““Unexplained illness”Unexplained illness”Managing Managing

somatizationsomatization: art & : art & evidenceevidence

Norman Jensen MD MSProfessor, General Internal Medicine

University of Wisconsin - Madison

nmj@medicine.wisc.edu

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What U learned that U didn’t expect …

Workshop ScheduleWorkshop Schedule1:001:00 Intro & Learning ObjectivesIntro & Learning Objectives1:151:15 Case TalkCase Talk2:002:00 DidacticDidactic2:502:50 BreakBreak3:003:00 Skills demonstrationSkills demonstration3:45 3:45 Skills work - small groupsSkills work - small groups4:154:15 Summary & assessmentSummary & assessment4:304:30 AdjournAdjourn

Somatization ILO s Somatization ILO s

Enhancement ofEnhancement of– Clinical concept of somatizationClinical concept of somatization

`definitions`definitions pathophysiologypathophysiology epidemiologyepidemiology diagnosisdiagnosis

– Medical managementMedical management The practical and the evidenceThe practical and the evidence

– Communication with patientCommunication with patient

Unexplained IllnessUnexplained Illness

How can it be explained? How can I be a good doctor

when I can’t explain my patient’s symptoms?

What is the evidence for effective management?

46 y/o woman from LaCrosse comes self-referred, as a new patient for the evaluation of multiple waxing and waning symptoms for more than 15 years. She comes with two bulging radiology folders and a 3 inch stack of medical records recording many normal physical exams and laboratory tests. She comes to the “U” to find out what’s wrong; “something is definitely wrong” and the other doctors “think it’s all in my head”. She is not worried about a specific condition.

PMH = lots of illness; no disease. FH = not significant.

Soc Hx = married twice, two young adult children, insurance office manager, “rough childhood”.

ROS = very +, see following slide. PE = She looks healthy and worried. VS and full PE normal.

Labs and Imaging = lots of them all normal

Somatization, a Somatization, a definitiondefinition

The indirect, unconscious, unintentional expression (transduction) of psych. distress through illness, as an alternate to direct expressions of emotion, anxiety and depression; a dysfunction just beginning to be describable in terms of anatomy and chemistry; its reality is appreciated only via patient’s subjective experience. Described 1960s; DSM dx 1980. N JensenN Jensen

Somatization DisorderSomatization Disorder 300.81300.81

A. Many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning. DSM IV

Somatization DisorderSomatization Disorder 300.81300.81

B. B. Each of following required to have occurred at any time in course of illness:– 1. Pain in at at least four sites or

functions– 2. Two GI symptoms other than pain– 3. One sexual symptom– 4. One neurological symptom.

Somatization DisorderSomatization Disorder 300.81300.81

CC. Either of the following:– 1. Each of the symptoms ( in criterion B)

cannot be fully explained by a known medical condition or direct effect of a substance.

– 2. In presence of a known medical condition, the symptoms or impairment are in excess of what the disease stage would explain.

D. Not intentionally produced / feigned.

Undifferentiated Undifferentiated Somatoform Disorder 300.81Somatoform Disorder 300.81

AKA, sub-threshold or abridged SD, or somatization syndrome

One or more symptom– medically unexplained, or– beyond expectation from known

pathology Causing distress or dysfunction Duration => 6 months

Suffering in somatoform Suffering in somatoform illnessillness

DiseaseDiseaseSicknessSicknessIllnessIllness

“By golly, you ARE crying on the inside!”

Theoretical Mechanisms: Theoretical Mechanisms: NeurobiologicNeurobiologic

Variable CNS modulation of incoming sensory information, e.g., – conversion = excessive inhibition– somatization = inadequate inhibition.

Melzack R & Wall P. Pain mechanisms: A new theory. Science. 1965;150:971-979

Wall P. The gate control theory of pain mechanisms: a re-examination and re-statement. Brain. 1978;101:1-18.

