Diagnosis High use of medical service UNIVERSITÄTSKLINIKUM Freiburg Treatment costs up to 9 times higher (Work disability time due to sick leave and retirement) Ineffective therapeutic measures in ca. half of the patients; e.g. non-indicated surgical procedures are performed in 20 % of hospitalized „somatisers‘ Frequent change of doctors, emergency admission to hospital and dissatisfaction with treatment UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Overview Medically unexplained Symptoms 1. Definition 2. Classification 3. Etiology ASIA LINK VN009 Definition and Terminology Medically unexplained Symptoms Medically unexplained symptoms (MUS) General term, very broad Functional syndroms Disturbance of bodily function rather than structure UNIVERSITÄTSKLINIKUM Freiburg Somatization A psychological problem or emotional disorder is expressed somatically Somatoform disorders Diagnostic category in the psychiatric classification of DSM and ICD UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Overlapping of MUS, Functional Syndroms, Somatization and Somatoform Disorders Medically unexplained Symptoms UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Definition of somatoform disorders Medically unexplained Symptoms Definition Repeated presentation of physical symptoms Stubborn demand for medical examination despite negative organic findings (dysfunctional illness behavior). Emotional problems denied, although there is close relationship with psychosocial life events or conflicts (somatic fixation). Symptoms are not feigned or aggravated Disappointing doctor-patient relationship (interpersonal disorder) Disruption of the Doctor-Patient Relationship Doctor retreats or refers to Specialist or the patient breaks off contact; doctor shopping Patient feels misunderstood and demands further diagnostic measures The doctor is irritated Doctor looks for psychosocial stress; Patient denies and becomes enraged Patient experiences physical symptoms and seeks help The doctor focuses on organically-caused symptoms and prescribes organ-medical diagnostic tests prescribes medications Patient sees no improvement; the findings are negative; Patient doesn´t know where to turn UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Medically unexplained Symptoms UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Overview Medically unexplained Symptoms 1. Definition 2. Classification 3. Etiology UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 ICD – 10 classification Medically unexplained Symptoms Classification F 45.0 Somatization disorders F 45.2 Hypochondrial disorders F 45.3 Somatoform autonomic dysfunction F 45.4 Persistent somatoform pain disorders F 44 Dissociative (conversion) disorders F 48.0 Neurasthenia ASIA LINK VN009 Subgroups of somatization Medically unexplained Symptoms Classification Initial somatizers Part somatizers UNIVERSITÄTSKLINIKUM Freiburg Facultativ somatizers True somatizers Functional somatizers UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Common Symptoms Medically unexplained Symptoms Classification Symptoms of pain backache headache bellyache (73%) (67%) (56%) Symptoms in the gastrointestinal tract feeling of pressure (54%) flatulence (56%) Symptoms in the cardiovascular tract heart palpitation (55%) sweating (62%) Rief et al. 1997 ASIA LINK VN009 Medically unexplained Symptoms Classification UNIVERSITÄTSKLINIKUM Freiburg Depressive disorder Anxiety disorder Somatisation UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Physical symptoms in anxiety disorders Medically unexplained Symptoms Affected Organ (system) Symptoms 1. Heart Irregular beat, chest pain 2. Vessels Pallor or flush 3. Musculature Trembling, weak knees, tension 4. Respiratory tract Feeling of constriction, suffocation 5. Gastrointestinal tract Lump in the throat, vomiting, stomach pain, diarrhea 6. Vegetative nervous Sweating, urinary urge system 7. Central nervous system Dizziness and feeling of helplessness, Classification UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Overview Medically unexplained Symptoms 1. Definition 2. Classification 3. Etiology UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Vicious circle of somatoform symptoms Medically unexplained Symptoms Etiology Elicitor e.g. Minor injury Psychosocial stress Sudden cardiac death of a close person Maintain Factors „Checking the body“ Excessive worries about health „Doctor shopping“ – many medical examinations Taking medications Protective behaviour Somatic concept of illness (Based on Rief 2000) Physical Changes Physical reactions Malaise Symptoms