Somatisation

Question 1

What are functional somatic syndromes?

Answer 1

Functional somatic syndromes = physical symptoms with no obvious pathology and there is an assumed organ or system dysfunction

Question 2

What are the predisposing factors of functional somatic disorders?

Answer 2

=> Perfectionist and introspective personality traits

=> Childhood traumas - physical or sexual abuse

=> Similar illnesses in 1st degree relatives

Question 3

What are the triggers for functional somatic disorders?

Answer 3

=> Infections esp in chronic fatigue syndrome, IBS

=> Traumatic events

=> Acute painful conditions

=> Incidents where patients believe others are responsible

Question 4

What are the perpetuating (maintaining) factors for functional somatic disorders?

Answer 4

=> Inactivity with consequent physiological adaptations i.e. seen in chronic fatigue syndrome, fibromyalgia

=> Avoidant behaviours i.e. chronic fatigue syndrome, multiple chemical sensitivity

=> Maladaptive illness belief i.e. chronic fatigue syndrome, multiple chemical sensitivity

=> Excessive dietary restrictions - ‘food allergies’

=> Stimulant drugs i.e. caffiene

=> Sleep disturbances

=> Mood disorders

=> Somatization disorder

=> Unresolved anger or guilt

=> Disputed compensation claim

Question 5

What is the general management functional somatic syndromes?

Answer 5

First step : identification and treatment of maintaining factors e.g. dysfunctional beliefs and behaviours, mood and sleep disorders

1. Communication:
   => Explanation of ill health
   => Education about management
2. Stopping drugs e.g. caffeine causing insomnia; analgesics causing dependency
3. Rehabilitation therapies:
   => CBT - challenge unhelpful beliefs and change coping strategies
   => Supervised and graded exercise therapy to reduce inactivity and improve fitness
4. Pharmacotherapies:
   => Specific antidepressants for mood disorders, analgesics and sleep disturbance
   => Symptomatic medicines

Question 6

What is chronic fatigue syndrome?

What are the symptoms?

Who does it affect?

What is its aetiology?

Answer 6

Cardinal symptom : chronic fatigue is made worse by minimal exertion ; fatigue is both mental and physical

Commonly assoc. with:
=> poor concentration
=> impaired registration of memory
=> alteration in sleep pattern (either insomnia or hypersomnia)
=> muscular pain 

Most common in women 20-50yrs

Aetiology: chronic fatigue syndrome can be triggered by infectious mononucleosis and viral hepatitis.

Question 7

How do you diagnosis and manage chronic fatigue syndrome?

Answer 7

Clinical diagnosis made my exclusion of other fatiguing conditions

Management:
=> Supervised programme of gradually increasing activity

*difficult for patients to accept what seems like psychological therapies for physical symptoms

Prognosis is poor without treatment + outcomes are worse with greater severity, increasing age and co-morbid mood.

Question 8

What is fibromyalgia?

Who does it affect?

What is its aetiology?

How do you manage it?

Answer 8

Fibromyalgia is chronic wide spread muscle and joint pain and can also be assoc. with chronic fatigue and sleep disturbances.

Commonly affects women aged 40-65yrs

Aetiology: underlying abnormal sensory processing perhaps related to abnormal regulation of central opiodergic mechanism

Management:
=> Centrally acting analgesia
=> Reversal of the sleep disturbance
=> Physical rehab programme

• Tricyclic antidepressant i.e. amitriptyline or dosulepin that inhibit both serotonin and noradrenaline uptake have the greatest effect on sleep and pain
• Other centrally acting noci-ceptive agents that are also anti-depressants = duloxetine, gabapentin, pregabalin.

Question 9

A chronic pain syndrome = chronic disabling pain for which no medical cause can be found

=> ‘Fuctional’ lower back pain = most common physical reason for being off sick long term in the UK

=> this type of pain responds poorly to analgesics

=> assoc. with sleep disturbances and co-morbid psychiatric disorders

Answer 9

=> brain responds abnormally to pain

=> increased response to chronic pain

=> brain’s ability to inhibit pain through descending pathways is impaired

Management:

=> Gabapentinoids i.e. gabapentin or pregabalin

=> Dual acting anti-depressants i.e. SNRI e.g. duloxetine have the greatest efficacy ; low dose tricyclic antidepressants that target both serotonin and noradrenaline also effective i.e. amitriptyline

Question 10

Irritable bowel syndrome is the most common functional somatic syndrome.

IBS not generally assoc. with psychiatric disorder but important to exclude:

=> depression in those with constipation and poor appetite

=> Anxiety in those with nausea and diarrhoea

=> Abdominal pain and feeling of emptiness in severe depression esp in elderly with a nihilistic delusion

Answer 10

INFO CARD

Question 11

Premenstrual syndrome consists of both physical and psychological symptoms:

Physical symptoms: headache, fatigue, breast tenderness, abdominal distention, fluid retention

Psychological symptoms: irritability, emotional lability or low mood and tension

PMS is very common - 75-80% women

Answer 11

Prementrual (late luteal) dysphoric disorder (PMDD) = severe form of PMS with marked mood swings, irritability, depression and anxiety alongside physical symptoms

PMDD = 3-8%

Question 12

What are somatoform disorders?

Answer 12

Somatoform disorders are psychological disorders which present physically.

Question 13

What is somatization disorder?

Answer 13

Multiple, recurrent, unexplained physical symptoms starting in early adult life.

Patient may have had multiple medical opinion and negative investigations but continues to ‘doctor shop’ and refuses to believe any underlying psychological or social factors

Somatization disorders assoc. with dependence or overuse of prescribed medications i.e. sedatives or analgesics

History of significant child hood traumas or chronic ill health

Question 14

What is hypochondriasis?

Answer 14

Patient believe they suffer from a serious illness

=> repeatedly request investigations either to prove they are ill or reassure themselves they are well

=> Reassurance doesn’t last long before another cycle or worry and request begins

=> Symptoms of hypochondriasis might be secondary to or assoc. with many psychiatric disorders i.e. depression or anxiety, delusional 2nd to schizophrenia or depressive psychosis

=> Patient’s concern is disproportionate and unjustified

Question 15

How do you manage somatoform disorders?

What is the prognosis?

Answer 15

Prognosis is poor => aim is to reduce disability

Same principle as general management of somatoform disorders highlighted above.

CBT

Sensitively explore psychological, social difficulties