“Unexplained illness” Managing somatization : art & evidence

1. “Unexplained illness”Managing somatization: art & evidence Norman Jensen MD MS Professor, General Internal Medicine University of Wisconsin - Madison nmj@medicine.wisc.edu

2. Take 1 minute to write 3 things you’d like to learn from this workshop

3. 3 things U’d like to learn from this workshop … 1. 2. 3. After the workshop, did U learn them? Y N ? What U learned that U didn’t expect …

4. Workshop Schedule 1:00 Intro & Learning Objectives 1:15 Case Talk 2:00 Didactic 2:50 Break 3:00 Skills demonstration 3:45 Skills work - small groups 4:15 Summary & assessment 4:30 Adjourn

5. Somatization ILO s • Enhancement of • Clinical concept of somatization • `definitions • pathophysiology • epidemiology • diagnosis • Medical management • The practical and the evidence • Communication with patient

6. Unexplained 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?

7. 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

9. Somatization, a definition • 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 Jensen

10. Somatization Disorder 300.81 • 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

11. Somatization Disorder 300.81 • 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.

12. Somatization Disorder 300.81 • C. 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.

13. Undifferentiated Somatoform 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

14. Suffering in somatoform illness • Disease • Sickness • Illness

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

16. Theoretical Mechanisms: Neurobiologic • 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.

17. Attention, emotion, memories of prior experience Central Control L - + + T Action System SG S G - - + s Gate Control System - Melzack & Wall, Science 1965 SG = Substantia Gelatinosa in dorsal horn

18. Harrison’s Textbook of Internal Medicine 1962 (4th) & 1970 (6th) 1983 (10th)

19. Harrison’s Textbook of Internal Medicine Afferent Efferent 1987 (11th) & 1991 (12th) 1994 (13th) & 1998 (14th)

20. The “Pain Matrix”

21. “Pain sensitivity linked to gene” Wisconsin 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.

22. NMDA – ReceptorN-methyl-D-aspartate • Hypotheses • Involved in neuropathic pain • Antagonists block “Opioid insensitive” component • Dextromethorphan • d-methadone • NMDA antagonist & Opioid agonists • (dl) Methadone • Dextropropoyphene • ketobemidone

23. Theoretical Mechanisms: Neurobiologic • 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”

24. Theoretical Mechanisms: Social-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.

25. Contexts of Somatization • normal daily experience • highly situational • marked individual differences • marked cultural differences • associated with ΨS stress • associated with DSM disorders

26. SD: 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%

27. Impact on Personal Health • Illness behavior • Social function • Role function • Mental functioning • Sense of well being • Physical functioning • Bed days slide in development

28. Impact on Health Services • 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.

29. Impact on Physicians’ Attitudes • 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”.

30. Rx

31. Medical ManagementPrinciple components • Patient education • Risk of a missed “organic” diagnosis • Medical resource conservation • Protect patient from medical injury • Use of consultants • Care for the doctor

32. Management:Patient 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

33. Management:RISK 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

34. Management:Resource 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

35. Management:Protect the patient • Marginal tests • especially invasive tests • Marginal treatments • toxicity • polypharmacy • Excess expense • Assert your primary care role

36. Management:Use of Consultants • Carefully explain purpose. • Assure your ongoing commitment -- “expert advice helps me be the best possible doctor for you”. • Psychiatry consultant helps diagnose co-morbid DSM disorders. • Prepare consultants so they too will judiciously use tests, procedures, drugs.

37. Management:Caring for the doctor • These patients consume energy • Confront and cope with negative responses • learn professional emotion handling skills • Seek support of colleagues, formal or informal • Credit yourself with hard work done well with your fair share of these patients • Refer to another doctor if you cannot provide state-of-the-art care for this patient.

38. Management that WORKSWhat is the Evidence ?  Consult-advice CBT for patient CBT training for MD Drug Therapy

39. 3 Randomized ControlledStudies of Psychiatric Consultation 1. Smith RG, NEJM 1986;314:1407-13 2. Rost K. General Hospital Psychiatry 1994;16:381-7. 3. Smith GR. Arch Gen Psychiatry 1995;52:238-43.

40. Intervention • Psychiatric consultation letter • described somatization disorder • MD encouraged to serve as primary • management suggestions • regular visits, q 4-6 weeks • physical exam at each visit • avoid hosp., procedures, surgery, tests • avoid, “it’s all in your head”

41. Results S MDs PTs%  $ Function F/U mo. 1 35 38 SD50 h  dis. day 18 2 59 73 S21 (12) mental  role 12  physical 3 51 58 SD33 physical 12

42. Evidence that CBT worksKroenke, Psychother Psychosom 2000;69(4):205-215.

43. Rx: Training 1 Physicians • 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”.

44. Drug Therapy • Insufficient evidence to recommend. • Small trials show interest for • tricyclic antidepressants • fluvoxamine • gabapentin • anti-psychotics (if psychosis)

45. The abstract ends here! Questions? Answers $0.25Answers requiring thought $1.00Correct answers $2.50 Comments?

46. Skills Work is Next Goal 1: Increase personal awareness Goal 2: Reduce instinctive responses Goal 3: Enhance trained responses Learning Method: Reflection on action Observed action Participatory action

47. Skills DemonstrationsDiscussion to Follow

48. Skills Demonstration • 46 y/o woman who has had multiple waxing and waning sx for > 15 years. • We’ve done a complete hx & pe and reviewed large stack of tests and images. Everything we’d have wanted has been done. • Her diagnosis is very clearly Somatoform Disorder, 300.81. • We must now inform & motivate this patient for management.

49. Skills Practice - evaluationThere are lots of good ways to communicate • Take time out anytime • For reflection • Ask for help • How well did it work? • Well enough? Why & how? • Less well? Alternative actions? • Feedback: Ask - Tell - Ask

50. Skills Practice • Role play is • voluntary; no one is required to do it • not real; it is simulation, practice • a rare opportunity; try something new • confidential; take some risk • play; have some fun.