ACHA Philadelphia June 4, 2010 Amy R. Alson, MD University of Virginia Elson Student Health Center Charlottesville, Virginia UNDERSTANDING THE PAINS THAT WONT GO AWAY HOW TO REDUCE THE BURDEN OF PSYCHOSOMATIC ILLNESS AMONG COLLEGE & UNIVERSITY STUDENTS Learning Objectives Attendees should be able to: 1. Explain the impact of unidentified

psychosomatic Illness on the college and university healthcare system. 2. Identify psychosomatic illness commonly seen among college and university students. 3. Describe strategies to effectively treat students with psychosomatic conditions. Overview The impact of somatoform disorders Diagnostic terms: now and future Pathophysiology & psychology Treatment recommendations Clinical course & prognosis

Cases References Describing the burden Prevalence of somatoform disorders in general practice reported as high as 30% Unexplained chronic pain affects >25% primary care patients Accrued twice the costs for medical care. Utilized twice the services (out and in-patient) Overuse of specialist consultation Unmeasured impact on patients

academic & social lives Jay,23, 2rd year med student Initial presentation: Nov 3, 2009 1. Intermittent vague LUQ abdominal discomfort 2. chronic loose stools 3. chronic GERD with concern about longterm PPI use. 4. Lymphadenopathy (R cervical & supraclavicular). Had a panic attack while driving and palpating nodes. He is very concerned about cancer. 5. Tremor in his hands, and numbness at

the tip of his tongue, both of which are chronic. Somatization Experiencing psychological distress in the form of physical symptoms for which one seeks medical care. Somatization can be conscious or not, and may be influenced by psychological distress or a desire for personal gain. Symptoms range from exaggeration of common problems to disabling and unrelenting clinical syndromes.

DSM-IV-TR: Somatoform disorders Undifferentiated somatoform disorder Pain disorder Somatization disorder Hypochondriasis Body dysmorphic disorder

Conversion Disorder Somatoform disorder NOS Somatization disorder A. A history of many physical complaints beginning before age 30, occurring over several years & resulting in treatment being sought or significant impairment in social, occupational or other important areas of functioning. B. Must include 4 pain symptoms, 2 GI symptoms, one sexual symptom, one pseudoneurologic symptom. C. Either not explained by a known GMC, or

impairment exceeds expected for existing GMC Somatization disorder Less than 1% of patients with Medically Unexplained Symptoms (MUS) meet criteria for Somatization Disorder. 1-year prevalence among US adults is 0.3%. Hypochondriasis Preoccupation with the fear of having a serious disease based on misinterpretation of bodily symptoms despite appropriate

medical evaluation and reassurance. Conviction about illness is not of delusional intensity, and is not restricted to concern about appearance. Preoccupation lasts at least 6 months & causes clinically significant distress or impairment. Hypochondriasis Male = female prevalence Insight varies among affected patients Commonly co-occurs with anxiety and depressive disorders.

Onset is typically later in life than somatization disorder 4-6% of general medical outpatients Undifferentiated somatoform disorder: One or more physical symptoms that cause significant distress or impairment in functioning lasting at least 6 months . Pain disorder: Pain in one or more sites, causing significant distress or impairment and associated with psychological factors. May be associated with a psychological factors,

or with psychological factors and a GMC. Acute if < 6 months; chronic if 6 months or longer. Body dysmorphic disorder Preoccupation with an imagined or exaggerated physical defect Conversion disorder Unintentionally produced deficits affecting voluntary motor or sensory function that suggest a neurological or other GM, associated with psychological factors.

Somatoform disorder NOS Psuedocyesis Nonpsychotic hypochondriacal symptoms of less than 6 months duration Unexplained physical complaints (fatigue, weakness) of less than 6 months duration DSM V (Draft) current terminology for somatoform disorders is confusing somatoform disorders, malingering, and factitious disorders all involve physical

symptoms and/or concern about medical illness, they will be reclassified as Somatic Symptom Disorders. Somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder shall be grouped into a new diagnosis: Complex Somatic Symptom Disorder. SomatoformDisorders.aspx Complex Somatic Symptom Disorder To meet criteria for CSSD, criteria A, B, and C are necessary. A. Somatic symptoms: One or more somatic symptoms that are distressing and/or result in

