Chronic illness and somatisation

Question 1

Somatic symptoms

Answer 1

Physical symptoms with a physical cause

Question 2

Somatoform symptoms

Answer 2

Physical symptoms without identifiable physiological cause (e.g. headache)

Question 3

Psychosomatic symptoms

Answer 3

Physical symptoms with psychological cause (e.g. nausea, diarrhoea, eczema)

Question 4

Somatisation

Answer 4

expression of emotional problems in somatic symptoms

Question 5

Somatic fixation

Answer 5

bias towards medicalisation of symptoms

Question 6

Common symptoms presentations where an identifiable physiological cause is not found

Answer 6

Pain GI: nausea, bloating, vomiting, intolerance Sexual: irregular periods, difficulties in arousal Pseudoneurological: voice loss, hallucination, balance/coordination

Question 7

Characteristics of somatoform disorders

Answer 7

A class of disorders defined by:

• presence of physical symptoms not fully explained by the presence of a medical condition
• symptoms cause clinically significant distress and impairment
• psychological factors important in symptom onset and severity
• symptoms are chronic and not normally intentionally produced

Question 8

Name 3 somatoform disorders

Answer 8

Somatisation disorder (Briquets syndrome)

Conversion disorder

Hypochondriacal disorder (hypochondriasis)

Somatoform pain disorder (psychogenic pain)

Body dysmorphic disorder (dysmorphophobia)

Question 9

Somatisation disorder (Briquet’s syndrome)

Answer 9

History of many physical complains starting before the age of 30 that occur over a period of several years and result in treatment seeking.

Patients feel they have been sick most of their lives

Very vague or dramatic description of medical history given. Often jump from one symptom to another in the conversation and will not give a detailed account of a specific symptom.

More common in females

Symptom onset and amplification with stress

Chronic fluctuating pattern, diagnosed before the age of 25.

Question 10

Conversion disorder

Answer 10

Symptoms or deficits affecting voluntary motor or sensory function (e.g. numbness or paralysis) with no neurological explanation

Rare condition with onset in adolescence or early adulthood.

Recurrent symptoms with short duration. Prone to seizures and convulsions, weakness of movement.

Onset caused by an inability to cope with traumatic events and stress

Question 11

Hypochondriacal disorder

Answer 11

Fears of developing or having a serious disease based on misinterpretation of bodily symptoms which persist despite medical reassurance. Symptoms last for more than 6 months

Onset at any age, typically adulthood

Heightened awareness of physical self; symptoms amplified when stressed.

Patients tend to Dr. shop, lots of background expertise

Question 12

Somatoform Pain Disorder

Answer 12

Severe pain which causes clinically significant distress or impairment for treatment to be sought. Chronic pain is due to psychological factors.

Chronic fluctuating pain. Often develops from illness or accidental injury or stress.

Patients often Dr. shop which is precipitated when maximum doses for pain relief is reached. Risk of addiction to prescribed pain medication if not taken correctly.

Question 13

Body dysmorphic disorder

Answer 13

Patient have an imagined or real defect in appearance, diagnosed when it causes significant distress or disrputs daily functioning.

Obsessions can be with: moles or freckles, acne, scars, facial/body hair, breast size, small muscles

Onset is in early adulthood and becomes increasingly distressing. Patients may become reclusive, refusing to leave the house, covered up, have suicidal thoughts.

Typically remain single, examined potential for plastic surgery, often have other mental health problems.

Question 14

How would you sreen for body dysmorphic disorder?

Answer 14

Are you very worried about your appearance in any way?
Are you unhappy with the way you look?

If yes - What is your concern?

Does this concern preoccupy you? How much time do you spend thinking about it?

What effect has this preoccupation had on your life?

Question 15

What factors affect when somatisation occurs?

Answer 15

Precipitating factors - trigger increased physiological self-awareness e.g. stress, depression, anxiety, illness

Predisposing factors - increase the chance that particular symptoms may develop and/or become important

Perpetuating factors - make it more likely that somatoform symptoms will persist.

Question 16

How do you distinguish between normal and abnormal somatisation?

Answer 16

Symptoms: are they beyond the norm? (multiplicity, severity, chronicity)

Coping: do symptoms significantly impair role functions? (social, familial and occupational roles)

Belief: is there resistance to explanation and reassurance?

Internalised: has the ‘sick role’ been accepted? Patients consider illness explanations as a way of life

Excessive: extensive but unsatisfactory service use. Patients consider consultations, providers and treatments.

Question 17

What is the management for a patient with a somatoform disorder?

Answer 17

Proactive not reactive: arrange to see patients at regular, fixed intervals

Broaden agenda: establish a problem list and allow patients to discuss relevant problems

Minimise providers: only one or two providers to reduce iatrogenic harm

Co-opt a relative to help implement and monitor the management plan

Cope not cure: cure is an unrealistic expectation, instead aim for containment and damage limitation, and remind patient at each consultation