Somatisation

1. Somatisation Dr Eugene Cassidy

3. Somatisation • The expression of personal and social distress in an idiom of bodily complaints with medical help seeking • A culturally determined mechanism of expressing psychological problems in a more socially acceptable form • A process rather than a diagnosis • Classification of ‘disorders’ currently unhelpful

4. Overview of ‘functional’ illness • Symptoms • Syndromes • Disorders • Feigned illness

5. Functional Somatic Symptoms • 3.4 symptoms per person general population over previous 2 years (Rief et al, 2001) • Pain and Fatigue most common • Medical OPD 52% presenting symptoms MUS (Nimnuan et al, 2001)

6. Functional somatic syndromes (1) GastroenterologyIBS/ Functional dyspepsia CardiologyNon-Cardiac chest pain NeurologyChronic Headache / CFS RheumatologyFibromyalgia / CRPS GynaecologyChronic pelvic pain OrthopaedicsChronic back pain DentalTMJ dysfunction ImmunologyMultiple Chemical Sensitivity

7. Functional somatic syndromes (2) • General Population: • 27% have CFS, IBS, CWP or CO-FP • 1% all 4 (Aggarwal et al, 2006) • Medical OPD: • 56% (Nimnuan et al, 2001) - There is only one …….. (Wessely, 1999)

8. Disorders • Mood disorders • Somatoform disorders • Somatoform-like disorders

9. Somatoform-like disorders • Malingering • feigned illness; conscious gain • Factitious disorder (Personal / By proxy) • feigned illness; no conscious gain

10. Somatoform disorders • Symptoms suggestive of a medical disorder but are medically unexplained • Disabling • May be severe, of long duration and involve multiple symptoms • ie Somatisation disorder

11. Somatoform disorders • Categorical Classification unhelpful • Somatisation disorder • Pain Disorder • Hypochondriasis • Body Dysmorphic Disorder • Dissociative / Conversion disorders • Syndromes overlap • Chronic Fatigue syndrome • FMS

12. Somatisation is typically notconsciously elaborated But…. isn’t it human nature to exaggerate/make ourselves heard?

13. The Cost of Somatisation (1) • More visits • More admission days • More ED attendances • More procedures • Annual US healthcare costs doubled • (Barsky et al, 2005)

14. 456 appendicectomies • followed for at least 15 years (Dummett et al, 2002) • Normal Inflamed • Attendance 6.5/100 yrs 3.4/100yrs • DSH 7.9% 2.2% • Psych attendance 10.5% 4.0%

15. ‘PSEUDO-STATUS’ Walker et al, 1996 • 54% Status Epilepticus • 23% Encephalopathy • 23% ‘Pseudostatus’ • (majority intubated)

16. ‘PSEUDO-STATUS’ Walker et al, 1996 • 54% Status Epilepticus • 23% Encephalopathy • 23% ‘Pseudostatus’ (majority intubated)

18. The Cost of Somatisation (2) • Somatization Disorder • 7 days per month in bed (Smith et al, 1986) • 10% wheelchair-bound (Bass & Murphy, 1991)

19. Somatisation is associated with • Gender • Childhood adversity • Parenting • Cultural factors • Gain • Life events / dilemmas • Depression • Litigation • Iatrogenic factors • Physical deconditioning

20. Women report more somatic symptoms (Kroenke & Spitzer, 1998) • 1000 patients PRIME-MD interview • 13 common symptoms • 10/13 common symptoms more common in women • OR (adjusted for anxiety, depression) 1.5-2.5

22. Pain & Childhood Trauma(McBeth et al, 1999) • Adult general population • Distress (GHQ>1) • High Tender point count (1/3) related to: • Abuse (OR 6.9) • Parental loss (OR 2.1) • Female (OR 3.5) • Illness behaviour (OR 2.3)

23. Fatigue and Childhood trauma • Population based study (n=56146) • 43 CFS V 60 controls • Childhood trauma • Increased CFS (OR 3-8) • More severe CFS (Heim et al, 2006)

24. Parenting (Craig et al, 2004) • Parental focus on health • Maternal somatisation • Parental Illness

25. Enhanced parental focus on health • Maternal somatisation • Parental Illness

26. Parental Illness • National birth cohort study (n=5362) followed from 1946 until 1989 • Predictors of adult somatisation: • Childhood MUS • Maternal reports of below average health in father

27. ‘Even ill-health, though it has annihilated several years of my life, has saved me from the distractions of society and amusement’ In the Darwin family tradition: another look at Charles Darwin's ill health (Katz-Sidlow, J Royal Soc Med, 1998)

28. Pain is increasingHarkness et al, 2005 • low back, shoulder and widespread pain now 2-4 times higher in the UK than 40 years ago • True increase? • Increased psychological distress • Increased reporting & awareness • x 7-11 sickness benefit rate • x 3 number of solicitors

