module: health psychology lecture:chronic illness and somatisation date:16 march 2009 chris bridle,...
TRANSCRIPT
Module: Health Psychology
Lecture: Chronic illness and somatisation
Date: 16 March 2009
Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick
Tel: +44(24) 761 50222 Email: [email protected] www.warwick.ac.uk/go/hpsych
Aims and Objectives
Aim: To provide an overview of the psychological aspects of chronic illness and somatisation
Objectives: You should be able to describe … common somatoform symptoms;
characteristics of somatoform disorders;
cause, course and consequence of somatoform disorders;
principles of assessment, treatment and management of somatoform disorders;
ways to distinguish between normal and abnormal somatisation.
Greek Origin
Σωμα Soma = 'the body'
Σωματικóς Somatic = 'of the body'
ψυχή Psyche = 'of the mind'
ψυχοσωματικός Psychosomatic = 'influence of the
mind on the body'
Terminology
Somatic symptoms: physical symptoms (assumption: with physiological cause)
Somatoform symptoms: physical symptoms without (identifiable) physiological cause
Psychosomatic symptoms: physical symptoms with psychological cause
Somatopsychic symptoms: psychological symptoms with physiological cause
Somatisation: expression of emotional problems in somatic symptoms
Somatic fixation: bias towards (automatic) medicalisation of symptoms
Somatisation
'Somatisation is a ubiquitous and diverse process in medicine, linking the physiology of distress and the
psychology of symptom perception'
Joseph Ransohoff (1915 - 2001)
'... the history of medicine has written the prehistory of psychosomatics'
William Osler (1849 - 1919)
'Representation of thebodily processing of emotion'
Leonardo da Vinci (1452 - 1519)
Symptom Prevalence
Over 1-week, 69%/1410 adults report 1> one symptom
Only about 10% of symptoms prompt medical help seeking
A physiological cause is found for only a small proportion of the most common physical symptoms presented in primary care
20% of patients present with (primary / main) physical symptoms that are not explained by physical disease - 1 in 5
Each primary care clinician in the UK will have on average 12 patients with chronic somatic symptoms
Physiological Cause Identified
Symptom Presentation
Of all the symptoms for which an identifiable physiological cause can not be found, the most common are:
Pain: related to different sites (e.g. head, abdomen, back) or bodily functions (e.g. menstruation, intercourse, urination)
Gastrointestinal: nausea, bloating, vomiting (not during pregnancy), diarrhoea, intolerance of several foods
Sexual: indifference to sex, difficulties with erection or ejaculation, irregular menses, excessive menstrual bleeding
Pseudoneurological: voice loss, impaired vision, hearing and balance/coordination, paralysis, hallucination, seizure, amnesia
Medical Specialties and TheirPatients with Problems
Specialty Problem / Symptom
Orthopedics - Low back pain
Obs/Gyn - Pelvic pain, PMS
ENT - Tinnitus
Neurology - Dizziness, headache
Cardiology - Atypical chest pain
Pulmonary - Hyperventilation, dyspnea
Rheumatology - Fibromyalgia
Internal Medicine - Chronic Fatigue Syndrome
Gastroenterology - Irritable Bowel Syndrome
Rehabilitation - Closed head injury
Endocrinology - Hypoglycemia
Patients with a wide range of somatoform symptoms are
encountered not only in primary care, but throughout
the specialities also
Characteristics of Somatoform Disorders
A class of disorder defined by
presence of physical symptoms that are not fully explained by the presence of a medical condition;
symptoms cause clinically significant distress and impairment;
psychological factors judged important in symptom onset, severity, and/or maintenance;
symptoms are chronic, independent of one another and not intentionally produced.