Action

System

TS GSG-

+

Central Control

Gate Control System - Melzack & Wall, Science 1965

SG = Substantia Gelatinosa in dorsal horn

+

+-

-

s

L

Attention, emotion, memories of prior experience

1962 (4th) & 1970 (6th) 1983 (10th)

Harrison’s Textbook of Internal Medicine

1994 (13th) & 1998 (14th)1987 (11th) & 1991 (12th)

Harrison’s Textbook of Internal Medicine

Afferent Efferent

The The “Pain “Pain MatriMatri

x”x”

““Pain sensitivity linked to Pain sensitivity linked to gene” gene” Wisconsin State Journal 1999Wisconsin State Journal 1999

muOR: thalamus and spinal cord muOR density

– :: 1/pain perception – :: morphine analgesia– varies by individual– varies with stress conditions

Uhl GR, et al. The mu opiate receptor as a candidate gene for pain: Polymorphisms, variations in expression, nociception, and opiate responses. Proc Natl Acad Sci U S A. 1999 Jul 6;96(14):7752-7755.

NMDA – ReceptorNMDA – ReceptorN-methyl-D-aspartateN-methyl-D-aspartate

HypothesesHypotheses– Involved in neuropathic painInvolved in neuropathic pain– Antagonists block “Opioid insensitive” Antagonists block “Opioid insensitive”

componentcomponent DextromethorphanDextromethorphan d-methadoned-methadone

– NMDA antagonist & Opioid agonistsNMDA antagonist & Opioid agonists (dl) Methadone(dl) Methadone DextropropoypheneDextropropoyphene ketobemidoneketobemidone

Theoretical Mechanisms: Theoretical Mechanisms: NeurobiologicNeurobiologic

Alexithymia, a cognitive-affective disturbance characterized by difficulties in verbally expressing moods, symbols, and feelings.

Kooiman CG. The status of alexithymia as a risk factor in medically unexplained physical symptoms. Comprehensive Psychiatry. 1998;39:152-159.

– Corpus callosum defects prevent symbolic & affective information in the right hemisphere from reaching the left hemisphere so as to be expressed in language

TenHouten W, et.al. Alexithymia: an experimental study of cerebral commissurotomy patients and normal control subjects. Am J Psychiatry 1986;143:312-316.

– “Emotional IQ”

Theoretical Mechanisms: Theoretical Mechanisms: Social-psychologicalSocial-psychological

Psychological (nature)– needs for nurturance & support – “defense mechanisms” that resolve conflict

Social-cultural (nurture)– SICK ROLE (1° gain)– CULTURAL CORRECTNESS

parents (“big kids don’t cry”) CLINICIANS - “Balint agreement”, “this won’t hurt” teachers, clergy, peers, etc.

Contexts of Contexts of SomatizationSomatization

normal daily experience highly situational marked individual differences marked cultural differences associated with ΨS stress associated with DSM disorders

SD: EpidemiologySD: Epidemiology

Community prevalence DSM IV

– 0.2 - 2.0% for women– ~ < 0.2% for men

Primary care prevalence– Somatization 25 - 75%– Somatization disorder ?– Hypochondriasis ~3%

Impact on Personal Impact on Personal HealthHealth Illness behaviorIllness behavior

– Social function Social function Role functionRole function

– Mental functioning Mental functioning Sense of well beingSense of well being

– Physical functioningPhysical functioning Bed daysBed days

slide in developmentslide in development

Impact on Health Impact on Health ServicesServices

60% of primary care patients recurrently present with unexplained somatic sx. “ … the failure to provide mental health service [had] the potential of bankrupting the health care financing system due to over-utilization of primary care physicians by somatizing patients.”

Rand / Permanente Study Cummings. Health Policy Quarterly 1981;1159-1175.

Impact on Physicians’ Impact on Physicians’ AttitudesAttitudes Gorlin: helplessness, loss of control,

inadequacy, impotence, frustration, threatened authority, anger, and guild.

Groves: aversion, fear / counter-attack, guilt, inadequacy, malice, wish that patients would “die and get it over with”.

