Curriculum Vitae

• Dr. Andri,SpKJ,FAPM • Lulus Dokter dari FKUI tahun 2003 • Lulus Psikiater dari FKUI tahun 2008 • Fellow of Academy of Psychosomatic Medicine, USA (2013) • Jabatan :

– Dosen FK UKRIDA (2008 – sekarang) – Ketua Sub Kredensial Komite Medik Omni Hospitals Alam Sutera

(2014 – sekarang) – Kepala Klinik Psikosomatik OMNI Hospitals (2008 – sekarang)

• 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)

PSYCHOSOMATIC DISORDER IN DAILY PRACTICE : DIAGNOSIS AND THERAPY

dr.Andri,SpKJ,FAPM Psychiatrist, Fellow of Academy of Psychosomatic Medicine

Faculty of Medicine, UKRIDA

Psychosomatic Clinic Omni Hospitals Alam Sutera, Tangerang Selatan

• 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

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

Historical Background and Changes from DSM III

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

• Somatoform Disorder Somatic Symptom Disorder

- First introduced 30 yrs 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.

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?

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

• 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

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

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

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)

Data 2009 di Puskesmas di Jakarta

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

Common types of somatization seen in primary care

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

(Croicu, C., et al. 2014)

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, and disability payments

Approach to the patient with multiple somatic symptoms.pdf

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

Relation Mind and Body : Physical and Behavior

Somatic Comorbidities of Anxiety Disorders

Inflammatory Bowel Disease

Diabetes Hypertension

Cardiovascular Disease

Anxiety Disorder

s

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

Essential Treatment Approaches for Patients with Somatic Symptom Disorder

• 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

(Croicu, C., et al. 2014)

Essential Treatment Approaches for Patients with Somatic Complaints

• Case management to minimize economic impact • Medications to treat anxiety and depression

(SSRIs : Fluoxetine, Sertraline or SNRI : Venlafaxine ) : Need specific competencies

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

• Non-pharmacological treatments • *CBT – Shows promising evidence • Psychodynamic therapy • Integrative therapy

(Croicu, C., et al. 2014)

Treatment options for anxiety disorders Psychological treatment

• Consider treatments that have been most thoroughly evaluated first

• If response inadequate, adapt treatment to the individual

Pharmacological treatment • Refer to section for diagnosed disorder for specific medication

choices • Consider short-term benzodiazepines if severe anxiety or agitation

or acute functional impairment

Step 1: First-line agent Optimize dosage and duration Step 2: If inadequate response or side effects, switch to alternate first-line agent. If partial response, adding another agent may be preferred over switching Step 3: Consider referral to specialist, or consider combination treatment, or switch to second- or third-line agents

Potential combinations • Psychological treatment + pharmacological treatment • SSRI-SNRI + benzodiazepines (short-term) • SSRI-SNRI + anticonvulsant or atypical antipsychotic • Refer to section for disorder for augmenting agents

Contraindicated combinations • SSRI-SNRI-TCA + MAOI • Buspirone + MAOI

Follow up • Response may take 8-12 weeks • Pharmacotherapy may be needed for 1-2 years or longer

Can J Psychiatry, Vol 51, Suppl 2, July 2006

http://www.psychiatrictimes.com/articles/achieving-remission-generalized-anxiety-disorder

By Laura A. Mandos, PharmD, Jennifer A. Reinhold, PharmD, BCPS, BCPP, and Karl Rickels, MD - See more at: http://www.psychiatrictimes.com/articles/achieving-remission-generalized-anxiety-disorder#sthash.pLl7TBKm.dpuf

Clobazam is Effective

• Clobazam has the same effectiveness compare to diazepam, lorazepam, chlordiazepoxide, bromazepam and alprazolam

• Maximum anxiolytic response seen one to two weeks • Clobazam was generally well tolerated. • Drowsiness was reported less frequently with clobazam

than with diazepam or lorazepam. • No objective evidence of any sedative or amnestic effects

or impairment of psychomotor function with clobazam. • Clobazam is a useful agent in the treatment of outpatients

and patients in general practice with anxiety disorders.

Clobazam: Epilepsy, Anxiety and General Psychopharmacology . Human Psychopharmacology: Clinical and Experimental. Volume 10, Issue Supplement 1, pages S27–S41, July 1995

Fluoxetine as the First Line Treatment • SSRIs are greatly preferred over the other classes

of antidepressants. • Fluoxetine is the first SSRI Antidepressant • SSRIs do not have the cardiac arrhythmia risk

associated with tricyclic antidepressants. • Level of Evidence A, Level of Recommendation 1 :

Panic Disorder and Post traumatic stress disorder • A group of 9087 patients (87 different RCTs)

confirms that fluoxetine is safe and effective in the treatment of depression from the first week of therapy.2

1. BORWIN BANDELOW. Guidelines for the pharmacological treatment of anxiety disorders, obsessive – compulsive disorder and posttraumatic stress disorder in primary care

. International Journal of Psychiatry in Clinical Practice, 2012; 16: 77–84 2. . Rossi A. Fluoxetine: a review on evidence based medicine.. Ann Gen Hosp Psychiatry. 2004; 3: 2

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

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

“Healing” painting by Devin Sutanujaya (2016)

Buku PSIKOSOMATIK

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