Understanding Somatization in the Practice of Clinical Neuropsychology

1. Understanding Somatization in the Practice of Clinical Neuropsychology Greg J. Lamberty, PhD, ABPP-Cn Noran Neurological Clinic Minneapolis, MN 5th Annual Conference of the American Academy of Clinical Neuropsychology June 7 - 9, 2007 Denver, Colorado

2. Noran Clinic Neuropsychology

3. Purpose and goals • The purpose of this workshop is to provide practitioners with the conceptual understanding andthe clinical tools needed to put a “constructive” approach into practice. • Neuropsychologists are encouraged to look upon these difficult patients as an opportunity to employ their unique skills in assessment, case conceptualization, and education/intervention. • With the current focus on “best practices” and cost-effective treatments, improving the management of notoriously high- utilizing patients could be a decided boon to our field and to healthcare in general.

4. Purpose and goals (continued) • Thus, this workshop is not about the neuropsychology of somatization or the somatizing patient per se, but about effectively identifying, assessing, educating, and referring such patients for appropriate management and intervention.

5. Organization of workshop • History • Nosology • Epidemiology • Developmental/Etiological considerations • Neuropsychological assessment • Treatment approaches • Management

6. A basic definition of our subject matter • Somatization, somatoform symptoms, & somatizing patients 1) the clinical report of multiple somatic complaints that are medically unexplained 2) significant functional impairment or disruption in every day life

7. History • Ancient Egyptians wandering uterus • Hippocrates hysteria • Galen (2nd century) sexual deprivation in females

8. History (cont.) • Somatization in the 18th & 19th centuries • E. Shorter (1992) – From Paralysis to Fatigue Somatization as a function of prevailing medical culture - Spinal irritation (back pain & associated peripheral symptoms) - Dissociation (somnambulism, catalepsy, & multiple personality) - Motor hysteria (paralysis) - Charcot’s hysteria (inherited functional CNS disease) - Freudian (Janetian, Breuerian) or psychological conceptualizations of hysteria - Modern day, patient-oriented conceptualizations

9. History (cont.) • Thomas Sydenham (1624-1689) “English Hippocrates” Proponent of observational methods Hysteria not only an affliction of women Hysteria is a product of the “mind”

10. History (cont.) • Robert Whytt(1714–1766) Spinal reflexes responsible for “nervous” conditions. “Nerves” were a common affliction from the late 18th to early 20th century. • Paul Briquet (1796–1881) Comprehensive listing of symptoms in 1859 monograph based on 400 (mostly) female patients from the Salpêtrière hospital in Paris from 1849-1859. Reaffirmed Sydenham’s view of hysteria as a nervous condition, not solely seen in women, and characterized by many predisposing factors. In DSM-III somatization disorder was co-named “Briquet’s syndrome” in recognition of the French psychiatrist’s seminal contributions.

11. History (cont.) • Treatment of nervous disorders Contemporary medical establishment focused on methods to bring humors into balance, like… bleeding blistering purging Meanwhile, in France, there was a burgeoning spa industry offering special curative waters, wraps, poultices, and massages. The curative powers of these treatments has never passed peer-review muster, but the spas live on. Go figure…

12. History (cont.) • Jean Martin Charcot (1825-1893) Father of modern neurology. His interest in treating hysterical patients with magnetism and hypnotism saw his views evolve. Janet & Freud took hysteria to a more psychological plane, but Charcot held fast in his belief of the neurologic basis of hysteria.

13. History (cont.) • Pierre Janet(1859–1947) Janet's work with Charcot led to his development of ideas about the connection between subconscious states and earlier traumatic events. Janet’s thinking about suggestibility, dissociation, and the subconscious is widely acknowledged to have predated ideas popularized by Freud in the late 19th and early 20th centuries. • Sigmund Freud (1856–1939) Freud's conceptualization of "conversion" became a dominant viewpoint in understanding the nature of hysteria. Even today, conversion disorder retains a place, although arguably, as a diagnostic entity in DSM-IV.

