28 - Somatic Symptoms Flashcards
We started with a Woody Allen movie, “Hannah and Her Sisters”
He thinks he has a brain tumor
How would you feel if you were Mickey’s doctor?
Overwhelmed
Patient is…
- Making things up
- Developing new symptoms all the time
What did Mickey’s doctor do well?
He did a work up
Even if you have someone who always has something they think is wrong, it doesn’t mean that at one point they won’t need treatment
Not hostile at all, reassuring
What could Mickey’s doctor have done better?
Didn’t give more information about what tests were needed at the hospital
Didn’t really sit down and give him a good explanation
Should have “dug a little deeper” - anxiety in life, stress, etc.
What did the second physician do well or poorly?
People will ask you about a different physician’s diagnosis
- He stated the possibilities
- Actually stated what it could be
- He was in a tricky position
- Could have said, this is hard for me to speculate about this, can you just talk to your real doctor?
What are the attributes of patients with unexplained symptoms?
- Patients with this presentation are commonly seen in practice
- Symptoms are often vague and/or atypical
- Symptoms often involve multiple organ systems
- Impairment in functioning may seem disproportionately high compared to observable pathology
- Higher level of awareness of bodily sensations (and higher reactivity to them)
- Often overt denial that symptoms might relate to psychological factors
Describe trends we see in patients with unexplained symptoms
- Medical utilization is often increased (office visits, ER visits, hospitalizations, tests, interventions)
- Often there are also high levels of use of complementary and alternative medical interventions
- Sensitivity to medication side effects is common, as are high rates of non-response to treatment
- These factors are stressful for the patient as well as the provider
This is expensive for the patient and medical system, but it also exposes patients to a higher level of risk
What are the possible reasons for somatization?
- Emotional disturbances have physical effects upon the body (and vice versa)
- A physical symptom may be perceived as a necessary ticket of admission to receive caring from the clinician
- Physical distress carries less shame and connotation of weakness than emotional distress
- Dysfunctions in the neuroendocrine system have been linked to functional disorders, including chronic fatigue syndrome and some kinds of chronic pain
- Psychiatric illness
A long-time patient might say that they are having more pain with their plantar fascitis, but then really have some emotional stress going on
What are some sources of frustration when dealing with a patient experiencing somatization?
- Inability to fix the problem
- Inability to establish a shared conceptualization of the problem with the patient
- Frustration with patient for demands for unneeded testing or interventions
- If these feelings are not managed, the tendency can be to either shame or try to get rid of the patient
- Patients with chronic, complex, or medically unexplained illnesses need more patience and caring from medical personnel, but the reality is that they tend to receive less
Define somatization
Somatization means the experiencing and communicating of emotional distress as physical distress
Describe the interpretation of somatization in modern medicine
- Has a negative connotation in Western medicine, but is a common and sometimes normal process
- Can be reinforced by care providers who attend to physical but not emotional symptoms
- One study found that in 80% of office visits for symptoms including dizziness, fatigue, and chest pain, no organic cause could be identified
Describe medically unexplained symptoms
It is unhelpful to focus on whether a symptom is “physical” or “psychological”
- Many symptoms have multiple causes
- Can lead to either over- or under-working up the patient’s symptoms
- Leads to an attitude that psychological symptoms either are not real or are not worthy of the clinician’s attention
- The mind and body are not two separate entities. They profoundly influence each other
How do you effectively work with patients who have unexplained symptoms
- Develop an empathic, trusting relationship (difficult but important to good care)
- Encourage a strong relationship with one primary care provider
- Accept that the symptoms are real, in the sense of being a valid expression of distress
- Acknowledge the patient’s suffering
Use descriptive terms to reflect back the symptoms; no need to dispute etiology - May eventually note that stress tends to worsen symptoms
What are some tips to follow when working with patients with unexplained symptoms?
- It is best to be honest with patients when you are unsure about etiology
- Avoid promising cure
- Avoid scolding or dismissing the patient
- Regular, brief office visits on a set schedule (e.g. every 4-6 wks) are often helpful (so the patient does not have to be sick to obtain care)
- Diagnostic and treatment efforts should be guided by signs rather than symptoms of disease; avoid over- or under-testing and treating
- Screen for psychiatric illness without dismissing the physical concerns
- Remain mindful that these patients have worse outcomes in terms of health status, emotional well being, and overall quality of life
What is the clinical approach to medically unexplained symptoms?
1 - Inability to find a physical cause for symptoms does not allow for a psychological diagnosis to be made unless affirmative evidence of psychological dysfunction is found
2 - Discovering a medical explanation does not mean that psychiatric factors are absent, particularly if symptoms and impairment are more severe than would be expected
3 - Avoid investing energy in determining whether symptoms are medically vs. psychologically caused. Both factors are typically relevant
4 - Take a multidimensional approach, and look to how the patient reacts to the symptoms and the subsequent functional impairment as indicators of somatization
5 - Be mindful that most people somatize at times, and there is a continuum from normal to quite pathological
Describe somatic symptom disorder
Criteria
- One or more somatic symptoms that are distressing or result in significant disruption of daily life
- Excessive thoughts, feelings, or behaviors related to the symptom(s)
- -> Disproportionate and persistent thoughts about symptoms’ seriousness
- -> Persistently high level of anxiety about health or symptoms
- -> Excessive time and energy devoted to these symptoms
Symptoms vary, but state of being symptomatic persists
Describe the prevalence and spectrum of somatic symptom disorder
- Prevalence estimated at 5-7%
- Symptoms vague, but may be dramatic and severe
- Psychiatric comorbidity is common
- Symptoms may increase and decrease over time
- Risk of real illness being missed (“crying wolf”)
Describe illness anxiety disorder
Formerly hypochondriasis, although many previously diagnosable with hypochondriasis now qualify for Somatic Symptom Disorder
Criteria
- Preoccupation with health to the exclusion of everything else (including other people)
- Somatic symptoms are either not present or are mild
- High level of anxiety about health
- Individual performs excessive health-related behaviors or else exhibits maladaptive avoidance
- Illness preoccupation must be present at least 6 months
Describe the condition of illness anxiety disorder
- Intense sensitivity to bodily sensation
- Fixed belief that one is seriously ill that is impervious to reassurance
- Leads to high usage of medical care
What is the other name for conversion disorder?
Functional Neurological Symptom Disorder
What is the criteria for conversion disorder?
- One or more symptoms of altered voluntary motor or sensory function
- Clinical findings show incompatibility between the symptom and recognized neurological or medical conditions
- The symptom causes clinically significant distress or impairment
What are some examples of conversion disorder?
Examples: inexplicable fainting, paralysis, seizures, blindness, etc.
Describe conversion disorder
- Can coexist with medically explained neurological disorders
- Etiology believed to be unconscious and unresolved psychological conflicts or needs, or response to trauma
- Found in approximately 5% of referrals to neurology clinics
- Freud treated a lot of this (he believed the symptoms served to keep unacceptable impulses or conflicts out of consciousness)
- Rather than telling the patients their symptoms are not real, can reassure that serious neurological causes have been ruled out and instead state that s/he has benign neurological dysfunction that is made worse by stress
Describe factitious disorder
- Intentional production of symptoms
- Presents self to others as ill or injured
- Goal is to assume the sick role rather than obtain external rewards
- More common among healthcare workers or their adult children
- Factitious Disorder Imposed on Another (symptoms produced in a child or another dependent; perpetrator, not victim, is diagnosed)
