Common Psychiatric Problems

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Common Psychiatric Problems in Family Practice
Somatoform Disorders
Saudi Diploma in Family Medicine Center of Post
Graduate Studies in Family Medicine
Dr. Zekeriya Aktürk zekeriya.akturk_at_gmail.com www.
aile.net
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Your most difficult patients ?
Pain everywhere
Comming every day
Not improving
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Aim-Objectives

• At the end of this session, the trainees will
  increase their knowledge in managing somatoform
  disorders
• Explain the pathopysiology
• List symptoms which might be somatic
• List diagnostic criteria of somatoform disorders
• Explain the management principles of somatisation
• Categorize the somatoform disorders

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somatization
desomatization
resomatization
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Definition

• Bodily symptoms without any organic, physical
  cause

Lipowsky 1988
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Why important?

• No explanatory organic cause can be found in
  20-84 of patients presenting with bodily
  symptoms.

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Epidemyology

• More common among less educated and less income

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Pathopysiology

• I. Increased bodily sensitivity
• Physical symptoms perceived are normal for
  most individuals

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Pathopysiology

• II. Defined patient
• Stress within the family stabilizes after the
  member bocomes sick

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Pathopysiology

• III. Need to be sick
• Becoming physically sick is less stressfull
  than being unsuccessfull

There is no medicine or surgery to remove the
need to be sick
Barsky,1997
BARSKY,1997
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Pathopysiology

• IV. Dissociation
• Perceiving a stimulus which is not present
• Phantom pain
• Depersonalization
• Flashback

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Somatoform Disorders

• Somatization
• Conversion disorder
• Hypochondriasis
• Pain disorder
• Body dysmorphic disorder

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Conversion

• Resemples a neurological problem
• Motor or sensorial symptoms
• Not explainable by neuroanatomy
• La belle indiference
• Females 10-35 years,
• Lower socioeconomic class

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Hypochondirasis

• Disease of having disease
• Severe anxiety
• M/F1
• No insight
• Resistant, causing functional losses

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Pain disorder

• Main symptom is pain
• M/F1/2
• Pain increases with stress
• Not explainable with nouroanatomy
• Organic problem may be superimposed

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Body Dysmorphic Disorder

• Belives that there is a problem with appearance
• Obsessive
• M/F1
• Frequent cosmetic surgery

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I
Organic cause? Substance abuse? Other
psychiatric dis.?
yok
Neurological symptom
conversion
II
Pain disorder
Pain predominant
III
Too busy with disease
Hypochondriasis
IV
Somatization dis.
Many symptoms
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Intentional symptoms
Malingering
VI
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SYMPTOMS WHICH MIGHT BE SOMATIC SYMPTOMS WHICH MIGHT BE SOMATIC SYMPTOMS WHICH MIGHT BE SOMATIC
GIS Nausea Abdominal pain Diarrhea Belching Bloating Food intolerance CVS Chest pain Palpitations Dyspnea UROGENITAL Burning Dysparonia Dysmenorrhea Irregular menstruation Vomiting
PAIN Generalized pain Extremity pain Back pain Joint pain Headache Dysuria PSEUDONEUROLOGICAL Amnesia Swallowing difficulty Loss of voice Blurred vision, blindness Fainting Muscle weakness Difficulty in walking SYNDROMES Atipical chest pain Temporomandibular joint s. hypoglycemia Premenstruel symdrome Unidentified food allergy Unidentified vitamin deficiency
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Diagnostic Criteria

• At least three symptoms of uknown cause
  (generally in different systems)
• Chronic course (more than two years)

Since too long
Too many systems
Too many symptoms
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Symptoms might be exaggerated and irrational
for us but they are REAL for the patient!
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Management Discuss the diagnosis
We 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 frequently
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Management Discuss the diagnosis
What is my diagnosis
Better 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 disorder
Chronique fatigue syndrome
Fibromyalgia
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Management Regular visits

• Frequent visits (15 min/month)
• Short PE
• Aim
• Prevent new symptoms
• Decrease admissions to ER
• Discuss open ended questions

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Management Regular visits

• Dont try to loose the symptoms, better try to
  teach how to deal with them
• Patients expect more care than cure.
• Patients expect continuous relationship.

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Management BATHEing the patient

• B ackground
• How is your life going?
• A ffect
• What do you feel?
• T rouble
• What is the most important problem?
• H andle
• What can help you?
• E mpathy
• I understand you. This is a tough
  situation...

Stuart MR, Lieberman JA, 1993
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Management - Pharmacological

• No specific medicine
• Treat concomittant psychiatric problem
• Deal with domiant symptom
• Pain ? Amitriptilline
• Fatigue ? Bupropion
• Anxiety, sleep dist ? SSRI, TCA

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Management - Psychotherapy

• Stress - somatic symptom relationship
• Symptom diary
• Group therapy

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Management Life style changes

• Light exercises (3x20 min/w)
• Increases self esteem
• Yoga, meditation, walks
• Non harmful methods cold-warm applications,
  acupuncture, vitamins

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Management - Problems

• Dont put goals you can not meet
• Co-morbidity
• Diagnositc requests
• Emergency admissions
• Phone calls

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Concentrating on symptoms
Its just in your mind, take it easy..
Unnecessary Referrals / cons.
Tests or Rx without Dx
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Concentrate on functions
Allow patient role
Frequent, short visits
Single doctor
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What did we learn?