Post on 24-Dec-2015
UNDERSTANDING THE PAINS THAT WON’T GO AWAYHOW TO REDUCE THE BURDEN OF PSYCHOSOMATIC ILLNESS AMONG COLLEGE & UNIVERSITY STUDENTS
ACHAPhiladelphiaJune 4, 2010
Amy R. Alson, MDUniversity of Virginia Elson Student Health CenterCharlottesville, Virginia
Learning Objectives
Attendees should be able to:1. Explain the impact of unidentified
psychosomatic Illness on the college and university healthcare system.
2. Identify psychosomatic illness commonly seen among college and university students.
3. Describe strategies to effectively treat students with psychosomatic conditions.
Overview
The impact of somatoform disorders Diagnostic terms: now and future Pathophysiology & psychology Treatment recommendations Clinical course & prognosis Cases References
Describing the burden
Prevalence of somatoform disorders in general practice reported as high as 30%
Unexplained chronic pain affects >25% primary care patients Accrued twice the costs for medical care. Utilized twice the services (out and in-patient)
Overuse of specialist consultation Unmeasured impact on patients’
academic & social lives
Jay,23, 2rd year med student
Initial presentation: Nov 3, 20091. Intermittent vague LUQ abdominal
discomfort2. chronic loose stools3. chronic GERD with concern about long-
term PPI use.4. Lymphadenopathy (R cervical &
supraclavicular). Had a panic attack while driving and palpating nodes. “He is very concerned about cancer.”
5. Tremor in his hands, and numbness at the tip of his tongue, both of which are chronic.
Somatization
Experiencing psychological distress in the form of physical symptoms for which one seeks medical care.
Somatization can be conscious or not, and may be influenced by psychological distress or a desire for personal gain.
Symptoms range from exaggeration of common problems to disabling and unrelenting clinical syndromes.
DSM-IV-TR: Somatoform disorders Undifferentiated somatoform
disorder Pain disorder Somatization disorder Hypochondriasis Body dysmorphic disorder Conversion Disorder Somatoform disorder NOS
Somatization disorder
A. A history of many physical complaints beginning before age 30, occurring over several years & resulting in treatment being sought or significant impairment in social, occupational or other important areas of functioning.
B. Must include 4 pain symptoms, 2 GI symptoms, one sexual symptom, one pseudoneurologic symptom.
C. Either not explained by a known GMC, or impairment exceeds expected for existing GMC
Somatization disorder
Less than 1% of patients with Medically Unexplained Symptoms (MUS) meet criteria for Somatization Disorder.
1-year prevalence among US adults is 0.3%.
Hypochondriasis
Preoccupation with the fear of having a serious disease based on misinterpretation of bodily symptoms despite appropriate medical evaluation and reassurance.
Conviction about illness is not of delusional intensity, and is not restricted to concern about appearance.
Preoccupation lasts at least 6 months & causes clinically significant distress or impairment.
Hypochondriasis
Male = female prevalence Insight varies among affected
patients Commonly co-occurs with anxiety
and depressive disorders. Onset is typically later in life than
somatization disorder 4-6% of general medical outpatients
Undifferentiated somatoform disorder: One or more physical symptoms that cause significant distress or impairment in functioning lasting at least 6 months .
Pain disorder: Pain in one or more sites, causing significant distress or impairment and associated with psychological factors.
May be associated with a psychological factors, or with psychological factors and a GMC.
Acute if < 6 months; chronic if 6 months or longer.
Body dysmorphic disorder Preoccupation with an imagined or
exaggerated physical defect Conversion disorder
Unintentionally produced deficits affecting voluntary motor or sensory function that suggest a neurological or other GM, associated with psychological factors.
Somatoform disorder NOS Psuedocyesis Nonpsychotic hypochondriacal symptoms of
less than 6 months duration Unexplained physical complaints (fatigue,
weakness) of less than 6 months duration
DSM V (Draft) “current terminology for somatoform disorders
is confusing” somatoform disorders, malingering, and
factitious disorders all involve physical symptoms and/or concern about medical illness,” they will be reclassified as Somatic Symptom Disorders.
Somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder shall be grouped into a new diagnosis: Complex Somatic Symptom Disorder. “
http://www.dsm5.org/ProposedRevisions/Pages/SomatoformDisorders.aspx
Complex Somatic Symptom Disorder To meet criteria for CSSD, criteria A, B, and C are necessary. A. Somatic symptoms: One or more somatic symptoms that are distressing and/or result in
significant disruption in daily life. B. Overwhelming concern or preoccupation with symptoms
and illness: At least three of the following are required to meet this criterion: (1) High level of health-related anxiety. (2) A tendency to fear the worst about one's health or bodily
symptoms (catastrophizing). (3) Belief in the medical seriousness of one's symptoms
despite evidence to the contrary. (4) Health concerns and/or symptoms assume a central role in
one's life (ruminative preoccupation). C. Chronicity: Although any one symptom may not be continuously
present, the state of being symptomatic is chronic (at least 6 months).