Somatoform Disorders
Somatisation disorder (Briquet's syndrome): A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought
Conversion disorder (conversion hysteria): Symptoms or deficits affecting voluntary motor or sensory function
Hypochondriacal disorder (hypochondriasis): Preoccupation with fears of developing or having a serious disease, based on (mis)interpretation of bodily symptoms, which persist despite medical reassurance
Somatoform pain disorder (psychogenic pain): Disabling pain of sufficient severity to cause treatment being sought
Body dysmorphic disorder (dysmorphophobia): Preoccupation with an imagined defect in appearance, or if real / present, concern is markedly excessive
Somatisation Disorder
Description: A history of many physical complaints beginning before age 30 years that occur over a period of several years and results in treatment being sought or significant impairment in social, occupational or other areas of functioning
Epidemiology: 10 X> females, familial pattern for 10-20% of 1st degree female relatives;
Course: Chronic, fluctuating and rarely remits. Diagnostic criteria usually met before age 25 yrs.
Cues: Symptom onset / progression following loss; symptom amplification with stress
Other features: Complicated medical history; numerous (12+) somatic complaints; Dr shopping
Date (Age)
Symptoms(life event)
Referral Investigation Outcome
1990 (21)
Abdominal painGP to surgical
outpatientsAppendicectomy Normal
1992 (23)
Nausea(boyfriend in prison)
GP to Obs/Gyn outpatient
PregnantTermination of
pregnancy
1994 (25)
Bloating, abdominal pain, (divorce)
GP to gastro outpatient
All testsnormal
IBS diagnosis; treat with Fybogel
1995 (26)
Pelvic pain(wants sterilisation)
GP to O&G outpatient
SterilisedPelvic pain for 2yrs
post-surgery
1997 (28)
Fatigue (dissatisfied at work)
GP to infectious disease clinic
Alltests normal
Self-diagnosed ME, joins self-help group
1998 (29)
Aching,painful muscles
GP torheumatology clinic
Mild cervical spondylosis
Tryptizol 50 mg,pain clinic referral
1999 (30)
Chest pain(lost job)
A&E tochest clinic
Normal; probable hyperventilation
Refer topsychiatric services
Somatisation Disorder: A 10-Year Example
Conversion Disorder
Description: Symptoms or deficits affecting voluntary motor or sensory function
Epidemiology: Rare condition; acute onset in adolescence or early adulthood; twice as prevalent in females; more common in rural populations and lower SES
Course: Recurrent symptoms with short duration
Cues: Traumatic events; stress; inability to cope
Other features: high suggestibility; prone to seizures and convulsions; unaware of retained functions
Samuel Pepys recorded conversion disorder after the Great Fire of London in 1666
Hypochondriacal Disorder
Description: Preoccupation with fears of developing or having a serious disease based on (mis)interpretation of bodily symptoms, which persists despite medical reassurance
Epidemiology: About 3% and 5% prevalence among general population and primary care outpatients, respectively
Course: Onset at any age, but typically early adulthood; familial deaths and illness; media
Cues: Heightened awareness of physical self; symptom amplification when stressed
Other features: Dr Shopping; background expertise
Somatoform Pain Disorder
Description: Pain of sufficient severity to cause clinically significant distress or impairment and treatment being sought
Epidemiology: Precise prevalence unknown but likely to be fairly common; small female bias possible; variable onset age
Course: Chronic, fluctuating and rarely remits
Cues: Often develops from illness or accidental injury; symptom amplification when exposed to illness, accident cues and stress
Other features: Dr shopping (often precipitated by maximum dose); risk for multiple registrations; pharmacologically informed; initiated and discontinued various CAM formulations
Body Dysmorphic Disorder (BDD)
Description: Preoccupation with an imagined defect in appearance, or if present, concern is markedly excessive
Epidemiology: Prevalence unknown in general population; 10-30% in mental health settings
Course: Onset early adulthood; increasingly distressing; potential for suicidal ideation
Cues: Unclear; possible sensitivity / bias to facial feature priming
Other features: Typically remain single; examined potential for plastic surgery
BDD?
What causes somatisation, and when?
What?
Aetiology is poorly understood, but biological, psychological and social factors are (likely to be) involved
Biopsychosocial contribution will vary between people and across somatoform disorders - size and interaction
Clinician factors may contribute to somatisation, i.e. iatrogenic harm
When?