RxRx

Medical ManagementMedical Management

Principle componentsPrinciple components Patient educationPatient education Risk of a missed “organic” Risk of a missed “organic”

diagnosisdiagnosis Medical resource conservationMedical resource conservation Protect patient from medical Protect patient from medical

injuryinjury Use of consultantsUse of consultants Care for the doctorCare for the doctor

Management:Management:

Patient EducationPatient Education Give the illness a name

– abnormal nervous system– leaky gates, weak editing / noise filtering– give examples from ordinary experience

Postpone psychological interpretation– resistance prone by nature or nurture– hypersensitive to doubt of sx reality– expect slow or no insight

Management:Management:

RISK of MISSED DXRISK of MISSED DX Share the diagnostic risk with patient

– Document discussion in medical record

Systematic surveillance– regular visits, longer duration– careful listening for change in sx– liberal physical exam of symptomatic parts

(somatoform relationship)– parsimonious use of tests, drugs, & surgery

Management:Management:

Resource conservationResource conservation Limit: ER, urgent care, walk-ins,

and phone calls - contract if needed. Raised threshold for tests, images,

drugs, surgery, procedures Substitute old-fashioned doctoring

– empathic listening / witnessing– liberal physical exam– reliable, accepting, helping relationship

Management:Management:

Protect the patientProtect the patient Marginal tests

– especially invasive tests Marginal treatments

– toxicity– polypharmacy

Excess expense Assert your primary care role

Management:Management:

Use of ConsultantsUse of Consultants Carefully explain purpose. Carefully explain purpose. Assure your ongoing commitment -- Assure your ongoing commitment --

“expert advice helps me be the best “expert advice helps me be the best possible doctor for you”.possible doctor for you”.

Psychiatry consultant helps diagnose co-Psychiatry consultant helps diagnose co-morbid DSM disorders.morbid DSM disorders.

Prepare consultantsPrepare consultants so they too will so they too will judiciously use tests, procedures, drugs.judiciously use tests, procedures, drugs.

Management:Management:

Caring for the doctorCaring for the doctor

These patients consume energyThese patients consume energy Confront and cope with negative responsesConfront and cope with negative responses

– learn professional emotion handling skillslearn professional emotion handling skills

Seek support of colleagues, formal or informalSeek support of colleagues, formal or informal Credit yourself with hard work done well with Credit yourself with hard work done well with

your fair share of these patientsyour fair share of these patients Refer to another doctor if you cannot provide Refer to another doctor if you cannot provide

state-of-the-art care for this patientstate-of-the-art care for this patient..

Management that WORKSManagement that WORKS

What is the What is the Evidence ?Evidence ?

Consult-advice CBT for patient CBT training for MDDrug Therapy

3 Randomized Controlled3 Randomized ControlledStudies of Studies of

Psychiatric ConsultationPsychiatric Consultation

1. Smith RG, NEJM 1986;314:1407-132. Rost K. General Hospital Psychiatry 1994;16:381-7.3. Smith GR. Arch Gen Psychiatry 1995;52:238-43.

InterventionIntervention

Psychiatric consultation letterPsychiatric consultation letter– described somatization disorderdescribed somatization disorder– MD encouraged to serve as primaryMD encouraged to serve as primary– management suggestionsmanagement suggestions

regular visits, q 4-6 weeksregular visits, q 4-6 weeks physical exam at each visitphysical exam at each visit avoid hosp., procedures, surgery, testsavoid hosp., procedures, surgery, tests avoid, “it’s all in your head”avoid, “it’s all in your head”

ResultsResults

S MDs PTsS MDs PTs % % $ $ FunctionFunction F/U F/U mo.mo.

1 35 38 1 35 38 SDSD 50 h 50 h dis. day dis. day 18 18

2 59 73 2 59 73 SS 21 21 (12) (12) mentalmental

rolerole 12 12

physicalphysical

3 51 58 3 51 58 SDSD 3333 physical physical 12 12

Evidence that CBT Evidence that CBT worksworks

Kroenke, Psychother Psychosom 2000;69(4):205-Kroenke, Psychother Psychosom 2000;69(4):205-215.215.