14. History (cont.) • The struggle against dualism DSM-III, perhaps unwittingly, reinforced the dualistic thinking of the past that separated mind and body. That is, by definition, symptoms seen in the somatoform disorders are medically unexplained and by default, psychological, or “in one’s mind/head.” This is a very unpopular notion with patients, as suggested by Shorter (1992) and the tide has seemingly turned…

15. History (cont.) • The struggle against dualism (continued) Advances in imaging technology and cognitive neuroscience have made it possible to convincingly demonstrate relationships between neurophysiology and behavior/mental illness (Damasio, 1994; Ledoux, 1996; Schore, 1994). Unfortunately, despite modern-day neuroscientists’ elegant attempts to convince us of the inseparability of mind and body, for many stigma and shame cling to mental illness and psychological difficulties. Fortunately, emotion has become the new final frontier for prominent neuroscientists. It seems like that this will lead to a better understanding of the complex interplay between emotions, somatic symptoms, and neuropsychiatric symptoms.

16. History (cont.) • In other words… It’s Not All in Your Head (Asmundson & Taylor, 2005) “How worrying about your health could be making you sick – and what you can do about it.” Marketing of clinical services is becoming cognizant of the public’s sensibilities (and maybe even reality).

17. Nosology • There is a clear lack of consensus regarding nosology in somatoform syndromes. Much of what we are interested in is clinically defined… hysteria somatization somatoform disorders functional somatic syndromes medically unexplained symptoms • Different systems define the problem in different ways, but none of them meet reasonable criteria for an adequate diagnosis.

18. Nosology (cont.) for example… • Hypertension • Diagnosis Chronically elevated blood pressure Systolic and diastolic pressures over 140 and 90 mm Hg • Treatment Dietary changes Exercise And, of course, drugs

19. Nosology (cont.) • DSM-III (APA, 1980) – a more descriptive, atheoretical system as compared to previous psychodynamically oriented systems (DSM I/II) Somatoform disorders In addition to somatization disorder, several relatively rare and specific syndromes were included, based mainly on the presence of unexplained physical symptoms (conversion, hypochondriasis, BDD, pain disorder). Somatization disorder “Hysteria” as a neurotic disorder in DSM-II (APA, 1968) was replaced in DSM-III (APA, 1980) by somatization disorder, which focused on the clinical description of “multiple somatic complaints” to the exclusion of a presumed neurotic etiology.

20. Nosology (cont.) • The descriptive/pathological approach to mental disorders positioned psychiatry favorably among traditional medical specialties. Schizophrenia, mood, and anxiety disorders have benefited because of a more clear sense of their biological underpinnings. This has allowed biomedical and pharmaceutical research to proceed, with generally positive findings. • Somatoform disorders have suffered a different fate. Because a “real” physical cause is, by definition, lacking, there has not been much interest in identifying therapeutics for these disorders, except as they overlap with mood or anxiety disorders.

21. Nosology (cont.) In fact, the lack of clear biological underpinnings for the somatoform disorders has led some to encourage the abolition of the category (e.g., Mayou et al., 2005) in favor of a more basically descriptive or “pragmatic” approach (Engel, 2006).

22. Nosology (cont.) • All contemporary systems borrow heavily from Briquet’s (1859) monograph (summarized by Mai & Mersky, 1980) 430 patients seen over a 10 year period. Etiologic factors were youth, female gender, “affective” and “impressionable” temperament, family history of the disorder, low social class, migration, sexual licentiousness, situational difficulties, and poor physical health. Briquet considered the "effective part of the brain" the final common pathway that mediated these causative agents. In treatment, Briquet emphasized the importance of an improvement in social circumstances and the need to minimize environmental problems.

23. Nosology (cont.) • Somatization disorder per DSM-IV (APA, 1994) A. A history of 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. B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: (1) four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)

24. Nosology (cont.) (2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods) (3) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, or vomiting throughout pregnancy) (4) one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms, such as impaired coordination or balance; paralysis or localized weakness; difficulty swallowing or lump in throat; aphonia; urinary retention; hallucinations; loss of touch or pain sensation; double vision; blindness; deafness; seizures; dissociative symptoms, such as amnesia; or loss of consciousness other than fainting)

25. Nosology (cont.) • Either (1) or (2): (1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication) (2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings D. The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering).