significant disruption in daily life. B. Overwhelming concern or preoccupation with symptoms and illness: At least three of the following are required to meet this criterion: (1) High level of health-related anxiety. (2) A tendency to fear the worst about one's health or bodily symptoms (catastrophizing). (3) Belief in the medical seriousness of one's symptoms despite evidence to the contrary. (4) Health concerns and/or symptoms assume a central role in one's life (ruminative preoccupation). C. Chronicity: Although any one symptom may not be continuously

present, the state of being symptomatic is chronic (at least 6 months). Pathogenesis Symptoms are real, exaggerated, and/or imagined Patients experience of symptoms leads to distressing fears and beliefs There is no clear bio, psycho or social explanation Existing theories are not mutually exclusive. Proposed neurobiology Efferent pathways: HPA Axis hypoactivity

Deficits lead arousal to cause increased bodily discomfort Afferent pathways: altered brain asymmetry in neuroendocrine regulation of sensory processing Central misinterpretation of physical experience Sensitization in the limbic system or pain pathway due to repeated toxic exposures Trauma, illness Overactive neurophysiological 'as-if loops

related to self-representation mirror neurons Psychology: Attachment Insecure , preoccupied attachment style (independent of negative affect) Negative self-view, idealized view of others Clingy, seek reassurance in relationships at times of stress Attachment style is relatively stable across

the first 19 years of life History of traumatic childhood experiences (loss, illness, inconsistent care) A major function of attachment behavior is affect regulation Psychology: Alexithymia Difficulty processing and communicating (representing) subjective feelings; focus on concrete external events Moderate correlation with somatization in a series of college student samples 40% of 118 general psychiatric outpatients scored in the alexithymic range of the Toronto

Alexithymia Scale. This subset scored significantly higher on validated measures of somatization, depression and anxiety. The feature-positive effect Unequal weighing of positive and negative information Unequal weighing of active and passive behaviors In hypochondriasis, patients focus on positive information of bodily

symptoms and discount negative information of empirical test results and PE findings. Cultural influences Pain comes from the Latin poena, for punishment or penalty Health and illness beliefs are informed by spirituality, superstition, and age Death beliefs affect health anxiety Negative beliefs about death are associated with increased health anxiety Positive beliefs about death are associated

with reduced health anxiety Risk factors? A history of sexual abuse is associated with: functional GI symptoms nonspecific chronic pain psychogenic seizures chronic pelvic pain. Risk factors? Patients with MUS often had ill parents as children

Patients with h/o childhood fatigue are more likely to report noncardiac chest pain. Children with benign murmurs have poor psychosocial outcomes, presumably due to parents fear of underlying serious illness The worried well Psychiatric comorbidity: 2/3 of hypochondriacs GAD OCD 5-10% of hypochondriacs

Social phobia MDD (may present only with somatic features) 40% of hypochondriacs Panic disorder 10-20% of hypochondriacs Substance dependance (opioids) Fig. 1 Overlap between somatoform disorders and anxiety or depressive disorders: weighted prevalence (s.e.). Observed comorbidity, 4.20%; expected comorbidity, 1.26%; ratio=3.3. Within somatoform disorders: 26% anxiety and/or depressive disorders; within anxiety and/or depressive disorders: 54% somatoform disorders. De Waal, M. W. M. et al. Br J Psychiatry 2004;184:470-476

Copyright 2007 The Royal College of Psychiatrists General medical conditions cause these symptoms, too Celiac disease: 1 in 250 Americans IBD: incidence 1-10 cases per 100,000; prevalence 200 N. Americans per 100,000. Ischemic heart disease is rare in young adults Evaluation

History HPI PMH: include psychiatric history recent physicians and patients experience of them Family history: especially during patients childhood elicit parental attitudes toward illness Social history: include history of sexual abuse childhood illnesses, school avoidance current academic and social pressures Physical Exam

Medical treatment Structured, scheduled visits with the same clinician minimize crises, reduce urgent contacts Start with weekly or biweekly brief (20-minute) visits progressively lengthen the intervals Centralize care Discuss purpose of and limit referrals, tests, meds