Predisposing factors increase the chance that particular symptoms may develop and/or become important
Precipitating factors trigger increased physiological self-awareness, e.g. stress, depression, anxiety, illness
Perpetuating factors make it more likely that somatoform symptoms will persist,
Aetiological Formulation
Aetiological Factors
Stage of Illness
Predisposing Precipitating Perpetuating
Biological Genetic Injuryat work
Lack ofmobility
Psychological Externalising explanatory style Trauma Fear
avoidance
Social Dissatisfactionat work
Employerresponse Litigation
Medical TreatmentTargets
'Rule-out' investigations
SomaticFixation
Example for a chronic pain patient Easiest to work through stage columns Each 'Factor X Stage' cell can have multiple entries, or none
Distinguishing Normal & Abnormal Somatisation
Symptoms: are symptoms beyond the norm? Consider multiplicity, severity, and chronicity
Coping: do symptoms significantly impair role functions? Consider social, familial and occupational roles
Belief: is there resistance to explanation and reassurance? Consider affect, refractoriness, and illness discourse
Internalised: has the 'sick role' been accepted? Consider illness explanations - as a way of life
Excessive: extensive but unsatisfactory service use? Consider consultations, providers, and treatments
Principles of Assessment
Be vigilant to iatrogenic harm, e.g. be a part of the solution and not the problem
Identify patients' concerns and beliefs, e.g. illness representation
Contextualise patients' health-related experiences, e.g. previous illness, symptoms, contact with medical services, etc.
Review recent history of current symptoms, paying particular attention to possible life events, i.e. stressors
Ask questions about patients' reaction to and coping with symptoms, e.g. habitual patterns of poor coping
Use screening questions for psychiatric morbidity
Somatic Symptoms and Psychiatric Co-morbidity
The more somatic symptoms a patient has, the less likely it is that their symptoms reflect the presence of physical disease and the more likely
there is co-morbid psychiatric morbidity (depression & anxiety)
Pat
ien
ts w
ith
Psy
chia
tric
Mo
rbid
ity
(%)
0 5 10 15 20
Number of Somatic Symptoms
Principles of Treatment
Validate patient experience, e.g. explain that the symptoms are real and familiar to doctor
Provide a framework, e.g. describe how psychological factors (ABC) may exacerbate somatic symptoms
Offer opportunity for discussion of patient's worries at the earliest opportunity
Give practical advice on coping with symptoms and encourage return to normal activity as soon as possible
Discuss and agree a treatment plan that includes a planned follow up and review
Encourage specific tasks before next meeting, e.g. identify three situations that worsen symptoms
Treatment Aims
Treatment focus should be on coping with symptoms and impairment rather than on symptomatic cure
Target perpetuating factors Depression, anxiety, or panic disorder
Chronic marital or family discord
Dependent or avoidant personality traits
Occupational stress
Abnormal illness beliefs
Iatrogenic factors
Pending medico-legal claim
Management Strategy
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: a therapeutic ally 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
Conclusions
Common: Somatoform symptoms are common and occur in all medical specialities
Harm: Somatisation is chronic, disabling, distressing and destructive
Cause: Multiple biological, psychological and social factors predispose, precipitate and perpetuate somatisation
Treatment: Focus on coping with symptoms and impairment, and removing perpetuating factors
Management: Somatisation can be managed effectively in primary care
Summary
This session would have helped you to understand …
common somatoform symptoms;
characteristics of somatoform disorders;
cause, course and consequence of somatoform disorders;
principles of assessment, treatment and management of somatoform disorders;
ways to distinguish between normal and abnormal somatisation.
Any questions?
What now?
Obtain / download one of the recommended readings
Consider today’s lecture in relation to your tutorial tasks:
a) integrated template
b) ESA question
Tutorial begins at 3.15
Completed templates (supported topics) available after today’s session on module webpage – tutor’s page