N % All Studies

All 31 ImproveDefinite

ImprovePossible

SomaticDistress

28 71 11

PsychDistress

26 38 8

Function 19 47 26

Rx: Training 1Rx: Training 1 PhysiciansPhysicians Moriss R, Gask L, Ronalds C, et.al.et.al. Cost-effectiveness of a

new treatment for somatized mental disorder taught to GPs.

Family Practice 1998;15:119-25. Before-after GP CBT 8hr. group training. 8

GPs. 102+112 patients with somatization & mental disorder. At 3 mo., 23.1% cost of referrals outside practice, patient-initiated consultations, cost variation per patient. 1/3 pts mental function, disqualifying as “mental”.

Drug TherapyDrug Therapy

Insufficient evidence to Insufficient evidence to recommend.recommend.

Small trials show interest forSmall trials show interest for– tricyclic antidepressantstricyclic antidepressants– fluvoxaminefluvoxamine– gabapentingabapentin– anti-psychotics (if psychosis)anti-psychotics (if psychosis)

The abstract ends here!

Questions?Answers $0.25Answers requiring thought $1.00Correct answers $2.50

Comments?

Skills Work is NextSkills Work is Next

Goal 1: Goal 1: Increase personal Increase personal awarenessawareness

Goal 2: Goal 2: Reduce instinctive Reduce instinctive responsesresponses

Goal 3: Goal 3: Enhance trained Enhance trained responsesresponses

Learning Method: Reflection on Learning Method: Reflection on actionaction

Observed actionObserved action

Participatory actionParticipatory action

Skills Skills DemonstrationsDemonstrations

Discussion to Discussion to FollowFollow

Skills DemonstrationSkills Demonstration 46 y/o woman who has had multiple 46 y/o woman who has had multiple

waxing and waning sx for > 15 waxing and waning sx for > 15 years.years.

We’ve done a complete hx & pe and We’ve done a complete hx & pe and reviewed large stack of tests and reviewed large stack of tests and images. Everything we’d have images. Everything we’d have wanted has been done. wanted has been done.

Her diagnosis is very clearly Her diagnosis is very clearly Somatoform Disorder, 300.81.Somatoform Disorder, 300.81.

We must now inform & motivate this We must now inform & motivate this patient for management.patient for management.

Skills Practice - Skills Practice - evaluationevaluation

There are lots of good ways to There are lots of good ways to communicatecommunicate Take time out anytimeTake time out anytime

– For reflectionFor reflection– Ask for helpAsk for help

How well did it work?How well did it work?– Well enough? Why & how?Well enough? Why & how?– Less well? Alternative actions?Less well? Alternative actions?

Feedback: Ask - Tell - AskFeedback: Ask - Tell - Ask

Skills PracticeSkills Practice Role play is Role play is

– voluntary; voluntary; no one is required to no one is required to do itdo it

– not real; it is simulation, practicenot real; it is simulation, practice– a rare opportunity; try something a rare opportunity; try something

newnew– confidential; take some riskconfidential; take some risk– play; have some fun.play; have some fun.

Summary & Summary & AssessmentAssessment

Take-home learning?Take-home learning?

Please complete Please complete evaluations.evaluations.

Thanks for coming!Thanks for coming!

END of END of WORKSHOPWORKSHOP

Additional information slides Additional information slides followfollow

Usual symptomsUsual symptoms Gastrointestinal (other than pain)

– nausea & bloating most common– vomiting, diarrhea, food intolerance

Sexual - reproductive– women: metrorrhagia, menorrhagia,

vomiting throughout pregnancy, sexual indifference

– men: “E D”, ejaculatory dysfunction, sexual indifference

Usual symptomsUsual symptoms Neurological

– impaired coordination or balance– paralysis or localized weakness– loss of touch or pain sensation– double vision or blindness– deafness– seizures – Dissociative, e.g., amnesia– loss of consciousness other than

fainting

DSM disorders DSM disorders associated with associated with

somatizationsomatizationMoodMoodAnxietyAnxietyAODAAODAAdjustmentAdjustment

SD: Epidemiology, SD: Epidemiology, cont.cont.