26. Nosology (cont.) • The major diagnostic systems have experimented with the somatization issues in various ways… DSM-IV requires 8 symptoms from 4 symptom groups. ICD-10 requires 6 symptoms from 2 symptom groups. DSM and ICD systems have “residual” or “undifferentiated” categories that require fewer overall symptoms to be reported. • But is there any validity to these approaches?

27. Nosology (cont.) • Basically… No. • Several studies have failed to indicate better diagnostic precision as a function of differing sets or number of symptoms (Gureje & Simon, 1999; Liu, Clark, & Eaton, 1997; Simon & Gureje, 1999). • A factor analytic study (Liu, Clark, & Eaton, 1997) highlighted the chronic nature of unexplained symptoms, regardless of the diagnostic scheme.

28. Nosology (cont.) • In general studies have highlighted… Variability in individual symptom report over time (Lieb et al., 2002) Variability in the consistency (accuracy) of the report of lifetime symptoms (Gureje & Simon, 1999; Simon & Gureje, 1999) • Thus, specific criteria do not influence the basic description of somatizing patient groups (i.e. chronic and unexplained). But they may influence epidemiological estimates of different somatoform syndromes. This observation highlights the fact that current diagnostic criteria are heuristically valuable, but quite limited from a practical clinical standpoint.

29. Nosology (cont.) Alternative descriptive systems • Medically unexplained symptoms Ultimately atheoretical Popular with neuropsychologists (Binder & Campbell, 2004) • Abridged somatization (Escobar et al., 1987) Based on this group’s experience with the Epidemiological Catchment Area (ECA) studies of the early 1980s A “less restrictive operational definition of the somatizer” 4+ unexplained symptoms for men; 6+ such symptoms for women

30. Nosology (cont.) • Multisomatoform disorder (Kroenke et al., 1997) DSM somatization disorder too restrictive, but undifferentiated somatoform disorder too inclusive Three or more medically unexplained symptoms, regardless of gender 2+ year history of somatization symptoms • Functional somatic syndromes (Barsky & Borus, 1999) “are characterized more by symptoms, suffering, and disability than by disease specific, demonstrable abnormalities of structure or function”

31. Nosology (cont.) • Functional somatic syndromes (cont.) Attribution to a more specific cause or “disease” Self-sustaining culture of patients and health care providers that perpetuate the disabling and serious medical status of these afflictions, contrary to a lack of compelling scientific or medical support A number of these conditions tend to come and go as a function of public interest or compelling story lines, while others have a strong following, even in the medical community. Those with staying power include fibromyalgia, chronic fatigue syndrome, multiple chemical sensitivities, and irritable bowel syndrome.

32. Nosology (cont.) Summary & suggestions for a new diagnostic approach • Mayou et al., (2005) suggest: Redistribution of the various somatoform disorders among the different axes of the DSM • For instance, hypochondriasis could be renamed “health anxiety” and reclassified as an anxiety disorder. • Conversion could be classified as a dissociative disorder. • Somatization disorder might more accurately be considered a personality disorder with mood and anxiety disorder features. • These suggestions are more consistent with clinical reality.

33. Nosology (cont.) • Mayou et al., (2005): (cont.) Specific symptoms might reasonably be coded on Axis III as "somatic symptoms" or "functional somatic symptoms.” As noted, many studies have indicated that a less extensive level of symptomatology is still associated with clinical impairment and psychiatric comorbidity (Escobar et al., 1987; Kroenke et al., 1997). While it might seem to be a matter of semantics, the fact that patients presenting with even a few somatoform symptoms tend to show marked increases in health care utilization, should be enough to encourage those in clinical and health policy fields to consider changes to the current diagnostic scheme.

34. Nosology (cont.) • Avoiding dualism As discussed earlier, many have criticized the nature of the DSM typology (Engel, 2006; Kirmayer et al., 2004; Mayou et al., 2005; Sharpe & Carson, 2001). Diagnoses within this category basically call for ruling out physical causes for the symptoms presented thus making such symptoms de facto “mental” or “psychogenic.” The "mental" view of somatoform symptoms has been an obstacle to more effective treatment of such symptoms by primary care personnel (Mayou et al., 2005; Sharpe & Carson, 2001; Stone et al., 2002), perhaps due to stigma or a sense of a lack of seriousness.

