Somatization

1. Somatization

2. Could the patient be suffering with a psychosomatic illness? • Somatization • Physical complaints or impairments: • Without organic pathology • That are grossly in excess of what would be expected from the physical findings

3. Somatization • Somatizing patients: • Are unable to use emotional language to describe their distress • Express their psychological illness or social distress with somatic symptoms • Somatization is an entirely unconscious process

4. Somatization • Psychosomatic complaints frequently involve: • Chronic pain • Problems with the digestive system, nervous system, and reproductive system • Typical onset – before age 30 • Higher prevalence for women than men (National Library of Medicine, 2006)

5. Mechanisms of Somatization • Somatization may be understood from four theoretical perspectives • Neurobiological • Psychodynamic • Behavioral • Sociocultural

6. Mechanisms of Somatization • Neurobiological • Somatization results from defective or deficient neurobiological processing of sensory and emotional information • Psychodynamic • Somatized physiological sensations occur as expressions of underlying emotional conflict • Somatization enables patients to meet latent needs for nurturing and support

7. Mechanisms of Somatization • Behavioral • Somatization is viewed as behavior that is brought about and reinforced by others in the patient’s environment • “Illness-maintenance systems”

8. Mechanisms of Somatization • Sociocultural • Social norms concerning emotions • When a culture does not allow direct communication of emotional content, one means available to express emotions is through physical symptoms • Somatization serves to notify others of emotional or psychological distress in an acceptable or non-stigmatized manner

9. Contributing Factors for Somatization • Childhood abuse • Acute stress • Societal roles • Learned behavior • Secondary gain • Cultural factors • Histrionic, narcissistic, and borderline personality traits

10. Significance of Somatization • Primary care physicians encounter perplexing somatic complaints in up to 40% of their patients (McCarron, 2008) • Many of these patients are suffering from depression and anxiety, which are common problems seen in the primary care setting

11. Significance of Somatization • Many patients experiencing depression or anxiety visit their physicians with predominantly physical complaints • Fatigue • Dizziness • Headache • Abdominal pain • Extremity pain • That are accompanied by requests for “check-ups”

12. Vomiting and/or nausea Abdominal pain Bloating Diarrhea Pain in the legs or arms Back pain Joint pain Pain during urination Headaches Shortness of breath Palpitations Chest pain Dizziness Amnesia Difficult swallowing Vision changes Paralysis or muscle weakness Pain during intercourse Impotence Painful or irregular menstruation (NLM, 2006)

13. Presentation of Somatizers • Most somatizers are unaware of the psychological disorders (or emotional conflicts) that underlie their symptoms • Even when/if they perceive anxious or depressed feelings, they rarely understand or acknowledge a connection between these feelings and their physical symptoms

14. Clinical Clues to Somatization • How can physicians detect this phenomenon and be comfortable with the diagnosis of somatization?

15. Clinical Clues to Somatization • Thick chart syndrome • Marked change in utilization pattern • Vague, confusing, or bizarre symptoms • Resistance to psychological inquiry or explanations • Specific complaints such as dizziness, fatigue, or insomnia • Physician’s “heartsink” response

16. Differential Diagnosis • Acute somatization • Chronic somatization • Somatoform disorders • Malingering and Factitious disorder

17. Differential Diagnosis • Acute Somatization • Results from transient stress that temporarily overwhelms usual coping mechanisms • Most common form of somatization • Usually no history of health care-seeking behavior, and fairly readily accept stress as a cause of their symptoms

18. Somatization • Chronic Somatization • Occurs in the context of a specific psychiatric disorder such as depression, anxiety, personality disorders • Long-lasting process • Two subcategories of chronic somatization • Somatoform disorders • Malingering and Factitious disorder

19. Somatoform Disorders • Psychiatric illness for which somatization is the sole manifestation • Presence of physical symptoms that suggest a general medical condition, and are not fully explained by a general medical condition, by the direct effects of a substance, or by another mental disorder • Symptoms cause clinically significant distress • Symptoms are involuntary

20. 7 Categories of Somatoform Disorders • Somatization Disorder • Undifferentiated Somatoform Disorder • Conversion Disorder • Pain Disorder • Hypochondriasis • Body Dysmorphic Disorder • Somatoform Disorder Not Otherwise Specified

