Transcript The Anxiety Disorders Some Practical Questions & Answers

The Somatoform Disorders
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process
A Presentation for the Students of Ohio University
Heritage College of Osteopathic Medicine
Kendall L. Stewart, MD, MBA, DLFAPA
November 8, 2012
1I
hope to provide practical insights that will assist you in caring for these patients.
let me know whether I’ve succeeded and how I could improve on your evaluation form and Facebook.
2Please
Why does this matter?
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About 60-80% of the general
population will experience a somatic
symptom in any given week.
About 60% of the people who visit
physicians come in for complaints
for which no physical or biological
abnormalities can be found.
Another 20-30% of patients are
seeking help for a “psychosomatic”
disorder such as Irritable Bowel
Syndrome (IBS).
While some of these patients have
physical problems that have not yet
been diagnosed, unexplained somatic
complaints are big business for
physicians.
And somatoform patients are hard to
satisfy.
• After mastering the
information in this
presentation, you will be able
to
– Specify the other diagnoses in
this category,
– Identify the diagnostic criteria
for these disorders,
– Describe the evaluation of the
patient with a somatoform
disorder,
– Discuss a differential
diagnosis,
– Write a typical treatment plan,
and
– Explain some of the usual
treatment challenges.
most clinical specialties, you will be impressed by the social needs you will face.
I was young, I tried to cut back on what I saw as exploitation; I learned to ask patients when they wanted to return.
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What other diagnoses are included in
the Somatoform Disorders category?
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Somatization Disorder
Undifferentiated Somatoform Disorder
Conversion Disorder
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With Motor Symptom or Deficit
With Sensory Symptom or Deficit
With Seizures or Convulsions
With Mixed Presentation
Pain Disorder
– Associated With Psychological Factors
– Associated With Both Psychological Factors and a General
Medical Condition
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1The
Hypochondriasis
Body Dysmorphic Disorder1
Somatoform Disorder NOS
In DSM-5, this category will likely be renamed Somatic
Symptom Disorders and much of the current terminology will
be changed.
current thinking is that this bizarre disorder is best conceptualized as part of the obsessive-compulsive disorder (OCD)
spectrum of disorders. Indeed, it will likely be moved to that category in DSM-5.
What are the diagnostic criteria for
Somatization Disorder?
• A history of many physical complaints over many years beginning
before age 30 that caused impairment1
• Each of the following criteria:
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Four pain symptoms
Two GI symptoms
One sexual symptom
One pseudo-neurological symptom
• Either
– After appropriate investigation, the above symptoms cannot be
explained by a General Medical Condition (GMD) or by a substance
– If a GMD exists, the symptoms are out of proportion
• The symptoms are not intentionally feigned or factitious
1A
man brought in a list of over 100 complaints. Unfortunately, I made a note on his list.
What are the diagnostic criteria for
Conversion Disorder?
• One or more symptoms or deficits affecting
voluntary motor or sensory function
• Associated psychological factors1
• Not feigned
• Not adequately explained by a GMD, a substance
or a culturally-sanctioned behavior or
experience2
• Not limited to pain or sexual dysfunction or a
part of Somatization Disorder
1A
patient became paralyzed after an argument with her father. “I just wanted to kick him out of the room.”
religious people are “slain by the spirit.” Hypnotic suggestion is another example.
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What are the diagnostic criteria for
Somatoform Pain Disorder?
• Pain in one or more anatomical sites that is
the focus of the presentation
• Causes impairment
• Psychological factors judged to have an
important role1
• Not feigned
• Pain is not better accounted for by another
mental disorder or a GMD
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pain has a significant psychological component. When people ask me if my back is hurting, I realize that it is.
What are the diagnostic criteria for
Hypochondriasis?
• Preoccupation that one has a serious illness
based on misinterpretation of bodily symptoms1
• Preoccupation persists despite evaluation and
reassurance
• Belief not of delusional intensity or due to Body
Dysmorphic Disorder
• Causes impairment
• Duration of at least 6 months
• Not better accounted for by another disorder
1My
mother spent most of her life convinced that she had diabetes.
How can you keep these patients
straight?
Is there an organic explanation?
No
Yes
Pain only?
