Module: Health Psychology Lecture: Chronic illness and somatisation Date: 16 March 2009

1. Module: Health PsychologyLecture: Chronic illness and somatisationDate: 16 March 2009 Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick Tel: +44(24) 761 50222 Email: C.Bridle@warwick.ac.ukwww.warwick.ac.uk/go/hpsych

2. Aims and Objectives • Aim: To provide an overview of the psychological aspects of chronic illness and somatisation • Objectives: You should be able to describe … • common somatoform symptoms; • characteristics of somatoform disorders; • cause, course and consequence of somatoform disorders; • principles of assessment, treatment and management of somatoform disorders; • ways to distinguish between normal and abnormal somatisation.

3. Greek Origin • Σωμα • Soma = 'the body' • Σωματικóς • Somatic = 'of the body' • ψυχή • Psyche = 'of the mind' • ψυχοσωματικός • Psychosomatic = 'influence of the mind on the body'

4. Terminology • Somatic symptoms:physical symptoms (assumption: with physiological cause) • Somatoform symptoms: physical symptoms without (identifiable) physiological cause • Psychosomatic symptoms: physical symptoms with psychological cause • Somatopsychic symptoms: psychological symptoms with physiological cause • Somatisation: expression of emotional problems in somatic symptoms • Somatic fixation: bias towards (automatic) medicalisation of symptoms

5. Somatisation 'Somatisation is a ubiquitous and diverse process in medicine, linking the physiology of distress and the psychology of symptom perception' Joseph Ransohoff (1915 - 2001) '... the history of medicine has written the prehistory of psychosomatics' William Osler (1849 - 1919) 'Representation of the bodily processing of emotion' Leonardo da Vinci (1452 - 1519)

6. Symptom Prevalence • Over 1-week, 69%/1410 adults report 1> one symptom • Only about 10% of symptoms prompt medical help seeking • A physiological cause is found for only a small proportion of the most common physical symptoms presented in primary care • 20% of patients present with (primary / main) physical symptoms that are not explained by physical disease - 1 in 5 Each primary care clinician in the UK will have on average 12 patients with chronic somatic symptoms Physiological Cause Identified

7. Symptom Presentation • Of all the symptoms for which an identifiable physiological cause can not be found, the most common are: • Pain:related to different sites (e.g. head, abdomen, back) or bodily functions (e.g. menstruation, intercourse, urination) • Gastrointestinal:nausea, bloating, vomiting (not during pregnancy), diarrhoea, intolerance of several foods • Sexual:indifference to sex, difficulties with erection or ejaculation, irregular menses, excessive menstrual bleeding • Pseudoneurological:voice loss, impaired vision, hearing and balance/coordination, paralysis, hallucination, seizure, amnesia

8. Medical Specialties and TheirPatients with Problems Patients with a wide range of somatoform symptoms are encountered not only in primary care, but throughout the specialities also

9. Characteristics of Somatoform Disorders • A class of disorder defined by • presence of physical symptoms that are not fully explained by the presence of a medical condition; • symptoms cause clinically significant distress and impairment; • psychological factors judged important in symptom onset, severity, and/or maintenance; • symptoms are chronic, independent of one another and not intentionally produced.

10. Somatoform Disorders • Somatisation disorder (Briquet's syndrome):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 • Conversion disorder (conversion hysteria):Symptoms or deficits affecting voluntary motor or sensory function • Hypochondriacal disorder (hypochondriasis):Preoccupation with fears of developing or having a serious disease, based on (mis)interpretation of bodily symptoms, which persist despite medical reassurance • Somatoform pain disorder (psychogenic pain):Disabling pain of sufficient severity to cause treatment being sought • Body dysmorphic disorder (dysmorphophobia):Preoccupation with an imagined defect in appearance, or if real / present, concern is markedly excessive

11. Somatisation Disorder • Description: A history of many physical complaints beginning before age 30 years that occur over a period of several years and results in treatment being sought or significant impairment in social, occupational or other areas of functioning • Epidemiology: 10 X> females, familial pattern for 10-20% of 1st degree female relatives; • Course: Chronic, fluctuating and rarely remits. Diagnostic criteria usually met before age 25 yrs. • Cues: Symptom onset / progression following loss; symptom amplification with stress • Other features: Complicated medical history; numerous (12+) somatic complaints; Dr shopping

12. Somatisation Disorder: A 10-Year Example

13. Conversion Disorder • Description: Symptoms or deficits affecting voluntary motor or sensory function • Epidemiology: Rare condition; acute onset in adolescence or early adulthood; twice as prevalent in females; more common in rural populations and lower SES • Course: Recurrent symptoms with short duration • Cues: Traumatic events; stress; inability to cope • Other features: high suggestibility; prone to seizures and convulsions; unaware of retained functions Samuel Pepys recorded conversion disorder after the Great Fire of London in 1666

14. Hypochondriacal Disorder • Description: Preoccupation with fears of developing or having a serious disease based on (mis)interpretation of bodily symptoms, which persists despite medical reassurance • Epidemiology: About 3% and 5% prevalence among general population and primary care outpatients, respectively • Course: Onset at any age, but typically early adulthood; familial deaths and illness; media • Cues: Heightened awareness of physical self; symptom amplification when stressed • Other features: Dr Shopping; background expertise

