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: C.Bridle@warwick.ac.uk 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

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Tutorial begins at 3.15

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