Psychological treatment About 50% of patients refuse psychotherapy referral Most patients with MUS are open to psychosocial treatment provided by PCP, in addition to usual care Clinician must reframe own expectations (cure is unlikely) CBT in Primary care Establish a partnership minimize shame & fear of abandonment

respond to patients emotions and concerns identify treatment goals provide education Establish a routine review interval since last visit set goals for current visit assign homework Psychological treatment CBT by an expert can focus on: misinterpretation of positive symptoms selective attention, safety-seeking, and

bodily discomfort due to anxiety revalue negative test results and physical exam findings Prognosis Medically Unexplained Symptoms 50-75% improve 10-30% deteriorate Hypochondriasis 30-50% recover Number of somatic symptoms and seriousness of condition at baseline

influences course and prognosis Inconclusive evidence regarding influence of untreated psychiatric comorbidity Kyle, 21, 3rd year CS major Initial presentation: Nov 2008 Chronic LUQ abdominal wall and recurrent periumbilical pain, GERD Recently seen in ER: normal CT and labs Per PCP (at Student Health): Bentyl for suspected IBS, Prilosec for GERD RTC if no improvement or symptoms worsen.

Kyle: Jan 2009 Patient calls with worsening, persistent pain: Extensive GI workup done over break in NoVa: EGD, bloodwork, repeat CT, camera endoscopy; GI told him: liver biopsy is the next step. Vicodin from GI Bentyl, Elavil, Prilosec from PCP (student health) KUB ordered to rule out stones: negative. Endorses depression & anxiety; requests referral to CAPS. Referred out to CBT therapist: Nice guy, but he didnt help.

Kyle: May 2009 Referred to MD in CAPS, for 2nd opinion. Endorses panic attacks, constant anxiety using Dads Xanax requests a benzo, refuses an SSRI. History of depression with suicide attempt at 13. Past meds: Prozac, Paxil, Celexa, Zoloft, Effexor, Cymbalta, Elavil. All cause atypical, intolerable

side effects. Therapists are nice but not helpful; felt mistreated by 3 psychiatrists. Help seeking, help-rejecting, insecure attachment style noted. Kyle: September 2009 Mirtazepine, TENS unit, nortriptyline tried. Now on clonazepam prn and trazodone. Biofeedback helps with sleep, not pain. Intensifying suicidal thoughts related to the relentless pain.

Discussed with treatment team. Patient aware, agrees to meet another CAPS psychiatrist for one- Kyle: September 2009 2nd Psychiatric assessment reveals: childhood history of sexual abuse by his brother, which parents didnt buy remote and recent cutting. Frequent appointments are comforting, but he fears wasting the doctors time. Recommendations: psychodynamic therapy

minimize psychotropic medication. Kyle, May 2010 Patient met therapist twice a week for 4 months; now meets with psychiatrist weekly. Focus has shifted to reducing, not eliminating pain, and on his unsupported negative self-evaluation. Clonidine for pain and BP is partially effective Coordinated referral to pain specialist : Recommendation: Trileptal or Nucynta (tapentadol, a mu-opioid receptor agonist and NRI active in painsignaling pathways).

One week later: Pain free. Summer break: scheduled visits offered; he prefers email contact. Jay,23, 2rd year med student Initial presentation: Nov 3, 2009 1. LUQ abdominal discomfort 2. chronic loose stools 3. chronic GERD with concern about longterm PPI use. 4. Lymphadenopathy, panic attack, concerned about cancer. 5. Chronic tremor and tongue numbness.

Jay: initial workup & plan Screening labs GI symptoms: CMP, lipase, TSH LAD: CBC with differential Bentyl GI referral (per patient request) CAPS referral for anxiety with panic attack. Patient encouraged to use walk-in hours. Follow-up scheduled to address chronic

tremor and tongue numbness Jay: follow-up Feb 18 Since last visit: new concern for elevated BP: 140s/80s at home since last visit, and at GI office visit Now predominanty constipated. GI started Kapidex and Benefiber, scheduled EGD, ordered TTG. Lymphadenopathy without constitutional symptoms persists. Patient is worried about being seen in CAPS. Patient expresses preoccupation with his own

health.For any symptoms he tends to jump to a terminal illness diagnosis for himself. He spends hours daily looking up diagnoses, surfing online forums, performing self-exams, daily temp. Jay: follow-up workup & plan BP: Stop body-building supplement; recheck in 2 weeks. GI: plan per consultant LN: 2 normal CBCs separated by 3 months; recheck HIV serology for completion. PPD reviewed (8/09), CXR to rule out mediastinal LAD. I do not think it is worth launching into a large workup for the LN w/out

any other symptoms, and I explained this to the patient today. Anxiety: clonazepam 0.5mg q12h prn; referral to Med-Psych colleague for 2nd opinion. ...follow up with me or with Dr A after he has had a 2nd opinion. I am happy to continue working with him. Jay: 2nd opinion visit April 2010 BP: off supplement, within normal limits LN: reporting epitrochlear nodes, which we learned are never normal. Has scheduled an appointment with HemeOnc attending for a definitive opinion on this concern.