35. Nosology (cont.) • Cultural awareness Some argue that (DSM-defined) somatoform disorders are not appreciative of cultural differences and unique syndromes with which they would appear to conflict (González & Griffith, 1996; Kirmayer, 1996; Kirmayer et al., 2004; Mayou et al., 2005). González and Griffith (1996) note that the DSM appears to make a distinction between mental disorders that are determined by biology (e.g., depression, schizophrenia) and those that are more culturally influenced. Such disorders are much more likely to show variability from one culture to another and, in fact, may not be regarded as pathological at all. This view emphasizes the value of clinical description rather than forcing a diagnostic label when it is unlikely to serve a utilitarian purpose.

36. Nosology (cont.) • Patient’s acceptance of diagnostic labels Some are concerned about the effects of proffering a diagnosis of somatization, hysteria, or medically unexplained symptoms, as all of these labels as tend to carry a strong connotation of “mental illness.” The use of diagnoses that are thought to convey a more objective sense of symptomatology raises patient defenses and makes it difficult to understand the nature of problems - “it’s all in your head” - trivializing the patient’s problems - questioning their character Whether patients’ concerns about this issue should be considered is something that clinicians will have markedly different views about. For now, we’ll note the existence of these different views, and move on.

37. Epidemiology • The epidemiology of somatization is obviously tied to the systems used in clinical and research contexts. • Accordingly, there is substantial variability in terms of prevalence estimates of various somatoform disorders. • DSM estimates are typically among the lowest (most conservative) with respect to prevalence of somatoform disorders. However, the “science” behind them seems a bit lacking…

38. Epidemiology (cont.) Prevalence estimates for DSM-IV somatoform disorders DSM-IV DiagnosisPrevalence Estimate Somatization Disorder .2% to 2% Undifferentiated Somatoform Disorder not provided Conversion Disorder <.1% to 3% Pain Disorder "common" (10%-15% work-related disability for back pain alone) Hypochondriasis 4% to 9% in general medical practice Body Dysmorphic Disorder "more common than previously thought"

39. Epidemiology (cont.) • Population based studies National Institutes of Mental Health Epidemiologic Catchment Area (ECA) study (Reiger et al., 1984) - 20,000 people from five urban settings in the United States - lifetime prevalence of somatization disorder was 0.13% Escobar et al. (1987) used the Los Angeles ECA data - .03% of 3132 met DSM-III criteria for somatization disorder - 4.4% met criteria for “abridged somatization” - Changing the criteria slightly increased prevalence dramatically - Also, significant differences in the reporting of depending upon gender, ethnic background, and pre-existing psychiatric diagnoses

40. Epidemiology (cont.) • Primary care studies • Gureje and Simon (1997) examined longitudinal data from a large (26,000 cases) international (14 countries) study examining psychological problems in primary health care settings. - Prevalence estimates between 1% and 3% depending upon whether DSM or ICD-10 criteria were employed. - Symptom reports were extremely variable over time with overall rates of DSM-IV somatization disorder that were similar when assessed 12 months later, but fewer than half of those initially diagnosed continued to report lifetime symptoms consistent with a somatization diagnosis.

41. Epidemiology (cont.) • Escobar et al. (1998) examined their abridged somat. construct in a university affiliated primary care clinic - Abridged somatization in this sample was around 20% - Strong associations with various forms of psychopathology and physical disability • Kroenke et al. (1997) examined their multisomatoform disorder (MSD) construct in 1000 pts from 4 primary care clinics - 8% of this primary care sample was diagnosed with MSD - showed similar health-related impairments to patients with mood and anxiety disorders - more disability days, clinic visits, and greater difficulty as perceived by clinicians

42. Epidemiology (cont.) - Therefore, MSD is a valid diagnosis and has an independent effect on functional difficulties apart from comorbid psychiatric diagnoses • Barsky, Orav & Bates (2005) examined self-reported somatoform symptoms and their association with medical care utilization - In an eligible sample of 1456 patients, 299 (20.5%) were given a provisional diagnosis of somatization - "somatizers" were noted to utilize both inpatient and outpatient services at roughly twice the level noted for non-somatizing patients - Barsky et al., (2005) suggest that the incremental medical care costs associated with somatization alone (i.e., not including comorbid psychiatric illness) is approximately $256 billion a year

