anxiety and psychosomatic

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Curriculum Vitae Dr. Andri,SpKJ,FAPM

Lulus Dokter dari FKUI tahun 2003

Lulus Psikiater dari FKUI tahun 2008

Fellow of Academy of Psychosomatic Medicine (2013)

Jabatan :

Dosen FK UKRIDA

Ketua Sub Kredensial Komite Medik Omni Hospitals Alam Sutera

Kepala Klinik Psikosomatik OMNI Hospitals

Sekretaris Seksi Consultation Liaison Psychiatry (CLP) PDSKJI

Organisasi :

Ikatan Dokter Indonesia (IDI)

Perhimpunan Dokter Spesialis Kedokteran Jiwa Indonesia (PDSKJI)

American Psychosomatic Society (Faculty Leader of Psychosomatic Medicine Interest Group in Indonesia)

Academy of Psychosomatic Medicine (Fellow Member)


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Psychosomatic Symptoms and

Anxiety Disorder

dr.Andri,SpKJ,FAPM

Psychiatrist, Fellow of Academy of Psychosomatic Medicine

Faculty of Medicine, UKRIDA

Psychosomatic Clinic Omni Hospitals Alam Sutera, Serpong


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What is Psychosomatic?

Somatic complaints in clinical practice

Somatic complaints in psychiatric disorder

Treatment strategy (Using Pharmacology and Non-

Pharmacology approach)

Conclusion

Outline for today’s talk


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What is Psychosomatic ?

• The term psychosomatic has been known for more than 50 years in the field of psychiatry

• Mind and Body Connection

• George Engel : Biopsychosocial concept (1977)

• Since it was misunderstood by lay people as a disorder ―Only in Your Head‖, since 1980, psychosomatic was not a diagnosis terminology in DSM anymore

• Psychosomatic Somatic symptoms

• The use of the term Psychosomatic for organization and journal until now

• Psychosomatic Medicine is a subspecialist in Psychiatry (APA,ABPN)

Kaplan and Saddock, Synopsis of Psychiatry, Psychosomatic

Medicine, Chapter 13, American Psychiatric Publishing 2015


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Historical Background and Changes from DSM III

to DSM 5 (Dimsdale, J. E., et al. 2013)

Somatoform Disorder Somatic Symptom Disorder

- First introduced 30yrs ago in DSM-III as Somatoform Disorder.

Somatoform didn’t translate to another language well

- DSM-IV – concept of medically unexplained symptoms were introduced.

Is it unexplained or unexamined medical condition?

- DSM-5 replaced Somatoform Disorder with Somatic Symptom Disorder and Related Disorders

The symptoms may or may not be medically unexplained. If the patient primarily had

anxiety but not somatic complaints, the diagnosis would be Illness Anxiety Disorder.


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Case Illustration

A 29 years old man complaint discomfort feeling in his left chest. He often felt palpitation that made him visit ER more than once.

He also felt bloating and fear of losing control at the same time. Physical examination and laboratory workup found nothing was wrong. He had already done ECG, Echo and Stress Test (Treadmil)

What was wrong with this patient?


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Somatic symptoms in Clinical Practice

25-50% No serious medical cause found

30-75% Remain medically unexplained

16-33% ―bothered the patient a lot‖ but remain

unexplained

Schneider R


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A 39 years old woman complaint about her uneasy feeling in her stomach. She

frequently felt bloating, sometimes accompanied by palpitation and feeling

imbalance. She had already visited her internist and had done regular examination

and specific workup (gastroscopy). All the findings were normal. She was afraid of

her condition and still thinking about having severe disease related to her

complaints.

