medically unexplained symptoms 1 (mus, somatoform disorders) medically unexplained symptoms h.afshar...

Medically unexplained symptoms 1 (MUS, Somatoform Disorders)

Medically unexplained Symptoms

H.Afshar

Psychosomatic research center

IUMS

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9 Medically unexplained Symptoms

Importance for the Health System (Western countries)

High prevalence in primary care (30 %) and secondary care (20 %)

High use of medical service

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

Diagnosis

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1. Definition

2. Classification

3. Etiology

Overview

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Medically unexplained symptoms (MUS)General term, very broad

Functional syndromsDisturbance of bodily function rather than structure

Somatization A psychological problem or emotional disorder is

expressed somatically

Somatoform disorders

Diagnostic category in the psychiatric classification of DSM and ICD

Definition and Terminology

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Overlapping of MUS, Functional Syndroms, Somatization and Somatoform Disorders

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Definition of somatoform disorders

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)

Definition

Patient experiences physical symptoms and seeks help

The doctor focuses on organically-caused symptoms and

prescribes organ-medical diagnostic testsprescribes medications

Patient feels misunderstoodand demands furtherdiagnostic measuresThe doctor is irritated

Doctor retreats orrefers to Specialist or

the patient breaks off contact; doctor shopping

Doctor looks for psychosocialstress; Patient denies and

becomes enraged

Patient sees no improvement;the findings are negative;

Patient doesn´t know where to turn

Disruption of the Doctor-Patient Relationship

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1. Definition

2. Classification

3. Etiology

Overview

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ICD – 10 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

Classification

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Subgroups of somatization

Initial somatizers

Part somatizers

Facultativ somatizers

True somatizers

Functional somatizers

Classification

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Common Symptoms

Symptoms of painbackache (73%)headache (67%)bellyache (56%)

Symptoms in the gastrointestinal tractfeeling of pressure (54%)flatulence (56%)

Symptoms in the cardiovascular tractheart palpitation (55%)sweating (62%)

Rief et al. 1997

Classification

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Somatisation

Depressive disorder Anxiety disorder

Classification

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Physical symptoms in anxiety disorders

Classification

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1. Definition

2. Classification

3. Etiology

Overview

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Elicitor e.g.

Minor injury

Psychosocial stress

Sudden cardiac death of a close person

Physical Changes

Physical reactions

Malaise

Symptoms

Maintain Factors

„Checking the body“

Excessive worries about health

„Doctor shopping“ – many medical examinations

Taking medications

Protective behaviour

Somatic concept of illness

Symptom potentiation

Increased attention to one’s own body

Physiological arousal

Anxiety, depressive

symptoms

Perception

Misinterpretation

as asign of threatening disease

Vicious circle of somatoform symptoms

Etiology

(Based on Rief 2000)

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My hair stood on end

Get cold feet

Have butterflies in the stomach

lBody related idioms

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What can the medical doctor do?

Avoid insults, recognize the illness as an attempt at solution, legitimization of the symptoms

Take the physical symptoms seriously

Pay attention to difficulties in the doctor- patient relationship (e.g. Negative feelings)

Avoid premature coupling of the symptoms to psychosocial stress

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Approach to patients: disease or illness oriented

Cognition: content, styles

Emotion

Function

Expectation

Concerns: questions

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The reattribution model- how to talk to somatizating patients and how to deal -

1. Take a full history of the symptoms

2. Explore emotional cues

3. Explore social and family factors

4. Explore health beliefs

5. Brief focused physical examination

Stage 1: Feeling understood

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The reattribution model

1. Feed back the results of the examination

2. Acknowledge the reality of the symptoms

3. Reframe the complaints: link physical, psychological, and life events

Stage 2: broadening the agenda

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The reattribution model

1. Simple explanation

Three-stage explanation for anxiety

How depression lowers the pain threshold

2. Demonstration

Practical

Link to life events

„Here and Now“

Stage 3: making the link

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Extra systoles

Palpitations

Shortness of breath

Tingling

Muscle pains, esp. shoulder and neck

Blood pressure increase

Heart rate increase

Rapid breathing

Tensed muscles

Anxiety

Excitation

Inner restlessness

Tension

Three Stage explanation for “Anxiety and physical complaints”

Emotions Physical Reactions Symptoms

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Headache

Aching joints

Stomache

Back pain

Susceptibility to infections

Neglect of preventive health measures

Reduced pain threshold

Increased sinsitivity to physical discomfort

Weakened immune system

Feeling blue

Lack of energy

Lack of interest

Withdrawal

Three Stage explanation for “Depression“

Emotions Physical Reactions Symptoms

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Viscious circle model of anxiety and panic attacks (Margraf & Schneider, 1990)

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Symptom DiaryRecord of thoughts and feelings during physical complaints

Date Symptom (Severity 0-10) 0 = not at all 10 = very strong Situation (what you are doing now or what occupies your thoughts.)

How did you feel? (Intensity 0 – 10) 0 = not at all 10 = very much e.g. anxious, very tense, sad, nervous, annoyed, happy, restless

What did you think about? (Intensity of these thoughts from 0-10) 0 = not at all 10 = very strongly

Problem solving strategies

Example: 14.09.98 20.09.98

Pains in the chest (8) working in the garden

K Shortness of breath ( rapid heart beat (6)

Anxiety (6) Anxiety (6)

I’m having a heart attack (9) Something’s wrong with my heart (7)

I relaxed, breathed deeply I took a rest

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Potentially acutely serious? (< 5 %) Expedited diagnostic evaluation

Yes

No

Likely minor and self-limited (70-75 %)1. Adress patient expectations2. Symptom-specific therapy

3. Follow-up in 2-6 weeks

Yes

No

Persistent unexplained somatic symptoms (20-25 %)

Depressive or anxiety disorder?

Yes

Functional somatic syndrome?

Yes

•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

Yes

No

No

Antidepressant and / or cognitive- behavioral therapy

Syndrom-specific therapy if evidence-based

Kroenke 2003

Ineffective

medically unexplained symptoms 1 (mus, somatoform disorders) medically unexplained symptoms h.afshar...

Documents

unexplained symptoms

unexplained symptoms

somatization disorders

terminology slide

classification f

hypochondrial disorders

etiology overview slide

medications patient