PowerPoint Presentation

/ 331Somatoform Disorders

12/ 33Your most difficult patients ?Pain everywhereNot improvingComming every day

2At the end of this session, the trainees will increase their knowledge in managing somatoform disordersExplain the pathopysiologyList symptoms which might be somaticList diagnostic criteria of somatoform disordersExplain the management principles of somatisationCategorize the somatoform disorders3/ 33Aim-Objectives34/ 33

somatizationdesomatizationresomatization4 Bodily symptoms without any organic, physical cause5/ 33Definition

Lipowsky 19885No explanatory organic cause can be found in 20-84% of patients presenting with bodily symptoms.6/ 33

Why important?67/ 33Epidemyology

More common among less educated and less income7I. Increased bodily sensitivity Physical symptoms perceived are normal for most individuals8/ 33Pathopysiology

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Pathopysiology II. Defined patient Stress within the family stabilizes after the member becomes sick / 3310

III. Need to be sick Becoming physically sick is less stressfull than being unsuccessfull11/ 33PathopysiologyBarsky,1997 There is no medicine or surgery to remove the need to be sickBARSKY,1997

IV. Dissociation Perceiving a stimulus which is not presentPhantom painDepersonalization Flashback12/ 33PathopysiologySomatization Conversion disorder HypochondriasisPain disorderBody dysmorphic disorder13/ 33Somatoform DisordersResemples a neurological problemMotor or sensorial symptomsNot explainable by neuroanatomyLa belle indiference Females 10-35 years,Lower socioeconomic class14/ 33ConversionDisease of having diseaseSevere anxietyM/F=1No insightResistant, causing functional losses15/ 33Hypochondriasis

Main symptom is painM/F=1/2Pain increases with stressNot explainable with nouroanatomyOrganic problem may be superimposed16/ 33Pain disorderBelives that there is a problem with appearanceObsessiveM/F=1Frequent cosmetic surgery17/ 33Body Dysmorphic Disorder

18/ 33Organic cause?Substance abuse?Other psychiatric dis.?

Neurological symptomconversionPain predominantToo busy with diseaseHypochondriasisPain disorderSomatization dis.Many symptomsIntentional symptomsMalingeringyok IIIIIIIVVVI19/ 33SYMPTOMS WHICH MIGHT BE SOMATICGISNausea Abdominal pain DiarrheaBelching BloatingFood intolerance CVS Chest pain PalpitationsDyspnea

UROGENITALBurningDysparoniaDysmenorrheaIrregular menstruationVomiting PAINGeneralized painExtremity painBack painJoint painHeadacheDysuriaPSEUDONEUROLOGICALAmnesiaSwallowing difficultyLoss of voiceBlurred vision, blindnessFaintingMuscle weaknessDifficulty in walkingSYNDROMESAtipical chest painTemporomandibular joint s.hypoglycemiaPremenstruel symdromeUnidentified food allergyUnidentified vitamin deficiency19At least three symptoms of uknown cause (generally in different systems)Chronic course (more than two years) 20/ 33Diagnostic CriteriaSince too longToo many systemsToo many symptoms2021/ 33Symptoms might be exaggerated and irrational for us but they are REAL for the patient! 22/ 33Management Discuss the diagnosisWe counldnt find anything serious after the exam or investigations. But htere is something bothering you. Although the reason is not clear, this is a situation we face frequently2223/ 33Management Discuss the diagnosisBetter we should discuss how we can help you instead of the name. However, although there are a lot of names given, we frequently call this situation as Somatoform disorderWhat is my diagnosis:Chronique fatigue syndromeFibromyalgiaFrequent visits (15 min/month)Short PE Aim: Prevent new symptomsDecrease admissions to ERDiscuss open ended questions24/ 33Management Regular visitsDont try to loose the symptoms, better try to teach how to deal with themPatients expect more care than cure. Patients expect continuous relationship.

25/ 33Management Regular visits B ackgroundHow is your life going? A ffectWhat do you feel? T roubleWhat is the most important problem? H andleWhat can help you? E mpathy I understand you. This is a tough situation... 26/ 33Management BATHEing the patientStuart MR, Lieberman JA, 199326No specific medicineTreat concomittant psychiatric problemDeal with domiant symptom:Pain AmitriptillineFatigue BupropionAnxiety, sleep dist SSRI, TCA27/ 33Management - Pharmacological

Stress - somatic symptom relationshipSymptom diaryGroup therapy 28/ 33Management - Psychotherapy

Light exercises (3x20 min/w)Increases self esteemYoga, meditation, walksNon harmful methods: cold-warm applications, acupuncture, vitamins

29/ 33Management Life style changes

Dont put goals you can not meetCo-morbidityDiagnositc requestsEmergency admissionsPhone calls

30/ 33Management - Problems

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Concentrating on symptomsUnnecessary Referrals / cons.Tests or Rx without DxIts just in your mind, take it easy..3132/ 33

Frequent, short visitsAllow patient roleConcentrate on functionsSingle doctor33/ 33What did we learn?