Family coincidence ( 1° rel.) DSM IV

– women, 10-20% S D– men, antisocial and AODA

Impact on Health Impact on Health Services IIServices II Collyer 1979, FP: 28% visits involved emotional illness, taking 48% of his time; 3.6% families too 32% his time.

Katon 1984: 25-75% 1° care visits were caused by somatized Ψ-S stress; these patients take time 2-4 X non-somatizing patients.

Burnum 1985, IM: Over 3 mos. 98/909 pts. had major Ψ-S problems, 65 combined with physical disease.

Impact on Health Impact on Health Services IIIServices III Regier 1984, citizens with any of 13

DSM disorders, 58% had seen their 1°MD in prior 6 mos -- used medical care 2X normal.

NAMCS 1978 & 1985: 70% pts with DX’d DSM disorders gave a somatic complaint as CC for MD visits.

(Regier 1978, Schurman 1985)

Impact on Impact on Physicians’ AttitudePhysicians’ Attitude

Katon, et.al: physicians found somatizing patients to be signif. more frustrating than other high utilizing HMO patients.

Managing SomatizationManaging Somatization Dx: complete problem listDx: complete problem list Doctor - patient relationshipDoctor - patient relationship Patient educationPatient education Cope: doctor anger, anxiety & Cope: doctor anger, anxiety &

fatiguefatigue missed diagnosismissed diagnosis time & energy requirementstime & energy requirements

Conserve resourcesConserve resources Care for the doctorCare for the doctor

ManagementManagement

First PrinciplesFirst Principles Observe adjustment responses.Observe adjustment responses. DX and RX mood and anxiety disorders.DX and RX mood and anxiety disorders. Doctor-Patient Relationship is central!Doctor-Patient Relationship is central!

– Commitment: Commitment: chronic care & realistic goalschronic care & realistic goals– Rogerian Rogerian helpinghelping relationship relationship

accepting, empathic, congruentaccepting, empathic, congruent (Carl Rogers)(Carl Rogers)

Treatment Effects ITreatment Effects I

Smith RG, NEJM 1986;314:1407-13

RCT-xo with 35 1° MDs & 38 SD patients. consult letter resulted in ~50% decrease in health care charges compared to patients of control doctors. Mostly hospitalization cost. Trend disability days. 18 month follow-up.

Treatment Effects IITreatment Effects II Rost K, et.al. General Hospital Psychiatry 1994;16:381-7.

A RCT-xo of MDs & somatizing patients, of consultation letter to 59 1° MDs. 73 patients reported 17% [0%*] greater physical capacity and had 21% [12%*] reduction in health care charges. Trend mental and role function. No change gen’l health or social functioning. One year follow-up.

Treatment Effects IIITreatment Effects III Smith GR, et.al. Arch Gen Psychiatry

1995;52:238-43. A RCT-xo of 51 MDs and 56

Somatizing patients of consult letter with management suggestions, resulted in 33% decrease in medical and psychiatric charges and significantly improved physical functioning up to one year after trial was finished.

Treatment Effects IVTreatment Effects IV

Hellman, C.J., Budd, M., Borysenko, J., McClelland, D.C., and Benson, H. A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic

complaints. Behav.Med. 16(4):165-173, 1990. RCT 80 primary care patients, Boston

HMO. COG-BEHAV RX vs information. At 6 months, subjects had reduced visits and less psych and somatic symptoms.

Treatment Effects VTreatment Effects V Speckens AEM, van Hemert AM, Spinhoven P, et. al. Cognitive Speckens AEM, van Hemert AM, Spinhoven P, et. al. Cognitive

behavioural therapy for medically unexplained physical symptoms: a behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial. BMJ 1995;311:1328-1332.randomised controlled trial. BMJ 1995;311:1328-1332.