Organic Disease
No Yes
Loss of sensory/motor function only? Pain Disorder
No
Yes
Conversion Disorder
Multiple symptoms?
No
Yes
Fear of disease?
Somatization Disorder
Yes
Hypochondriasis
Is the patient preoccupied with an imagined defect in appearance?
Yes
Body Dysmorphic Disorder
How do Somatization Disorder
patients present?1,2
• “I’m 36-year-old woman.”
• “I have this unbearable pain in
my stomach.”
• “I’ve had this many times over
the past 15 years.”
• “No doctor has ever been able
to figure out what is wrong.”
• “I’ve had several surgeries, but
the pain just keeps coming
back.”
• “I’ve been given many
diagnoses and much treatment,
but nothing has really helped.”
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2But
• “I have dizziness, chest pain,
painful urination, urinary
retention, chronic low back
pain and I have pain when I
have intercourse.”
• “I’ve tried to kill myself several
times.”
• “Both of my parents were
alcoholic.”
• “I was in and out of foster
homes as a child.”
• “My father and brothers abused
me sexually and physically.”
• “The only time I was happy as a
child was when I was in the
hospital.”
people are “hypochondriacs” and this causes diagnostic confusion.
patients with Hypochondriasis have the persistent fear that they have some undiagnosed disease.
What are some of the differential
diagnoses in Somatization Disorder?
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Somatic disorders that present with vague or multiple somatic
complaints
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Multiple sclerosis
Systemic lupus erythematosus
Hyperparathyroidism
Porphyria
The onset of somatic disorder after age 301,2
Schizophrenia with multiple somatic delusions
Panic disorder with somatic complaints
PTSD
Conversion disorder
Somatoform pain disorder
Hypochondriasis
Factitious disorder
patients have an occult GMD until proven otherwise.
man was anxious and was excessively sedated by low-dose lorazepam. He turned out the have ALS.
What is the biological basis of the
Somatoform Disorders?1
• These patient may have characteristic
attention and cognitive impairments.
• Excessive distractibility
• Inability to habituate to repetitive
stimuli,
• Partial and circumstantial
associations
• Lack of selectivity
• Decreased metabolism in the frontal
lobes and the nondominant
hemisphere
• Transmission of Somatization Disorder
has genetic components.
• Abnormal regulation of the cytokine
system may play a role.
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Kaplan & Sadock, 2008
How do you evaluate patients with
Somatization Disorder?
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Very carefully
After a painstaking history
After gentle confrontation about the diagnosis
After accepting that the patient is really
suffering
After consultation with a psychiatrist
After the offer of a referral to a major center1
After agreeing that this is best managed as a
chronic illness2
When new symptoms appear
When the character of the patient’s symptoms
change
you feel that every reasonable thing has been done?”
you ready to cope with this as a chronic illness?”
2“Are
How do you treat patients with
Somatization Disorder?
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1“In
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Begin with an acceptance of their
suffering.
Try to get them to talk about their
feelings instead of their physical
symptoms.
Order additional tests
circumspectly.
Monitor your own feelings.
Recommend a psychiatric
consultation, but reassure the
patient that you are not dumping.
Gently insist on a team approach.
Make regular appointments even
though you can see no reason for
them.
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Tolerate and admit the uncertainty.
Do not make guarantees.
Admit that more testing could
always be done, but tell the patient
you understand that he or she does
not want more unnecessary
testing.
Refer the patient when you realize
the patient is not satisfied with
your service, is not doing well in
spite of your best efforts or when
you just can’t stand it any more.1,2
spite of my best efforts, you are just not doing well. The time has come someone to take a fresh look at this problem.”
not offer to refer; insist.
What are some of the typical
treatment challenges?
• These folk are tough, miserable, insistent—
displeased and displeasing.
• They resist a referral to a psychiatrist.
• They have maddeningly-little insight.
• They have a need to see the doctor regularly and
complain.
• They often fire their physicians.
• Sometimes, something is physically wrong.1
• Then they sue—and win.
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still wake up in a sweat thinking about some of the things I’ve missed. A woman with depression had occult cancer.
Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April
2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Justin Greenlee, DO
Darren Adams, DO
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