GI: diagnosed with celiac disease; not yet on gluten-free diet. Anxiety: wont go to CAPS; wants to start an SSRI. Susan, 20: postprandial pain Recovering from Anorexia nervosa, still in weight-gain phase of treatment. Normal physical exam except for low BMI, no alarm symptoms. Work-up: Serology for celiac disease ESR for Inflammatory Bowel Disease

CBC for infection Comprehensive metabolic Amylase Neil, 21: Headache and insomnia GP6D deficiency, alpha-thalassemia trait with mild anemia Normal physical exam except for severely depressed affect, no alarm symptoms. Neurology consultation: imaging, HA meds Referral to CAPS: resistant to behavioral techniques but open to psychodynamic

psychotherapy Limited medication trials and reiteration of sleep hygiene for insomnia Kara, 19: Chest pain PE notable for reproducible costochondral tenderness, otherwise normal. Patient previously seen in CAPS for anxiety and long history of disordered eating. EKG Basic metabolic panel & CBC Event monitoring

Review of recommendations The relationship is the key! Frequent scheduled contact Standardized, centralized care Set limits specialists medications tests Support systems Patient-centered Clinician-centered University of Virginia

Acknowledgments My colleagues in General Medicine Meredith Hayden, Amber Pendleton, Neil Silva, Claire Veber My colleagues in CAPS Daniel Ciudin, Emily Lape, Katy Rice, Rafael Triana References American Psychiatric Assn, DSM-IV-TR, 2000. Barsky, A. N Engl J Med, Vol 345, No 19, (2001) 1395-1933.

Greenberg, DB, Somatization, (version 18.1 Jan 2010) De Waal, M. W. M. et al. Br J Psychiatry 2004;184:470-476 Gros, D, et al Frequency and severity of the symptoms of irritable bowel syndrome across the anxiety disorders and depression. Journal of Anxiety Disorders 23 (2009) 290-296. Haugaard, J. Recognizing and Treating Uncommon Behavioral and Emotional Disorders in Children and Adolescents Who have been Severely Maltreated: Somatization and Other Somatoform Disorders. Child Maltreatment, Vol 9, No 2 (2004) 169-176. Henningsen, P. The body in the brain: towards a representational

neurobiology of somatoform disorders. Acta Neuropsychiatrica 2003 15: 157-160. Hotopf, MB ,et al. Psychosocial and Developmental antecedents of chest pain in young adults, Psychosomatic Medicine 61: 861-867 (1999). James A and Wells A, Death beliefs, superstitious beliefs and health

anxiety. British Journal of Clinical Psychology, 41, (2002) 43-53. Lamberg, L. New Mind/Body Tactics Target Medically Unexplained Physical Symptoms and Fears. JAMA, Vol 294, No 17 (2005) 21522154. olde Harteman, T, et al. Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. Journal of Psychosomatic Research 66 (2009) 363377. Rassin, E, et al The feature-positive effect and hypochondriacal concerns. Behaviour Res & Therapy 46 (2008) 263-269. Roelofs, K and Spinhoven, P. Trauma and medically unexplained

symptoms: towards an integration of cognitive and neuro-biological accounts. Clinical Psychology Review 27 (2007) 798-820. Smith, R and Dwamena, F. Primary care management of medically unexplained symptoms, (version 18.1 Jan 2010 ) Taylor, G. et al Alexithymia and Somatic complaints in Psychiatric outpatients. Journal of Psychosomatic Research, Vol 36, No 5, (1992) 417-424 Tyrer, S. Psychosomatic Pain. British Journal of Psychiatry, 188 (2004) 9193. Verhaak, P, et al. Persistent presentation of medically unexplained symptoms in general practice. Family Practice Advance Access, April 2006. Weardon, A et al. Adult Attachment, Reassurance Seeking and

Hypochondriacal Concerns in College Students, Journal of Health Psychology, (2006) Vol 11 (6) 877-886. Wise, T and Birket-Smith, M. The Somatoform Disorders for DSM-V: The need for changes in process and content. Psychosomatics 43:6, (2002)

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