She was a manager in one of the telecommunication company. A very strong and

persistent woman. She thought about her stress in her work but she thought they

were all regular stress until 6 months ago she started complaint about her stomach

Case Illustration


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Somatic Complaints

Somatic complaint is a poorly understood ―blind spot‖ of medicine

Somatic complaints and somatoform disorder (now is somatic

symptoms disorder based on DSM 5 ) remain neglected by

psychiatrist and also primary care physician

It can be conceptualized in a variety of different ways but

fundamentally it appears to be a way of responding stress

Not all somatizing patients have a diagnosis of somatoform

disorder, many have another Axis 1 disorder or transiently somatize

in the context of significant life stress

Abbey, Wulsin and Levenson in Somatization and Somatoform Disorder, Textbook

of Psychosomatic Medicine, 2nd ed, 2011


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Somatic Complaints

Patients commonly present to their primary care physician complaining of physical symptoms.

More often than not, appropriate medical work-up fails to reveal a clear underlying physical etiology

The prevalence of somatic symptoms that are multiple, chronic, and associated with medical help-seeking—but do not meet full criteria for a DSM-IV somatization disorder :19.7% – 22%

Psychosomatics 42:3, May-June 2001


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Survey bertween February 23rd 2013 until February 1st, 2014, patient with

depression and anxiety disorder were asked to fill the BSI (Bradford Somatic

Inventory)

There were 1433 respondents who filled the BSI,704 (49.13%) were men ad 729

(50.8%) were women.

Forty two point ninety seven percent (42.97%,N=617) respondents were between

21-30 years old, 29.60% (N=425) respondents were between 31-40 years old and

15.25% (N=219) below 21 years old.

Somatic Symptoms in Patients With Anxiety and

Depression

Unpublished data. Survey conducted by Andri from

Psychosomatic Clinic Omni Hospital (2014)


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1. palpitations (pounding heart) : 90.52%,

2. ache or discomfort in the abdomen : 84.94%

3. lack of energy (weakness) much of the time : 84.41%,

4. pain or tension in neck or shoulder : 82.86%

5. feeling giddy or dizzy : 81.88%

6. feeling tired even when are not working : 81.39%

7. suffered from excessive wind (gas) or belching : 73.6%

8. pain in the chest or heart : 73%

9. trembling or shaking : 72.7%

10. buzzing noise in ears or head : 71.34%.

Top 10 Somatic Symptoms

Unpublished data. Survey conducted by Andri from

Psychosomatic Clinic Omni Hospital (2014)


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Data 2009 di Puskesmas di Jakarta

Dan Hidayat, dkk. Majalah Kedokteran Indonesia, Vo. 60 No.10 Oktober 2010


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0

10

20

30

40

50

60

Panic

Dis

GAD Somatic MDD Schizo

% Diagnosis

Prevalensi Diagnosis Gangguan Jiwa Pada Pasien dengan

Keluhan Psikosomatik Jan– Des 2009

Panic Disorder 57.85 %

Generalized Anxiety

Disorder

21.07 %

Somatization Disorder 10.3 %

Major Depression

Disorder

9.5 %

Schizophrenia 2.07 %

Survey dilakukan di Klinik Psikosomatik RS OMNI,

Tangerang


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Common types of somatization seen in

primary care (Croicu, C., et al. 2014)

1. Acute somatization

Temporary production of physical symptoms associated with transient stressors

2. Relapsing somatization

Repeated episodes of physical symptoms associated with repetitive stressors & anxiety or depressive episodes

3. Chronic somatization

Nearly continuous somatic focus, perception of ill health,

development of disability


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Assessing for Somatic Symptom Disorder Using the 3-Ps (Croicu C, et al. 2014)

Predisposing

Chronic childhood illnesses, childhood adversities, comorbid medical illness,

lifetime psychiatric diagnosis, poor coping ability

Precipitating

Medical illness, psychiatric disorder, social & occupation stress, and changes in

social support

Perpetuating

Chronic stressors, maladaptive coping skills, negative health habits


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Identifying Somatic Symptom Disorder (Croicu C, et al. 2014)

• Do a thorough history and detailed physical assessment

• Rule out medical illness

• Consider medication side effects

• Identify ability to meet basic needs

• Identify secondary gains

• Identify ability to communicate emotional needs

• Determine substance use

• Build therapeutic alliance with the patient

• Use screening tools appropriate for somatic symptom disorder

: SSS-8 and PHQ-15


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Somatic Symptoms in Psychiatry Disorder