15. Somatoform Pain Disorder • Description: Pain of sufficient severity to cause clinically significant distress or impairment and treatment being sought • Epidemiology: Precise prevalence unknown but likely to be fairly common; small female bias possible; variable onset age • Course: Chronic, fluctuating and rarely remits • Cues: Often develops from illness or accidental injury; symptom amplification when exposed to illness, accident cues and stress • Other features: Dr shopping (often precipitated by maximum dose); risk for multiple registrations; pharmacologically informed; initiated and discontinued various CAM formulations

16. Body Dysmorphic Disorder (BDD) • Description: Preoccupation with an imagined defect in appearance, or if present, concern is markedly excessive • Epidemiology: Prevalence unknown in general population; 10-30% in mental health settings • Course: Onset early adulthood; increasingly distressing; potential for suicidal ideation • Cues: Unclear; possible sensitivity / bias to facial feature priming • Other features: Typically remain single; examined potential for plastic surgery BDD?

17. What causes somatisation, and when? • When? • Predisposing factors increase the chance that particular symptoms may develop and/or become important • Precipitating factors trigger increased physiological self-awareness, e.g. stress, depression, anxiety, illness • Perpetuating factors make it more likely that somatoform symptoms will persist, What? • Aetiology is poorly understood, but biological, psychological and social factors are (likely to be) involved • Biopsychosocial contribution will vary between people and across somatoform disorders - size and interaction • Clinician factors may contribute to somatisation, i.e. iatrogenic harm

18. Aetiological Formulation • Example for a chronic pain patient • Easiest to work through stage columns • Each 'Factor X Stage' cell can have multiple entries, or none

19. Distinguishing Normal & Abnormal Somatisation • Symptoms: are symptoms beyond the norm? Consider multiplicity, severity, and chronicity • Coping:do symptoms significantly impair role functions? Consider social, familial and occupational roles • Belief:is there resistance to explanation and reassurance? Consider affect, refractoriness, and illness discourse • Internalised:has the 'sick role' been accepted? Consider illness explanations - as a way of life • Excessive:extensive but unsatisfactory service use? Consider consultations, providers, and treatments

20. Principles of Assessment • Be vigilant to iatrogenic harm, e.g. be a part of the solution and not the problem • Identify patients' concerns and beliefs, e.g. illness representation • Contextualise patients' health-related experiences, e.g. previous illness, symptoms, contact with medical services, etc. • Review recent history of current symptoms, paying particular attention to possible life events, i.e. stressors • Ask questions about patients' reaction to and coping with symptoms, e.g. habitual patterns of poor coping • Use screening questions for psychiatric morbidity

21. Somatic Symptoms and Psychiatric Co-morbidity The more somatic symptoms a patient has, the less likely it is that their symptoms reflect the presence of physical disease and the more likely there is co-morbid psychiatric morbidity (depression & anxiety) Patients withPsychiatric Morbidity (%) 0 5 10 15 20 Number of Somatic Symptoms

22. Principles of Treatment • Validate patient experience, e.g. explain that the symptoms are real and familiar to doctor • Provide a framework, e.g. describe how psychological factors (ABC) may exacerbate somatic symptoms • Offer opportunity for discussion of patient's worries at the earliest opportunity • Give practical advice on coping with symptoms and encourage return to normal activity as soon as possible • Discuss and agree a treatment plan that includes a planned follow up and review • Encourage specific tasks before next meeting, e.g. identify three situations that worsen symptoms

23. Treatment Aims • Treatment focus should be on coping with symptoms and impairment rather than on symptomatic cure • Target perpetuating factors • Depression, anxiety, or panic disorder • Chronic marital or family discord • Dependent or avoidant personality traits • Occupational stress • Abnormal illness beliefs • Iatrogenic factors • Pending medico-legal claim

24. Management Strategy • Proactive not reactive:arrange to see patients at regular, fixed intervals • Broaden agenda:establish a problem list and allow patients to discuss relevant problems • Minimise providers:only one or two providers to reduce iatrogenic harm • Co-opt a relative:a therapeutic ally to help implement and monitor the management plan • Cope not cure:cure is an unrealistic expectation, instead aim for containment and damage limitation, and remind patient at each consultation

25. Conclusions • Common:Somatoform symptoms are common and occur in all medical specialities • Harm:Somatisation is chronic, disabling, distressing and destructive • Cause:Multiple biological, psychological and social factors predispose, precipitate and perpetuate somatisation • Treatment:Focus on coping with symptoms and impairment, and removing perpetuating factors • Management:Somatisation can be managed effectively in primary care

26. Summary • This session would have helped you to understand … • common somatoform symptoms; • characteristics of somatoform disorders; • cause, course and consequence of somatoform disorders; • principles of assessment, treatment and management of somatoform disorders; • ways to distinguish between normal and abnormal somatisation.

27. Any questions? • What now? • Obtain / download one of the recommended readings • Consider today’s lecture in relation to your tutorial tasks: a) integrated template b) ESA question Tutorial begins at 3.15 Completed templates (supported topics) available after today’s session on module webpage – tutor’s page