Pathogenesis
Symptoms are real, exaggerated, and/or imagined
Patients’ experience of symptoms leads to distressing fears and beliefs
There is no clear bio, psycho or social explanation
Existing theories are not mutually exclusive.
Proposed neurobiology
Efferent pathways: HPA Axis hypoactivity Deficits lead arousal to cause increased bodily
discomfort Afferent pathways: altered brain asymmetry in
neuroendocrine regulation of sensory processing Central misinterpretation of physical experience
Sensitization in the limbic system or pain pathway due to repeated “toxic exposures” Trauma, illness
Overactive neurophysiological 'as-if loops’ related to self-representation mirror neurons
Psychology: Attachment Insecure , preoccupied attachment style
(independent of negative affect) Negative self-view, idealized view of others Clingy, seek reassurance in relationships at
times of stress Attachment style is relatively stable across
the first 19 years of life History of traumatic childhood experiences
(loss, illness, inconsistent care) A major function of attachment behavior is
affect regulation
Psychology: Alexithymia
Difficulty processing and communicating (representing) subjective feelings; focus on concrete external events
Moderate correlation with somatization in a series of college student samples
40% of 118 general psychiatric outpatients scored in the alexithymic range of the Toronto Alexithymia Scale. This subset scored significantly higher on
validated measures of somatization, depression and anxiety.
The feature-positive effect Unequal weighing of positive and
negative information Unequal weighing of active and
passive behaviors
In hypochondriasis, patients focus on “positive information” of bodily symptoms and discount “negative information” of empirical test results and PE findings.
Cultural influences
“Pain” comes from the Latin ‘poena’, for punishment or penalty
Health and illness beliefs are informed by spirituality, superstition, and age
Death beliefs affect health anxiety Negative beliefs about death are
associated with increased health anxiety Positive beliefs about death are
associated with reduced health anxiety
Risk factors?
A history of sexual abuse is associated with:
functional GI symptoms nonspecific chronic pain psychogenic seizures chronic pelvic pain.
Risk factors?
Patients with MUS often had ill parents as children
Patients with h/o childhood fatigue are more likely to report noncardiac chest pain.
Children with benign murmurs have poor psychosocial outcomes, presumably due to parents’ fear of underlying serious illness
The “worried well”
Psychiatric comorbidity: 2/3 of hypochondriacs GAD OCD
5-10% of hypochondriacs Social phobia MDD (may present only with somatic features)
40% of hypochondriacs Panic disorder
10-20% of hypochondriacs Substance dependance (opioids)
Copyright © 2007 The Royal College of Psychiatrists
De Waal, M. W. M. et al. Br J Psychiatry 2004;184:470-476
Fig. 1 Overlap between somatoform disorders and anxiety or depressive disorders: weighted prevalence (s.e.). Observed comorbidity, 4.20%;
expected comorbidity, 1.26%; ratio=3.3. Within somatoform disorders: 26% anxiety and/or depressive disorders; within anxiety and/or depressive
disorders: 54% somatoform disorders.
General medical conditions cause these symptoms, too Celiac disease: 1 in 250 Americans IBD: incidence 1-10 cases per
100,000; prevalence 200 N. Americans per 100,000.
Ischemic heart disease is rare in young adults
Evaluation
History HPI PMH:
include psychiatric history recent physicians and patient’s experience of them
Family history: especially during patient’s childhood elicit parental attitudes toward illness
Social history: include history of sexual abuse childhood illnesses, school avoidance current academic and social pressures
Physical Exam
Medical treatment
Structured, scheduled visits with the same clinician minimize crises, reduce urgent contacts
Start with weekly or biweekly brief (20-minute) visits progressively lengthen the intervals
Centralize care Discuss purpose of and limit
referrals, tests, meds
Psychological treatment
About 50% of patients refuse psychotherapy referral
Most patients with MUS are open to psychosocial treatment provided by PCP, in addition to usual care
Clinician must reframe own expectations (“cure” is unlikely)
CBT in Primary care
Establish a partnership minimize shame & fear of abandonment respond to patient’s emotions and
concerns identify treatment goals provide education
Establish a routine review interval since last visit set goals for current visit assign homework
Psychological treatment
CBT by an expert can focus on: misinterpretation of positive symptoms selective attention, safety-seeking, and
bodily discomfort due to anxiety revalue negative test results and
physical exam findings
Prognosis
Medically Unexplained Symptoms 50-75% improve 10-30% deteriorate
Hypochondriasis 30-50% recover
Number of somatic symptoms and “seriousness of condition” at baseline influences course and prognosis
Inconclusive evidence regarding influence of untreated psychiatric comorbidity
Kyle, 21, 3rd year CS major
Initial presentation: Nov 2008 Chronic LUQ abdominal wall and
recurrent periumbilical pain, GERD Recently seen in ER: normal CT and labs Per PCP (at Student Health): Bentyl for
suspected IBS, Prilosec for GERD “RTC if no improvement or symptoms
worsen.”
