Medically unexplained symptoms 1 (MUS, Somatoform Disorders)

1. Medically unexplained Symptoms Medically unexplained symptoms 1 (MUS, Somatoform Disorders) H.Afshar Psychosomatic research center IUMS

2. Importance for the Health System (Western countries) Diagnosis • High prevalence in primary care (30 %) and secondary care (20 %) • High use of medical service • Treatment costs up to 9 times higher (Work disability time due to sick leave and retirement) • Ineffective therapeutic measures in ca. half of the patients; e.g. non-indicated surgical procedures are performed in 20 % of hospitalized „somatisers‘ • Frequent change of doctors, emergency admission to hospital and dissatisfaction with treatment

3. Overview • Definition 2. Classification • Etiology

4. Definition and Terminology • Medically unexplained symptoms (MUS) • General term, very broad • Functional syndroms • Disturbance of bodily function rather than structure • Somatization • A psychological problem or emotional disorder is • expressed somatically • Somatoform disorders • Diagnostic category in the psychiatric classification of DSM and ICD

5. Overlapping of MUS, Functional Syndroms, Somatization and Somatoform Disorders

6. Definition of somatoform disorders Definition • Repeated presentation of physical symptoms • Stubborn demand for medical examination despite negative organic findings (dysfunctional illness behavior). • Emotional problems denied, although there is close relationship with psychosocial life events or conflicts (somatic fixation). • Symptoms are not feigned or aggravated • Disappointing doctor-patient relationship (interpersonal disorder)

7. Disruption of the Doctor-Patient Relationship Doctor retreats or refers to Specialist or the patient breaks off contact; doctor shopping Patient experiences physical symptoms and seeks help Patient feels misunderstood and demands further diagnostic measures The doctor is irritated The doctor focuses on organically-caused symptoms and prescribes organ-medical diagnostic tests prescribes medications Doctor looks for psychosocial stress; Patient denies and becomes enraged Patient sees no improvement; the findings are negative;Patient doesn´t know where to turn

9. Overview • Definition 2. Classification • Etiology

10. ICD – 10 classification Classification • F 45.0 Somatization disorders • F 45.2 Hypochondrial disorders • F 45.3 Somatoform autonomic dysfunction • F 45.4 Persistent somatoform pain disorders • F 44 Dissociative (conversion) disorders • F 48.0 Neurasthenia

11. Subgroups of somatization Classification • Initial somatizers Part somatizers • Facultativ somatizers • True somatizers • Functional somatizers

12. Common Symptoms Classification Symptoms of pain • backache (73%) • headache (67%) • bellyache (56%) Symptoms in the gastrointestinal tract • feeling of pressure (54%) • flatulence (56%) Symptoms in the cardiovascular tract • heart palpitation (55%) • sweating (62%) Rief et al. 1997

13. Depressive disorder Anxiety disorder Somatisation Classification

14. Physical symptoms in anxiety disorders Classification

15. Overview • Definition 2. Classification • Etiology

16. Vicious circle of somatoform symptoms Etiology Perception Misinterpretation as asign of threatening disease (Based on Rief 2000)

17. l Body related idioms • My hair stood on end • Get cold feet • Have butterflies in the stomach

18. What can the medical doctor do? • Avoid insults, recognize the illness as an attempt at solution, legitimization of the symptoms • Take the physical symptoms seriously • Pay attention to difficulties in the doctor- patient relationship (e.g. Negative feelings) • Avoid premature coupling of the symptoms to psychosocial stress

19. Approach to patients: disease or illness oriented • Cognition: content, styles • Emotion • Function • Expectation • Concerns: questions

20. The reattribution model- how to talk to somatizating patients and how to deal - Stage 1: Feeling understood • Take a full history of the symptoms • Explore emotional cues • Explore social and family factors • Explore health beliefs • Brief focused physical examination

21. The reattribution model Stage 2: broadening the agenda • Feed back the results of the examination • Acknowledge the reality of the symptoms • Reframe the complaints: link physical, psychological, and life events

22. The reattribution model Stage 3: making the link • Simple explanation • Three-stage explanation for anxiety • How depression lowers the pain threshold • Demonstration • Practical • Link to life events • „Here and Now“

23. Three Stage explanation for “Anxiety and physical complaints” Symptoms Emotions Physical Reactions Anxiety Excitation Inner restlessness Tension Blood pressure increase Heart rate increase Rapid breathing Tensed muscles Extra systoles Palpitations Shortness of breath Tingling Muscle pains, esp. shoulder and neck

24. Three Stage explanation for “Depression“ Symptoms Emotions Physical Reactions Feeling blue Lack of energy Lack of interest Withdrawal Reduced pain threshold Increased sinsitivity to physical discomfort Weakened immune system Headache Aching joints Stomache Back pain Susceptibility to infections Neglect of preventive health measures

25. Viscious circle model of anxiety and panic attacks (Margraf & Schneider, 1990)

26. Symptom DiaryRecord of thoughtsand feelingsduringphysical complaints

27. Yes Expedited diagnostic evaluation Potentially acutely serious? (< 5 %) No Yes • Adress patient expectations • Symptom-specific therapy • Follow-up in 2-6 weeks Likely minor and self-limited (70-75 %) No Persistent unexplained somatic symptoms (20-25 %) Antidepressant and / or cognitive- behavioral therapy Yes Yes Depressive or anxiety disorder? Ineffective No Yes Syndrom-specific therapy if evidence-based Functional somatic syndrome? • Regular time-limited clinic visits • Psychological assesment (e.g. somatoform disorders, personality • disorders, history of trauma/abuse) • Individual or group chronic symptom management programs • Complementary medicine treatments when evidence-based • Rehabiltative rather than disability approach No Kroenke 2003