RCT in NL GIM consultation clinic. RCT in NL GIM consultation clinic. 39 S & 40 C. 6-16 CBT vs. usual care. 39 S & 40 C. 6-16 CBT vs. usual care. 6 & 12 mo. S = 6 & 12 mo. S = “recovery”, sx “recovery”, sx intensity & frequency, sleep, social intensity & frequency, sleep, social life, leisure activities, and illness life, leisure activities, and illness behavior. Severity somatization behavior. Severity somatization unspecified.unspecified.

Treatment Effects VITreatment Effects VI Hellman, C.J., Budd, M., Borysenko, J., McClelland, D.C., and

Benson, H. A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints.

Behav.Med. 16(4):165-173, 1990. RCT 80 PC somatizing patients. At 6-

mo. CBT subjects HMO visits, Ψsx & somatic sx. Effective therapy =~ teaching pts about the relationship among thoughts, behaviors and sx.

Treatment Effects VIITreatment Effects VII RCT group therapy with 70 SD patients, 8 RCT group therapy with 70 SD patients, 8

sessions + consultation to primary doctorsessions + consultation to primary doctor Better physical and mental health at 1yr Better physical and mental health at 1yr Improvement :: # sessions attendedImprovement :: # sessions attended 52% net savings in health care charges 52% net savings in health care charges Kashner, T.M., Rost, K. Enhancing the health of Kashner, T.M., Rost, K. Enhancing the health of

somatization disorder patients. Effectiveness of somatization disorder patients. Effectiveness of short-term group therapy.short-term group therapy. Psychosomatics. Psychosomatics. 36(5):462-470, 1995.36(5):462-470, 1995.

Hypochondriasis 300.7Hypochondriasis 300.7 Preoccupation with fears of having, or the

idea that one has, a serious disease based on misinterpretation of symptoms.

Despite medical evaluation and reassurance.

Not delusional. Causes distress or impairment in function For at least 6 months Not better explained by another DSM

disorder.

Conversion DisorderConversion Disorder 300.11300.11

A motor or sensory dysfunction that suggests neurological or medical disease

Psychological factors precede onset or exacerbation.

Not intentionally produced or feigned. Cannot be fully explained by a organic disease,

direct effects of a substance, or culturally sanctioned behavior.

Causes distress or impairment. Not limited to pain or sexual dysfunction, Not better explained by another DSM disorder.

Body Dysmorphic Body Dysmorphic DisorderDisorder 300.7 300.7

A. Preoccupation with an imagined or exaggerated defect in appearance.

B. Causes distress or impairment.

C. Not better accounted for by another DSM disorder.

Somatoform Disorder, Somatoform Disorder, NOSNOS

300.81 300.81Does not meet criteria for any S D

Pseudocyesis Hypochondriacal symptoms < 6

months Somatoform symptoms < 6 months

Somatoform Pain Somatoform Pain DisorderDisorder

307.80 307.80 with psychological factorswith psychological factors307.89 307.89 with both psych. factors and with both psych. factors and

medical conditionmedical condition Pain in one or more sites as the main warrant for clinical consultation.

Causes distress or impairment. Psychological factors judged to have

important etiologic or mechanistic role Not intentionally produced or feigned. Not better accounted for by another DSM

disorder

Skills Practice - Skills Practice - evaluationevaluation

There are lots of good ways to There are lots of good ways to communicatecommunicate How well did it work? (score?)How well did it work? (score?)

If it worked well, what If it worked well, what happened?happened?

If it didn’t work as well as I’d If it didn’t work as well as I’d like, what might I do differently like, what might I do differently next time?next time?

You can take time out anytime.You can take time out anytime. You can ask the group for help.You can ask the group for help.

Workshop Schedule - 105 Workshop Schedule - 105 min.min.3:303:30 Intro & Learning ObjectivesIntro & Learning Objectives3:353:35 Case TalkCase Talk3:503:50 DidacticDidactic4:10 Skills demonstration4:10 Skills demonstration4:20 4:20 Skills work - small groupsSkills work - small groups5:005:00 Summary & assessmentSummary & assessment5:155:15 AdjournAdjourn