21. Somatoform Disorders • Somatization Disorder • Polysmptomatic disorder (combination of pain, gastrointestinal, sexual, pseudoneurological symptoms) • Begins before age 30 • Chronic pattern • Undifferentiated Somatoform Disorder • Unexplained physical complaints (6 mths) • Below the threshold for a dx of Somatization Disorder

22. Somatoform Disorders • Conversion disorder • Psychosomatic symptoms affecting voluntary motor or sensory function that suggest a neurological or other general medical condition • Hypochondrias • Preoccupation with fears of having, or the idea that one has, a serous disease based on the person's misinterpretation of bodily symptoms

23. Somatoform Disorders • Body Dysmorphic Disorder • Preoccupation with an imagined defect in appearance • Pain Disorder • Pain – predominant focus of clinical attention • Psychological factors are judged to have an important role in its onset, severity, exacerbation, or maintenance

24. Factitious Disorders • Characterized by: • Physical or psychological symptoms that are intentionally produced or feigned in order to assume the sick role • Conscious fabrication of symptoms to gain attention • Diagnosis is based on direct evidence and by excluding other causes of the symptoms • The presence of factitious symptoms does not preclude the coexistence of true physical or psychological symptoms

25. Malingering • Intentionally feigning or grossly exaggerating illness or disability to derive benefit or secondary gain(e.g., to escape work, gain compensation, or obtain drugs)

26. Factitious Disorder May agree to unnecessary surgery and interventions Motivated by psychological needs (attention, security, etc) Malingering Will not agree to unnecessary surgery/interventions Motivated by secondary gains (avoid work/stay on disability) More common in military populations and legal settings Factitious Disorder vs. Malingering

27. Risk Factors for Malingering • Risk factors for malingering include: • Ongoing litigation • Significant discrepancy between subjective disability and objective findings • Lack of cooperation with the evaluation and with treatment • Antisocial personality disorder

28. Evaluation of Patients • Even when a previously diagnosed psychiatric disorder is present, to what extent should other health complaints be evaluated and excluded as possible causes of unexplained, persistent symptoms? • Are physicians negligent if they do not perform extensive diagnostic testing?

29. Evaluation of Patients • Each person deserves: • Careful and empathic listening • Thorough physical exam • A review of previous records • And, for some, limited diagnostic testing

30. Evaluation of Patients • The laboratory evaluation should be directed with patient-specific symptoms and physical signs

31. Waddell Behavioral Signs • A clinical assessment usually begins with history taking and records review, and continues with a physical examination. • In the assessment of low back pain, the patient's response to the physical examination is particularly important. • In 1980, Dr. Gordon Waddell and associates drew attention to nonorganic signs in back pain and attempted to integrate them into modern concepts of pain and illness behavior. They published a standardized assessment of behavioral (nonorganic) responses to examination.

32. Waddell Behavioral Signs • Waddell grouped eight signs into five types. • These five types (or categories of signs) are: • tenderness • simulation • distraction • regional disturbances • overreaction

33. The presence of three or more of these signs is considered a positive finding and is associated with other clinical measures of illness behavior and psychological distress, suggesting the patient does not have a straightforward physical/organic problem

34. Tenderness • Superficial and non-anatomic skin discomfort on palpation • Tenderness related to physical disease is usually localized • Physical (organic) back pain does not make the skin tender to light touch

35. Simulation • Axial loading or simulated rotation with report of low back pain. • Pressure on the top of the head (axial loading) of a standing patient should not cause low back pain. • When the shoulders and pelvis are rotated in unison (simulated rotation), the structures in the back are not stressed. • If the patient reports back pain with this maneuver, the test is considered positive for a nonorganic source of the patient's complaints.