Symptom potentiation Increased attention to one’s own body Physiological arousal Anxiety, depressive symptoms Perception Misinterpretation as asign of threatening disease ASIA LINK VN009 Body related l idioms Medically unexplained Symptoms My hair stood on end Get cold feet UNIVERSITÄTSKLINIKUM Freiburg Have butterflies in the stomach ASIA LINK VN009 What can the medical doctor do? Medically unexplained Symptoms Avoid insults, recognize the illness as an attempt at solution, legitimization of the symptoms UNIVERSITÄTSKLINIKUM Freiburg Take the physical symptoms seriously Pay attention to difficulties in the doctorpatient relationship (e.g. Negative feelings) Avoid premature coupling of the symptoms to psychosocial stress UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Approach to patients: disease or illness oriented Medically unexplained Symptoms Cognition: content, styles Emotion Function Expectation Concerns: questions The reattribution model ASIA LINK VN009 - how to talk to somatizating patients and how to deal Medically unexplained Symptoms Stage 1: Feeling understood 1. Take a full history of the symptoms 2. Explore emotional cues UNIVERSITÄTSKLINIKUM Freiburg 3. Explore social and family factors 4. Explore health beliefs 5. Brief focused physical examination ASIA LINK VN009 The reattribution model Medically unexplained Symptoms Stage 2: broadening the agenda 1. Feed back the results of the examination UNIVERSITÄTSKLINIKUM Freiburg 2. Acknowledge the reality of the symptoms 3. Reframe the complaints: link physical, psychological, and life events ASIA LINK VN009 The reattribution model Medically unexplained Symptoms Stage 3: making the link UNIVERSITÄTSKLINIKUM Freiburg 1. Simple explanation Three-stage explanation for anxiety How depression lowers the pain threshold 2. Demonstration Practical Link to life events „Here and Now“ UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Three Stage explanation for “Anxiety and physical complaints” Medically unexplained Symptoms Emotions Anxiety Excitation Inner restlessness Tension Physical Reactions Symptoms Blood pressure increase Heart rate increase Rapid breathing Tensed muscles Extra systoles Palpitations Shortness of breath Tingling Muscle pains, esp. shoulder and neck UNIVERSITÄTSKLINIKUM Freiburg ASIA LINK VN009 Three Stage explanation for “Depression“ Medically unexplained Symptoms Emotions Physical Reactions Symptoms Feeling blue Lack of energy Lack of interest Withdrawal Reduced pain threshold Increased sinsitivity to physical discomfort Weakened immune system Headache Aching joints Stomache Back pain Susceptibility to infections Neglect of preventive health measures Viscious circle model of anxiety and panic attacks (Margraf & Schneider, 1990) Vicious circle model of anxiety and panic attacks ASIA LINK VN009 Medically unexplained Symptoms Physical Stimuli UNIVERSITÄTSKLINIKUM Freiburg Physical Sensations Perception Physiological Changes Thoughts („Danger“) Anxiety Visible Behaviour Symptom Diary ASIA LINK VN009 Record of thoughts and feelings during physical complaints Medically unexplained Symptoms Date UNIVERSITÄTSKLINIKUM Freiburg Example: 14.09.98 Symptom (Severity 0-10) 0 = not at all 10 = very strong How did you feel? (Intensity 0 – 10) 0 = not at all 10 = very much What did you think Problem about? solving (Intensity of these strategies thoughts from 0-10) 0 = not at all Situation (what you e.g. anxious, very 10 = very strongly are doing now or tense, sad, what occupies your nervous, annoyed, thoughts.) happy, restless Pains in the chest Anxiety (6) (8) working in the garden 20.09.98 K Shortness of breath ( Anxiety (6) rapid heart beat (6) I’m having a heart I relaxed, attack (9) breathed deeply Something’s wrong with my heart (7) I took a rest ASIA LINK VN009 Medically unexplained Symptoms Potentially acutely serious? (< 5 %) Yes Expedited diagnostic evaluation No Likely minor and self-limited (70-75 %) Yes No 1. Adress patient expectations 2. Symptom-specific therapy 3. Follow-up in 2-6 weeks Persistent unexplained somatic symptoms (20-25 %) Yes Yes Antidepressant and / or cognitive- behavioral therapy Depressive or anxiety disorder? UNIVERSITÄTSKLINIKUM Freiburg Ineffective No Functional somatic syndrome? No Kroenke 2003 Yes Syndrom-specific therapy if evidence-based •Regular time-limited clinic visits •Psychological assesment (e.g. somatoform disorders, personality disorders, history of trauma/abuse) •Individual or group chronic symptom management programs •Complementary medicine treatments when evidence-based •Rehabiltative rather than disability approach