43. Epidemiology (cont.) • Smith et al., (2006) used a chart review procedure with HMO patients to identify “high-utilizing MUS patients.” - Of 206 patients that were identified, 60.2% had a “nonsomatoform diagnosis,” meaning that they did not meet criteria for full or abridged somatization based on the DSM-IV, but rather had one or more psychiatric diagnoses. - 4.4% of the selected sample met full DSM-IV criteria for a somatoform diagnosis, while 18.9% met criteria for abridged somatization disorder. - 23.3% of the high-utilizing MUS sample met criteria for full or abridged somatization (somatoform-positive), while 76.7% did not (somatoform-negative).

44. Epidemiology (cont.) - The somatoform-negative group showed less overall anxiety, depression, mental dysfunction, psychosomatic symptoms, and physical dysfunction than did the somatoform-positive group. - Patients who utilize services frequently and report MUS are not necessarily a homogenous group. Patients that have MUS, but do not meet criteria for a somatization diagnosis are more likely to be characterized by lower levels of depression and anxiety than a wide range of psychiatric, functional, and disability issues (like the somatoform positive group).

45. Epidemiology (cont.) • Neurology clinic studies • Carson et al., (2002) - 300 new referrals to a regional neurology clinic in Scotland - Neurologists rated patients’ symptoms to the extent that they were explained by physical findings. - 30% (n=90) had substantially unexplained symptomatology - Patients with lower "organicity" ratings consistently showed a higher number of median physical symptoms and pain complaints. - 70% of patients in the "not at all explained" group had a depression or anxiety disorder, compared to 32% of patients in the "completely explained" group

46. Epidemiology (cont.) • Carson et al., (2003) - A follow-up study by Carson et al., (2003) reported on 66 of the 90 patients with significantly unexplained symptoms - 14% of these patients rated themselves as much or somewhat worse - 63% reported no change or modest improvement - 23% of the patient's were "much better” - 54% of patients with unexplained symptoms at baseline showed no improvement or worsening symptoms eight months later - The best predictor of poor outcome at follow-up was greater physical difficulty at baseline. In no case did an actual neurologic cause emerge as the reason for the originally unexplained symptoms at follow-up.

47. Epidemiology (cont.) • Fink, Hansen, & Sondergaard (2005) - Of 198 first time neurology referrals, 61% had at least one medically unexplained symptom - 35% met diagnostic criteria for ICD-10 somatoform disorder - Outpatients were more likely than inpatients to have a somatoform diagnosis - Women were more likely than men to have somatoform diagnoses - The gender difference was much more pronounced in younger (18-44) and older (>60 years old) patients, with little gender difference in the middle age group (45-59) - Among patients with somatoform diagnoses, 60.5% also had another psychiatric diagnosis

48. Epidemiology (cont.) - Collectively, patients referred to neurology clinics tended to meet criteria for somatoform diagnoses about 30% of the time. - Within this patient group, there were more females, more psychiatric diagnoses, and higher level of physical dysfunction and disability. - This is in contrast to primary care settings in which roughly 20% of patients tend to meet either full or abridged criteria for somatoform disorders.

49. Epidemiology (cont.) • Pediatric studies • Fritz, Fritsch, & Hagino (1997) reviewed literature from the previous 10 years with regard to conceptual and clinical reports of somatization in children • a lack of developmentally appropriate schemas and a call for more thorough outcome studies • Campo et al., (1999) examined a group of pediatric "somatizers" to determine risk for greater psychopathology, functional impairment, and utilization of health services - parental reports of pain related symptomatology to identify somatizing children (4-15 y.o.) from a pediatric primary care clinic

50. Epidemiology (cont.) - children with and without significant somatization were compared on a number of variables including demographic, psychopathologic, functional status, and utilization - adolescents, females, minority individuals, children from urban practices, nonintact families, and families with lower parental education - heightened risk of clinician and parent identified psychopathology, poor school performance, perceived health impairment, and increased utilization