36. Distraction • In the standard straight-leg raise test, the patient is recumbent and aware of the test being performed • In contrast, a distracted straight-leg raise test is performed anytime the hip is flexed with the knee straight • The distracted straight-leg raise test can be done by examining the foot with the patient seated with one knee extended • Another example of a distraction test would be when the patient uses the injured limb when distracted

37. Regional Disturbances • Sensory change or weakness; any widespread or global numbness that involves an entire extremity (stocking, glove) or side of the body and does not follow expected neurologic patterns is suspect • Regional, sudden, or uneven weakness (cogwheeling, giving way, breakaway) is a nonorganic, behavioral sign

38. Overreaction • The patient may be hypersensitive to light touch at one point during examination but later give no response to touching of the same area • This is a positive sign of overreaction, as evidenced by a disproportionate grimace, tremor, exaggerated verbalizations, sweating, or collapse • Other behavioral signs include inappropriate sighing, guarding, bracing, and rubbing; insistence on standing or changing position; and questionable use of walking aids or equipment

39. The original purpose of the Waddell behavioral signs was to: • Aid clinical assessment by separation of the organic and nonorganic elements of the presentation • Direct appropriate resources toward the physical pathology • Identify illness behavior • Reduce or eliminate unnecessary procedures, diagnostic studies, and therapies

40. Waddell’s caveats • In his article, Waddell cautioned the use of the behavioral signs in the following situations: • Multiple false positives were found in the elderly patients and it was recommended that such patients should be fully evaluated. • Behavioral signs can occur in the presence of organic pathology. The presence of these behavioral signs does not contradict organic findings.

41. Validity of Waddell’s behavioral signs • Since Waddell published his article, multiple studies have independently validated his findings and have shown correlation between behavioral signs, level of disability, and physical and psychological factors. • However, over the last 20 years, Waddell behavioral signs have been misinterpreted and misused both clinically and medical-legally. • Behavioral responses to examination provide useful clinical information, but need to be interpreted with care and understanding.

42. Multiple behavioral signs suggest that the patient does not have a straightforward physical problem and that psychological factors need to be considered. • Patients who present with multiple behavioral signs require management of their physical pathology, as well as close attention and management of the psychological aspects of their illness. • Behavioral signs offer only a psychological "red-flag" and not a complete psychological assessment. Behavioral signs on their own are not a test of credibility or validity.

43. Physical Exams for Nonorganic back pain • Mankopf’s test: This test is based on the fact that pain raises the pulse rate. Palpation of a painful area should increase the pulse rate by 5% or more. Absence of this finding is a positive behavioral sign.

44. O'Donoghue's maneuver: In patients with true physiologic (organic) pain, passive range of motion is greater than active range. If the patient's active range of motion is greater, it is a positive behavioral sign.

45. McBride's test: Ask the patient to stand on one leg while raising the opposite knee to the chest. Because the knee is bent, no sciatic stretch occurs and the spine is flexed, thereby removing pressure from the facets. Thus, this position should lessen low back pain. A reported increase in pain, or a refusal to do the test, is a positive behavioral sign.

46. Hoover's test • This test is performed on a supine patient. Hold the patient's heels off the table, and ask him or her to raise one leg. If the leg is raised easily, the test is negative • However, if this movement is difficult due to organic LBP, the patient will push the contralateral leg toward the table for assistance in raising the leg • Therefore, lack of downward pressure from the contralateral leg is a positive sign of malingering

47. Burn's test: Ask the patient to kneel on a chair and touch the floor. Because the knees are bent, patients with true back pain or sciatica should be able to do the test without much difficulty, but those with nonorganic back pain usually cannot.

48. Management • Most important aspect of managing somatizing patients? • Development of an empathic, trusting doctor-patient relationship • It is critical to both diagnosis and treatment • Early detection is important • Better response to psychological treatment • Fewer iatrogenic effects • Stronger doctor-patient relationship

49. Management • CARE-MD treatment approach • Cognitive behavioral therapy (CBT) • Assess: rule out medical causes • Regular visits: Short frequent visits with focused exams • Explore stressors, promote healthy coping • Set boundaries • Empathy • Med-psych interface • Do no harm (McCarron, 2008)

50. Management • Physician as educator • Explain that symptoms are due to a disorder of the autonomic nervous system, which can be present despite "normal" diagnostic tests • Attempt to identify psychosocial stressors that worsen the patient's pain complaint • Draw a link between these stressors and the autonomic nervous system • Efforts can then be directed by the patient toward reducing or eliminating these stressors