10 Somatoform

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CoCommon Psychiatric Problemsmmon Psychiatric Problemsin Family Practice in Family Practice

Somatoform DisordersSomatoform Disorders

Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine

Dr. Zekeriya Aktürkzekeriya.akturk@gmail.com

www.aile.net

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Your most difficult

patients ?Pain everywhe

reNot

improving

Comming every day

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• At the end of this session, the trainees will increase their knowledge in managing somatoform disorders– Explain the pathopysiology

– List symptoms which might be somatic

– List diagnostic criteria of somatoform disorders

– Explain the management principles of somatisation

– Categorize the somatoform disorders

Aim-Objectives

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somatization

desomatization

resomatization

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Bodily symptoms without any organic, physical cause

Definition

Lipowsky 1988

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• No explanatory organic cause can be found in 20-84% of patients presenting with bodily symptoms.

Why important?

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More common among less More common among less educated and less incomeeducated and less income

Epidemyology

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I. Increased bodily sensitivity Physical symptoms perceived are normal

for most individuals

Pathopysiology

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II. Defined patient Stress within the

family stabilizes after the member bocomes “sick”

Pathopysiology

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III. Need to be sick

Becoming physically sick is less stressfull than being unsuccessfull

Barsky,1997

“There is no medicine or surgery to remove the

need to be sick”BARSKY,1997

Pathopysiology

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IV. Dissociation

Perceiving a stimulus which is not present

• Phantom pain

• Depersonalization

• Flashback

Pathopysiology

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• Somatization

• Conversion disorder

• Hypochondriasis

• Pain disorder

• Body dysmorphic disorder

Somatoform Disorders

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• Resemples a neurological problemResemples a neurological problem

• Motor or sensorial symptomsMotor or sensorial symptoms

• Not explainable by neuroanatomyNot explainable by neuroanatomy

• ““La belle indiference” La belle indiference”

• Females 10-35 years,Females 10-35 years,

• Lower socioeconomic classLower socioeconomic class

Conversion

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• “Disease of having disease”

• Severe anxiety

• M/F=1

• No insight

• Resistant, causing functional losses

Hypochondirasis

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• Main symptom is pain

• M/F=1/2

• Pain increases with stressPain increases with stress

• Not explainable with nouroanatomyNot explainable with nouroanatomy

• Organic problem may be superimposedOrganic problem may be superimposed

Pain disorder

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• Belives that there is a problem with appearance

• Obsessive

• M/F=1

• Frequent cosmetic surgery

Body Dysmorphic Disorder

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Organic cause?Substance abuse?

Other psychiatric dis.?

Neurological symptom conversion

Pain predominant

Too busy with disease Hypochondriasis

Pain disorder

Somatization dis.Many symptoms

Intentional symptoms Malingering

yok

I

II

III

IV

V

VI

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SYMPTOMS WHICH MIGHT BE SOMATIC

GIS

Nausea

Abdominal pain

Diarrhea

Belching

Bloating

Food intolerance

CVS

Chest pain

Palpitations

Dyspnea

UROGENITAL

Burning

Dysparonia

Dysmenorrhea

Irregular menstruation

Vomiting

PAIN

Generalized pain

Extremity pain

Back pain

Joint pain

Headache

Dysuria

PSEUDONEUROLOGICAL

Amnesia

Swallowing difficulty

Loss of voice

Blurred vision, blindness

Fainting

Muscle weakness

Difficulty in walking

SYNDROMES

Atipical chest pain

Temporomandibular joint s.

“hypoglycemia”

Premenstruel symdrome

Unidentified “food allergy”

Unidentified “vitamin deficiency”

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• At least three symptoms of uknown cause (generally in different systems)

• Chronic course (more than two years)

Since too long

Too many systems

Too many symptoms

Diagnostic Criteria

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Symptoms might be exaggerated and

irrational for us but they are

REAL for the patient!

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“We counldn’t find anything serious after the exam or investigations. But htere is something bothering you. Although the reason is not clear, this is a situation we face frequently…”

Management – Discuss the diagnosis

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“Better we should discuss how we can help you instead of the name. However, although there are a lot of names given, we frequently call this situation as “Somatoform disorder”

What is my diagnosis:

Chronique fatigue

syndrome

Fibromyalgia

Management – Discuss the diagnosis

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• Frequent visits (15 min/month)

• Short PE

• Aim: o Prevent new symptomso Decrease admissions to ER

• Discuss open ended questions

Management – Regular visits

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• Don’t try to loose the symptoms, better try to teach how to deal with them

• Patients expect more “care” than “cure”.

• Patients expect continuous relationship.

Management – Regular visits

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B ackgroundHow is your life going?

A ffectWhat do you feel?

T roubleWhat is the most important problem?

H andleWhat can help you?

E mpathy I understand you. This is a tough situation...

Stuart MR, Lieberman JA, 1993

Management – BATHE’ing the patient

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• No specific medicine

• Treat concomittant psychiatric problem

• Deal with domiant symptom:o Pain Amitriptillineo Fatigue Bupropiono Anxiety, sleep dist SSRI, TCA

Management - Pharmacological

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• Stress - somatic symptom relationship

• Symptom diary

• Group therapy

Management - Psychotherapy

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• Light exercises (3x20 min/w)

• Increases self esteem

• Yoga, meditation, walks

• Non harmful methods: cold-warm applications, acupuncture, vitamins…

Management – Life style changes

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• Dont put goals you can not meet

• Co-morbidity

• Diagnositc requests

• Emergency admissions

• Phone calls

Management - Problems

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Concentrating on symptoms

Unnecessary Referrals / cons.Tests

or Rx without Dx

It’s just in your mind, take it

easy..

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Frequent, short visits

Allow patient roleConcentrate on

functions

Single doctor

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What did we learn?