Somatization and Medically Unexplained Symptoms; What’s Normal and What’s Not Arthur J. Barsky, M.D. Professor of Psych

1. Somatization and Medically Unexplained Symptoms; What’s Normal and What’s Not Arthur J. Barsky, M.D. Professor of Psychiatry, Harvard Medical School Director of Psychiatric Research, Brigham and Women’s Hospital Boston, MA

2. Disclosure: Arthur J. Barsky, MD With respect to the following presentation, there has been no relevant financial relationship between the party listed above (and/or spouse/partner) and any for-profit company in the past 24 months which could be considered a conflict of interest.

3. Somatization Has Multiple Definitions (1) Medically Unexplained Symptoms: disproportionate to demonstrable disease; attributed by patient to disease; prompt medical help-seeking (2) Somatization: the experience and reporting of psychiatric disorder as bodily symptom; the tendency to selectively focus on the physical aspects of psychological distress and minimize, ignore, remain unaware of affective distress

4. Somatization Has Multiple Definitions, (cont) (3) Somatoform Disorders (e.g., somatization disorder); group of Axis I disorders characterized by physical symptoms suggesting a medical illness but on closer inspection better understood as psychiatric rather than medical conditions. We will use definition #1

5. High Prevalence of Somatic Symptoms Good health not symptom free Part of daily life, endemic human experience 80-90% general population: > 1 symptom per week Typical adult: 1 symptom every 5-7 days 81% college students report > 1 symptom within 3 days 20% adults: “substantial,” “prolonged” fatigue 80% complain of lifetime back pain, 45% within one year 15%-30% back pain, joint pain, muscle pain within 2 weeks Only small minority  medical consultation

6. High Prevalence of Somatic Symptoms, (cont) Usual response Normalization; benign attributions Symptoms generally transient, self-limited “Most things really are better by morning” Physical and psychological distress highly correlated GHQ and somatic symptom inventory r = 0.42 Physical sickness dysphoria and dysphoric emotions accompanied by bodily sensations Anxiety and depression

7. Somatic Symptoms: A Final Common Pathway Product of interpersonal, socio-cultural, psychological, characterological, situational forces (1) Response to stressful life events - E.g., grief reaction, s/p MI, spousal abuse, medical school (2) Interpersonal communication - Non-verbal request for care, attention, special consideration, support (e.g., back rub; “tired feet”) - Need acknowledgment of distress - Trying to enlist help to deal with a problem

8. Somatic Symptoms: A Final Common Pathway, (cont) (3) A coping style: Learned illness and sick role behavior - Seek “time out” via sick role - Unwittingly learned that illness has secondary gains: exempted from duties, avoid challenges, postpone obligations - Control family members, avoid intimacy, excuse ill temper (“A family is an autocracy ruled by its sickest member.”) - An explanation for failure to cope successfully - Not conscious malingering

9. Somatic Symptoms: A Final Common Pathway, (cont) (4) A personality characteristic - Alexithymia: unawareness of emotion; inability to distinguish physical and psychological; mechanistic cognitive style - Negative affectivity: stable, enduring tendency to report generalized emotional distress; highly correlated with somatic symptom reporting - Amplifying somatic style: tendency to monitor bodily sensation; select out and focus upon particular sensation; experience mild, ambiguous bodily sensations as alarming, noxious and intense

10. Somatic Symptoms: A Final Common Pathway, (cont) (5) An intra-psychic defense mechanism - Symptoms have unconscious meaning, gratification - Dependency (“Pain brings love”) - Hostility (“Turn reproach towards someone into complaints to someone”) - Narcissism

11. Somatic Symptoms: A Final Common Pathway, (cont) (6) Non-specific, secondary feature of psychiatric disorder - Psychological ESR - Most somatoform disorder cases have psychiatric comorbidity - GAD, PD, MDD, OCD, Axis II

12. Distinguishing Normal and Abnormal Somatization (1) Symptoms: multiplicity, severity, chronicity (2) Difficulty coping: extreme role impairment (3) Disease conviction: resistance to benign explanation, reassurance (4) Illness as a way of life; invalidism (5) Maladaptive medical care; extensive but unsatisfactory (6) Refractoriness to palliative, symptomatic treatment

13. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

14. Common Reservoir of Bodily Distress Normal physiology Self-limited, minor, benign ailments Previously diagnosed medical disease Autonomic concomitants of emotion Stress response

15. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

16. Precipitants Onset of psychiatric disorder (e.g., panic attack) Medical threat Personally meaningful event/stressor

17. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

18. Provisional Disease Attribution Provisional reattribution of symptom to disease

19. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

20. Cognitive and Perceptual Processing Bodily hypervigilance Selective attention Confirmatory bias Health-related anxiety

21. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

22. Symptom Amplification Symptoms become more intense, noxious, intrusive, alarming

23. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

24. Medical Care Seek medical attention

25. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

26. Reassurance Explanation Education Symptomatic treatment “Tincture of time”

27. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

28. Normal Transient Somatization Resolution of symptom and concern

29. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

30. Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate Secondary gain Situation/stressor does not resolve Illness behaviors reinforce symptoms Iatrogenesis Major psychiatric comorbidity

31. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

32. Chronic, Severe, Disabling, Refractory ? Somatoform disorder ?

33. Symptom Amplification Model Reassurance Normal Transient Somatization Common Reservoir of Distress Provisional Disease Attribution Symptom Amplification Medical Care Chronic, Severe, Disabling, Refractory Precipitants Cognitive and Perceptual Processing Psychiatric and Psychosocial Factors Perpetuate, Maintain, Exacerbate

34. Summary Good health is not symptom-free and therefore is a reservoir of distress available for misattribution, somatization Multiple psychological, interpersonal and situational forces can precipitate symptom amplification and misattribution of these symptoms to disease This process not necessarily psychopathological Psychopathological forces may be more important in maintaining and perpetuating symptoms, and in producing intractability and refractoriness to medical management, than in initiating the symptoms Treatment focus should be on coping with symptoms and an impairment and disability than on symptomatic cure