Major Depression and Dysthymia

Panic Disorder

Generalized Anxiety Disorder (GAD)

OCD

Somatoform Disorders

Substance abuse

Delirium

Dementia

Schizophrenia and delusion disorder

Brown 1990


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Comorbid

psychological

conditions

often include:

Anxiety Disorders Are Chronic and Often Present With Comorbid Psychological Conditions1-3

1.Baldwin DS, et al. J Psychopharmacol. 2014;28(5):403-439. 2. Katzman MA, et al. BMC

Psychiatry. 2014;14(Suppl 1):S1. 3. Fried EI. Front Psychol. 2015;6:309.

Other anxiety disorders

Major depressive disorder

Bipolar disorder

Schizophrenia

Addictive disorders


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Somatic Comorbidities of Anxiety Disorders

Inflammatory

Bowel Disease

Diabetes Hypertension

Cardiovascular

Disease

Anxiety

Disorders


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Pharmacotherapy and

Cognitive-Behavioral Therapy

Effective Treatment of Anxiety Disorders Both Removes Symptoms and Prevents Relapse

Anxiety Disorder Treatment

Bandelow B, et al. Int J Psychiatry Clin Pract. 2012;16(2):77-84.

Goals of treatment:

Removal of symptoms

Prevention of relapse


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Essential Treatment Approaches for Patients with

Somatic Symptom Disorder (Croicu, C., et al. 2014)

• Avoid the temptation to order unnecessary, repetitive, or invasive

investigations

• Educate the patient on how to cope with their symptoms instead of

focusing on a cure

• Evaluate somatic symptom burden

• Collaborate with the patient in setting treatment goals

• Screen for common psychiatric conditions associated with somatic

complaints such as depression and anxiety

• Treat identified comorbid psychiatric disorders


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Essential Treatment Approaches for Patients with

Somatic Complaints (Croicu, C., et al. 2014)

• Case management to minimize economic impact

• Medications to treat anxiety and depression (SSRIs : Sertraline or SNRI : Venlafaxine ) : Need specific competencies

• Short term use of anxiety medication (benzodiazepine, e.q : diazepam, alprazolam)

• Non-pharmacological treatments

• *CBT – Shows promising evidence

• Psychodynamic therapy

• Integrative therapy


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Alprazolam Speed of Action to Remove Symptoms

of Anxiety

Sheehan DV, et al. Psychopharmacol Bull. 2007;40(2):63-81.

Ma

gn

itu

de

Average Benefit Observed 1 Hour

After Morning Dose

Ho

urs

Average Time to

Peak Benefit

Pe

rce

nt

(%)

Patients Achieving Peak

Benefit Within 1 Hour

Results from a 9-week, open-label, switch-over study in 30 patients with DSM-IV panic disorder. Patients stable on alprazolam compressed tablet for 3 weeks were

switched to alprazolam extended release. Analysis of profile data derived from the clinician and patient from daily diary records was used to determine magnitude of benefit.

According to several measures, alprazolam demonstrated a rapid onset of action in the majority of patients

In patients treated with alprazolam, 90% of the peak benefit occurred within

the first hour post-dose

64%

DSM=Diagnostic and Statistical Manual of Mental Disorders.


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Improvements in Anxiety and Panic Attacks

Pecknold J, et al. J Clin Psychopharmacol. 1994;14(5):314-321.

Data from a double-blind, placebo-controlled, flexible-dose (1-10 mg/d), multicenter, 6-week study (n=209) comparing regular alprazolam given four times per day with placebo in adult patients, evaluated with the

Structured Clinical Interview for DSM-III-R in order to establish a diagnosis of panic disorder

and extensive phobic avoidance (agoraphobia with panic attacks) or limited phobic avoidance. Results are calculated using LOCF.