29. The late whiplash syndrome is influenced by cultural expectation Schrader et al, 1996

30. Secondary gain • Part of their strategy for dealing with life • Disability may hold advantages • Material • Care and attention • Excuse for avoidance • Social mystique • Look for ‘diagnosis’ not ‘cure’

31. Any alternative to taking the sensible correct path forward was inconceivable I remember the day when I knew I was going down with some kind of illness. I talked to Mum about it..realising that although I didn’t feel too ill at the time, it was on its way. I don’t know why I was so sure I was going to be ill. It was a month before I set foot outside the front door again. I would gaze outside and worry tormenting myself about recovering the energy to complete those final weeks at school before the A-levels (Watching Whitbread Cup on TV). With a feeling of most intense energy and clarity, I suddenly realised that there was another way. In an instant my exam pressures evaporated. From then on my illness was somehow different ‘Taking on the World’

32. ‘Jean Van de Velde suffering from unknown illness’ ‘A mysterious ailment that has his doctors puzzled’ ‘After a good start to the season with good performances in Thailand, I’m physically out of shape. I feel ill. I’m basically very tired. I have muscle pains and am frequently sick.’ ‘There’s a big question mark on the reason for this illness. I went through several medical exams but the doctors can’t quite seem to find a reason. I hit balls for half an hour and then have to stop because I’m just too tired.’ "To be really honest, I think my health is more important than playing in a golf tournament,"

34. Physician know thyself Veysman, B. BMJ 2005;331:1529

35. Likes / Hates adults & children equally GP?

36. Pain and Depression co-occur 92% of 150 patients about to be hospitalised with major depression in France had at least one painful symptom and 75% had several painful symptoms (Corruble, 2000)

37. Depression and somatic symptoms • Large WHO study in primary care (n=25,916) • 10.1 percent had major depression. • 45-95% of depressed patients reported only somatic symptoms • Half the depressed patients reported multiple unexplained somatic symptoms

38. Gender and ‘Somatic’ Depression • National Co-morbidity and ECA studies • Pure (non-somatic) depression (m=f) • Anxious somatic depression • Female>male • Earlier onset • Pain • Anxiety Silverstein, 2002

39. DENIAL Culture did not effect the likelihood of a somatic presentation Only 11 percent denied psychological symptoms of depression

40. Predictors of Chronic Pain • Clinic based studies • Crossectional • Population-based prospective study • McBeth et al, 2001 • Female • Non-pain somatic symptoms (OR 3.8) • Illness behaviour (OR 8.7) • Psychological Distress (OR 2.0)

41. Chronic Pain and Mental Disorder • Clinic samples • Population samples (n=1953) • GHQ + were interviewed • 22% CWP; 32% Mental disorder • OR 3.2 mood disorder in CWP v no CWP Benjamin et al, 2000

42. Depression is a risk factor for pain • Baltimore ECA Survey prospective community cohort (3 samples: 1981; 1982-3; 1993-1996) • Depression doubles later risk of CLBP • (Larson et al, 2004)

43. Litigation Cassidy et al, 2000 Canadian Whiplash injuries Change to no-fault • Reduced claims (417/100,000-296/100,000) • Reduced time to closure of claims (433 – 194 days) • Time to closure strongly associated with: • Pain severity, • functioning, • depression

44. Exercise cessation & pain Pain predicted by: • Lower basal cortisol • Lower NK cell response • HR variability

45. Medical Model doesn’t Help (Stokes) • Trained to define disease in terms of pathology • No identifiable pathology? • Feel cheated • Angry towards patients • Frustrated

46. Cognitive-behavioural model Attributions of cause / condition worsening, loss of control Cognitions - somatic focus, misinterpretation of symptoms, catastrophic / depressive thinking Behaviour change- avoidance of physical and social activity, Loss of fitness, seeking reassurance /cure, limited engagement with treatment, Loss of function and role Emotion Anticipatory anxiety, mood change, symptom increase,

47. Bodily Signals Cortical Perception Illness Behaviour Filter System • Visits doctor • Avoids physical activity • Adopts sick role • Enhanced by: • Overarousal • Physical deconditioning • Loss/Trauma • Enhanced by: • Selective attention • Depression • Health anxiety • Absence of distractors • Infection • Affected by: • Cultural/Family beliefs • Misinterpret symptoms • Catastrophic thinking • Attributions • Depressive cognitions

48. Key points • Somatoform disorders are common but neglected. This is unfortunate as they are disabling and costly. • ‘Somatisation’ is associated with inter alia female gender, childhood experiences, cultural expectations, social ‘gain’, depression, life stress, litigation, iatrogenic factors and physical fitness

49. Treatment

50. Attitudes required to treat • Unqualified acceptance of validity of pt illness experience • Willing to listen to patients views • Positive attitude to therapy • Tolerate slow progress • Willing to let patient take credit for success (don’t expect chocolates!)