Walking Into the Eye of the Storm: Somatic Symptom Disorders in Primary Care Derek Enns, DPT, Cameron Froude, PhD, Perry Dickinson, MD

Transcription

1 Walking Into the Eye of the Storm: Somatic Symptom Disorders in Primary Care Derek Enns, DPT, Cameron Froude, PhD, Perry Dickinson, MD

2 Objectives Describe pathophysiology of somatization and frustrating clinical scenarios, Explain effective long-term treatment and appointment management for somaticizing patients, Building a multidisciplinary team and explaining team-based approach to patients and providers

3 Case Presentation 55 y/o woman followed by me for about six years (moved away several years ago) List of complaints over last six visits: fatigue, dizziness, headaches, chest pain, palpitations, nausea, tingling in arm, weakness of arm and leg, abdominal pain, dysurea, increased urinary frequency, pelvic pain, decrease in visual field, myalgias, joint aches Family history - father and mother both alcoholics, mother committed suicide (found by patient); sexual abuse by family friend as young teen, rape at age 24

4 Case Presentation Continued Past history of alcohol abuse - abstinent Symptoms of depression, anxiety, panic attacks, PTSD Over the last year before she moved - 14 visits with me, 6 with other physicians in our clinic; 8 specialist visits, 4 trips to ER, one hospitalization for RUQ pain (had cholecystectomy for what turned out to be a normal gall bladder with sludge only)

5 The Newest Set of Labels Conversion Disorder Factitious Disorder Illness Anxiety Disorder Somatic Symptom Disorder Other somatic symptom disorders Psychological factors affecting medical condition

6 Making Sense of the (DSM) Madness Screen for Illness Anxiety Disorder and/or Psych. Factors Affecting Medical Conditions Is psychiatric disorder characterized by somatic symptoms? YES Are symptoms intentionally produced? Why? Factitious Disorder Do symptoms result in loss of motor or sensory function? Malingering Somatic Symptom Disorder Conversion Disorder

7 Prevalence of Somatization Lifetime: ~40% report unexplained somatic symptoms Snapshot: ~50% primary care, unexplained somatic symptoms 12 months later, symptoms remained

8 Impact of Somatization High level of suffering and day to day impairment associated with somatization High level of utilization of health care resources Tend to have a high number of other mental health symptoms Tend to have a lot of explained symptoms as well Very frustrating patients to take care of

9 Abuse and Violence Sexual abuse or assault is very common among patients with somatization Our study: Past history of contact sexual abuse in childhood or forced sexual activity against their wishes in adulthood Somatization Disorder Group - 2/3 Control group - 1/3 Add other forms of child abuse, trauma, domestic violence - numbers go even higher

10 Patterns of Violence Many patients had history of violence in their family of origin as well The more violence and abuse, in the patients and in their families, the more somatization and the more other mental health symptoms Also, younger age of onset of abuse, abuse by family members, re-victimization - all associated with more problems Start seeing a complex web of symptoms, both physical and mental, resulting from the violence

11 What is a pathophysiologic explanation for these symptoms? Let s look at the neurobiologic theory

12 Neurobiologic Theory

13 The Root is Trauma A threat to survival in the name of helplessness. FIGHT. FLIGHT. FREEZE.

14 Healthy Nervous System

15 Traumatized Nervous System

16 Implications for Practice Somatization is very common in family practice - and causes a lot of problems for patients and physicians, as well as a lot of cost We can cause a great deal of harm to somatizing patients - unnecessary tests, surgery, medications We also can reinforce somatizing behavior and compound the problem - especially a problem in somatizers with other, real illness

17 Component Description Care MD Approach C onsultation Consult and collaborate with mental health professionals A ssessment Evaluate for other medical and psychiatric diseases R egular visits E mpathy Schedule short-interval follow-up Spend most of the time listening to the patient and acknowledge what he or she is feeling is real. M edical-psychiatric interface Emphasize the mind-body connection; avoid comments such as there is nothing medically wrong with you. D o no harm Limit diagnostic testing and referrals to subspecialists; reassure the patient that serious medical diseases have been ruled out

18 Screening GRADE: C

19 Therapy Cognitive behavioral therapy Mindfulness based therapy GRADE: B Amitriptyline SSRIs St. John s Wort monoamine oxidase inhibitors, bupropion [Wellbutrin], anticonvulsants, and antipsychotics

20 What to Avoid Dysregulation Adding to the Illness Narrative Refer and Forget Water Cooler Stories

21 Comments and Questions Welcome!