Ch

an

ge

Fro

m B

as

eli

ne (

%)

HAM-A Score

P=0.03

Pati

en

ts (

%)

Freedom From Panic Attacks

P<0.04

P<0.01

After 6 weeks of treatment, alprazolam was found to be significantly more effective than placebo, according to HAM-A

scores and the percentage of patients experiencing freedom from panic attacks

LOCF=last observation carried forward; HAM-A=Hamilton Rating Scale for Anxiety; DSM=Diagnostic and Statistical Manual of Mental Disorders.


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Extended-Release Alprazolam Provides

Additional Safety

1. Susman J, et al. Prim Care Companion J Clin Psychiatry. 2005;7(1):5-11. 2. Rickels K. Expert Opin Pharmacother. 2004;5(7):1599-1611.

Patients taking alprazolam XR exhibit a reduction in peaks and troughs in plasma concentrations that in turn reduces the

occurrence of side effects1

The bioavailability and pharmacokinetics of alprazolam XR are similar to those of alprazolam

IR tablets, with the exception of a prolonged absorption time1

07:00 09:00 11:00 13:00 15:00 17:00 19:00 21:00 23:00 01:00 03:00 05:00 07:00

Alp

razo

lam

Co

nc

en

tra

tio

n (

ng

/mL

)

Time of Day

Alprazolam IR 1.5 mg q.i.d.

Alprazolam XR 6 mg every morning

Comparison of the plasma concentrations of the original formulation of alprazolam administered four times daily with that of

alprazolam XR (administered once in the morning) over a 24-hour period

Alprazolam Plasma Concentrations1,2


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Non-Pharmacological Approach :

The BATHE Technique

B: Background - What is going on in your life? And What brings you in

here today?

A: Affect – How do you feel about that?

T: Trouble – What bothers you the most about this situation?

H:Handling - How are you handling that?

E: Empathy – That must be very difficult for you.


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PHQ-15 - Screening for Somatic Symptom Presence

and Severity Not bothered

at all (0)

Bothered a little (1)

Bothered a lot (2)

a. Stomach pain

b. Back pain

c. Pain in your arms, legs, or joints (knees, hips, etc.)

d. Menstrual cramps or other problems with your periods

WOMEN ONLY e. Headaches

f. Chest pain

g. Dizziness

h. Fainting spells

i. Feeling your heart pound or race

j. Shortness of breath

k. Pain or problems during sexual intercourse

l. Constipation, loose bowels, or diarrhea

m. Nausea, gas, or indigestion

n. Feeling tired or having low energy

o. Trouble sleeping


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Somatic Symptom Scale – 8 [SSS-8]

(Table is hyperlinked)

SSD SSS-8.docx


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High prevalence and impact on patient and society

Effective treatment of anxiety disorders may be useful in the management of psychological and medical comorbidities

Diagnostic and rating criteria are useful in clinical practice

Necessity for accurate diagnosis to ensure appropriate treatment plan

Effective treatment reduces symptoms and leads to remission of anxiety disorders

Recognizing and Managing Anxiety Disorders in Clinical Practice


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Essential Treatment Approaches for Patients with Somatic

Symptom Disorder (Croicu, C., et al. 2014)

• Schedule time-limited regular appointments (e.g. 4-6 weeks) to address

complaints

• Explain that although there may not be a reason for their symptoms, you will

work together to improve their functioning as much as possible

• Educate patients how psychosocial stressors and symptoms interact

• Avoid comments like ―Your symptoms are all psychological.‖ or ―There is

nothing wrong with you medically.‖

• Relief their symptoms with appropriate and effective drug. Consider to ask

about drug history and alcohol use


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Summary

• Acknowledge the patients symptoms

• Non-pharmacological interventions such as CBT has shown evidence in

decreasing somatic symptom disorder.

• Initial treatment must be effective and relief patient’s symptoms

• Therapeutic alliance with the patient with somatic complaints improves

outcomes.

• Know our competencies, refer the patients with somatic symptoms if you think

they need further assessment and therapy


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Buku PSIKOSOMATIK


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Twitter : @mbahndi

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Website : www.psikosomatik.net

My Social Media

https://www.researchgate.net/profile/Andri_Andri

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anxiety and psychosomatic

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