Kyle: Jan 2009
Patient calls with worsening, persistent pain: Extensive GI workup done over break in NoVa:
EGD, bloodwork, repeat CT, camera endoscopy; GI told him: “liver biopsy is the next step.”
Vicodin from GI Bentyl, Elavil, Prilosec from PCP (student health) KUB ordered to rule out stones: negative.
Endorses depression & anxiety; requests referral to CAPS. Referred out to CBT therapist: “Nice guy, but he didn’t
help.”
Kyle: May 2009
Referred to MD in CAPS, for 2nd opinion. Endorses panic attacks, “constant anxiety” using Dad’s Xanax requests “a benzo,” refuses an SSRI.
History of depression with suicide attempt at 13. Past meds: Prozac, Paxil, Celexa, Zoloft, Effexor,
Cymbalta, Elavil. All cause atypical, intolerable side effects.
Therapists are “nice but not helpful”; felt mistreated by 3 psychiatrists.
Help seeking, help-rejecting, insecure attachment style noted.
Kyle: September 2009
Mirtazepine, TENS unit, nortriptyline tried. Now on clonazepam prn and trazodone.
Biofeedback helps with sleep, not pain.
Intensifying suicidal thoughts related to the relentless pain.
Discussed with treatment team. Patient aware, agrees to meet another CAPS psychiatrist for one-time 2nd opinion.
Kyle: September 2009
2nd Psychiatric assessment reveals: childhood history of sexual abuse by his
brother, which parents “didn’t buy” remote and recent cutting. Frequent appointments are comforting,
but he fears “wasting the doctor’s time”. Recommendations:
psychodynamic therapy minimize psychotropic medication.
Kyle, May 2010
Patient met therapist twice a week for 4 months; now meets with psychiatrist weekly. Focus has shifted to reducing, not eliminating pain,
and on his unsupported negative self-evaluation. Clonidine for pain and BP is partially effective
Coordinated referral to pain specialist : Recommendation: Trileptal or Nucynta (tapentadol,
a mu-opioid receptor agonist and NRI active in pain-signaling pathways).
One week later: “Pain free.” Summer break: scheduled visits offered; he
prefers email contact.
Jay,23, 2rd year med student
Initial presentation: Nov 3, 20091. LUQ abdominal discomfort2. chronic loose stools3. chronic GERD with concern about long-
term PPI use.4. Lymphadenopathy, panic attack,
concerned about cancer.5. Chronic tremor and tongue numbness.
Jay: initial workup & plan Screening labs
GI symptoms: CMP, lipase, TSH LAD: CBC with differential
Bentyl GI referral (per patient request) CAPS referral for anxiety with panic
attack. Patient encouraged to use walk-in hours.
Follow-up scheduled to address chronic tremor and tongue numbness
Jay: follow-up Feb 18
Since last visit: new concern for elevated BP: 140s/80s at home since
last visit, and at GI office visit Now predominanty constipated. GI started Kapidex and Benefiber, scheduled EGD,
ordered TTG. Lymphadenopathy without constitutional symptoms
persists. Patient is worried about being seen in CAPS. “Patient expresses preoccupation with his own
health….For any symptoms he tends to jump to a terminal illness diagnosis for himself.” He spends hours daily looking up diagnoses, surfing online forums, performing self-exams, daily temp.
Jay: follow-up workup & plan BP: Stop body-building supplement; recheck in 2
weeks. GI: plan per consultant LN: 2 normal CBCs separated by 3 months; recheck
HIV serology for completion. PPD reviewed (8/09), CXR to rule out mediastinal LAD. “I do not think it is worth launching into a large workup for the LN w/out any other symptoms, and I explained this to the patient today.”
