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Somatoform Disorder or Medically Unexplained Symptoms

Somatoform Disorder or Medically Unexplained Symptoms. Bruce Slater, MD, MPH Associate Professor (CHS) University of Wisconsin School of Medicine. Learning Objectives . Discuss Several Theories of Somatoform Disorder List Techniques for Recognizing Somatoform Disorder

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Somatoform Disorder or Medically Unexplained Symptoms

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  1. Somatoform Disorderor Medically Unexplained Symptoms Bruce Slater, MD, MPH Associate Professor (CHS) University of Wisconsin School of Medicine

  2. Learning Objectives • Discuss Several Theories of Somatoform Disorder • List Techniques for Recognizing Somatoform Disorder • Review Treatment Approaches for Patients With Medically Unexplained Symptoms

  3. Financial Disclosure • No Financial Support

  4. Case Presentation • 12 Visits Over 9 Months for Abdominal Pain • Apparently Unnecessary Treatment for Presumed Disease • Extensive Diagnostic Evaluation • Several Consultants

  5. Clinical Features of Case • Slowly Evolving Nature of Symptoms • Contradictory Symptomatology • Minimal Secondary Gain • Underlying Anxiety Uncovered

  6. Historical Origins • Dark Ages Organ Based Explanations of Disease • Uterus Frequently Blamed for MUS • Hysterical Symptoms • 1667 Thomas Willis - ? Brain Involvement • 1889 Charcot ?Nervous Center Lesion • Babinski/Freud Psychological Explanations

  7. (Loose) Diagnostic Criteria • Several Non-specific Symptoms in Different Organ Systems • Chronic Course • Frequently Co-morbid for Psychiatric Disease • Ten Times More Common in Women • Fully Developed by Age 30

  8. Diagnostic Criteria • Diagnostic and Statistical Manual (DSM IV) • Multiple Recurring Pains and Symptoms • Gastrointestinal • Sexual • Pseudoneurological • Occurring Over a Period of Years • Not Intentionally Induced • Significance • Result in Medical Attention • Functional Impairment

  9. Therapeutic Approach • Empathy • Rational Reassurance • Evaluation of Equivocal Symptoms • Symptom Based Care • Emphasize Return to Normal Activities • Approach Psychiatric Disease Separately • Treat Psychiatric Disease Actively

  10. Therapeutic Approach (Details) • Step 1 Set Stage, Intro, Ensure Comfort • Step 2 Agenda (Constraints, the List, Negotiate) • Step 3 HPI Open Ended, Non-focused, Gather Data • Step 4 Focus on Symptoms, Context, Emotion, Address Emotion • Step 5 Transition – Summary, Check, Assess Readiness to Change Focus to Physician Centered From RC Smith, et al. JGIM 2003

  11. Interesting Findings and Theories • Patients With Irritable Bowel Are Sensitive to Distention in the Gut, but Not As Sensitive to Pain From Skin. • Increased Anxiety Is Associated With Increased Pain (Battlefield Versus Mva) • Adrenaline Released at Sympathetic Nerve Endings May Sensitize Nociceptors and Trigger Somatic Muscle Tension Reflexes

  12. From Wilhelmsen, Gut 2000;47 (Suppl 4);iv5-iv7(December)

  13. More Interesting Theories • Amplification of Bodily Sensations • Panic Attacks • Somatisation • Family Dynamics and the Identified Patient • The Need to Be Sick • Dissociation • (Sensory Experience in the Absence of Sensory Stimulation) From D Servan-Schreiber AFP 2000

  14. Summary • Evolving Concepts • Frequent in Minor Incomplete “Form Frust” • Rule Out Disease for Rational And/or Potentially Serious Symptoms • Understand the Patient With the Disease • Care Not Cure

  15. Questions for Me? • Do You Enjoy Seeing Patients With Mus? • What Diagnostic Clues Can You Add? • What Have You Tried Therapeutically? Questions for You

  16. References • Brain-gut Axis As an Example of the Bio-psycho-social Model. I Wilhelmsen, Gut 2000;47(Suppl IV):Iv5-iv7 (December) • Treating Patients With Medically Unexplained Symptoms in Primary Care. RC Smith. J Gen Intern Med 18:478-488. June 2003 • Somatizing Patients: Part I. Practical Diagnosis. D Servan-Schreiber, et al. Am Fam Physician 61/4; pp. 1073-1079 2/15/2000.

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