Anxiety: clonazepam 0.5mg q12h prn; referral to Med-Psych colleague for 2nd opinion. “...follow up with me or with Dr A after he has had a 2nd opinion. I am happy to continue working with him.”
Jay: 2nd opinion visit
April 2010 BP: off supplement, within normal limits LN: reporting epitrochlear nodes, “which
we learned are never normal”. Has scheduled an appointment with Heme-Onc attending for a definitive opinion on this concern.
GI: diagnosed with celiac disease; not yet on gluten-free diet.
Anxiety: won’t go to CAPS; wants to start an SSRI.
Susan, 20: postprandial pain Recovering from Anorexia nervosa, still
in weight-gain phase of treatment. Normal physical exam except for low
BMI, no alarm symptoms. Work-up:
Serology for celiac disease ESR for Inflammatory Bowel Disease CBC for infection Comprehensive metabolic Amylase
Neil, 21: Headache and insomnia GP6D deficiency, alpha-thalassemia trait
with mild anemia Normal physical exam except for
severely depressed affect, no alarm symptoms. Neurology consultation: imaging, HA meds Referral to CAPS: resistant to behavioral
techniques but open to psychodynamic psychotherapy
Limited medication trials and reiteration of sleep hygiene for insomnia
Kara, 19: Chest pain
PE notable for reproducible costochondral tenderness, otherwise normal.
Patient previously seen in CAPS for anxiety and long history of disordered eating. EKG Basic metabolic panel & CBC Event monitoring
Review of recommendations
The relationship is the key! Frequent scheduled contact Standardized, centralized care Set limits
specialists medications tests
Support systems Patient-centered Clinician-centered
University of Virginia
Acknowledgments
My colleagues in General Medicine Meredith Hayden, Amber Pendleton, Neil
Silva, Claire Veber My colleagues in CAPS
Daniel Ciudin, Emily Lape, Katy Rice, Rafael Triana
References
American Psychiatric Assn, DSM-IV-TR, 2000. Barsky, A. N Engl J Med, Vol 345, No 19, (2001) 1395-1933. Greenberg, DB, “Somatization,” uptodate.com (version
18.1 Jan 2010) De Waal, M. W. M. et al. Br J Psychiatry 2004;184:470-476 Gros, D, et al “Frequency and severity of the symptoms of
irritable bowel syndrome across the anxiety disorders and depression.” Journal of Anxiety Disorders 23 (2009) 290-296.
Haugaard, J. “Recognizing and Treating Uncommon Behavioral and Emotional Disorders in Children and Adolescents Who have been Severely Maltreated: Somatization and Other Somatoform Disorders.” Child Maltreatment, Vol 9, No 2 (2004) 169-176.
Henningsen, P. “The body in the brain: towards a representational neurobiology of somatoform disorders.” Acta Neuropsychiatrica 2003 15: 157-160.
Hotopf, MB ,et al. “Psychosocial and Developmental antecedents of chest pain in young adults,” Psychosomatic Medicine 61: 861-867 (1999).
James A and Wells A, “Death beliefs, superstitious beliefs and health anxiety.” British Journal of Clinical Psychology, 41, (2002) 43-53.
Lamberg, L. “New Mind/Body Tactics Target Medically Unexplained Physical Symptoms and Fears.” JAMA, Vol 294, No 17 (2005) 2152-2154.
olde Harteman, T, et al. “Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review.” Journal of Psychosomatic Research 66 (2009) 363-377.
Rassin, E, et al “The feature-positive effect and hypochondriacal concerns.” Behaviour Res & Therapy 46 (2008) 263-269.
Roelofs, K and Spinhoven, P. “Trauma and medically unexplained symptoms: towards an integration of cognitive and neuro-biological accounts.” Clinical Psychology Review 27 (2007) 798-820.
Smith, R and Dwamena, F. “Primary care management of medically unexplained symptoms,” uptodate.com (version 18.1 Jan 2010 )
Taylor, G. et al “Alexithymia and Somatic complaints in Psychiatric out-patients.” Journal of Psychosomatic Research, Vol 36, No 5, (1992) 417-424
Tyrer, S. “Psychosomatic Pain.” British Journal of Psychiatry, 188 (2004) 91-93.
Verhaak, P, et al. “Persistent presentation of medically unexplained symptoms in general practice.” Family Practice Advance Access, April 2006.
Weardon, A et al. “Adult Attachment, Reassurance Seeking and Hypochondriacal Concerns in College Students,” Journal of Health Psychology, (2006) Vol 11 (6) 877-886.
Wise, T and Birket-Smith, M. “The Somatoform Disorders for DSM-V: The need for changes in process and content.” Psychosomatics 43:6, (2002)