Somatization

1
Somatization

• Linda Gask
• York November 2007

2
Defining the problem

• Somatization is the manifestation of
  psychological difficulty or distress through
  somatic symptoms, a tendency to experience and
  communicate somatic distress and symptoms
  unaccounted for by pathological findings and to
  attribute them to physical illness and seek
  medical help
• Lipowsky, 1988

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Multiple meanings

• Family of psychiatric disorders (somatoform in
  ICD-10 or DSM-IV)
• Medically Unexplained Symptoms (MUS)
• Hypochondriacal worry or somatic preoccupation
• Somatic presentation of anxiety, depression other
  disorders
• Often co-exist with medically explained symptoms

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Multiple meanings

• Somatization disorder rare in the community
• Medically Unexplained Symptoms common in primary
  care settings
• WHO study evidence of cultural variation in
  symptoms.
• Cultural factors influence illness behaviour

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The extent of the problem

• Ubiquitous- present in all cultures
• The point prevalence of MUS lasting all the time
  or on a regularly recurrent basis for six months
  in the general population is around 20.
• Patients with MUS account for
• around 50 more visits to primary care doctors
• one-third more outpatient costs
• one-third more hospitalizations
• than patients without MUS.
• Patients with MUS for six months or more are
  usually distressed or functionally impaired by
  the same or other MUS 12 months later

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Styles of clinical presentation of primary care
patients with depression and anxiety
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gynaecological symptoms e.g. heavy/painful periods
neurological symptoms e.g. pseudo seizures
gastrointestinal symptoms e.g. abdominal pain
How do patients Present?
generalised malaise/fatigue e.g. chronic fatigue,
fibromyalgia
regional pain presentations e.g. atypical chest
pain, headaches
musculoskeletal symptoms e.g. low back pain
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Aetiology

• People may emphasise somatic symptoms in coming
  to the doctor to make sure they get appropriate
  attention
• Somatic symptoms more legitimate reasons for
  consulting
• But- ?somatic distress associated with ?emotional
  distress
• Doctors may be more dualistic than patients
• Specific culture-related syndromes
• Benefits
• Socially acceptable
• Protective- e.g. from negative effects of
  depression on self-esteem
• Absolves from guilt and blame

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Potential meaning of somatic symptoms

• Index of disease or disorder
• Expression of psychological conflict
• Indication of specific psychopathology abnormal
  illness behaviour
• Cultural idioms of distress
• Metaphor
• Social positioning power and gain
• Social commentary or protest

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Meeting of two experts

• GP brings
• evidence-base
• access to treatment, investigation
• ability to legitimise experience with
  diagnosis/label

• Patient brings
• evidence-base
• access to sensory information
• expectation of diagnosis and treatment

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Patients with MUS are seeking

• recognition from their doctor of their distress
• to form an alliance with the doctor to understand
  their health problems through discussion and
  appropriate examination or investigation
• to feel that their problems are considered
  legitimate concerns by the doctor rather than to
  be blamed for their problems or considered
  wasteful of the doctors time

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Patients with MUS seek recognition of their
distress

• Use of graphic and emotional language to describe
  symptoms, e.g. nightmare
• Effects of symptoms on patients daily living,
  e.g. cant sleep so cant work
• Patient gives biomedical explanation for symptoms
  to discuss with doctor, e.g. wind, arthritis
• Emotional distress caused by symptoms e.g. worry,
  being scared

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Patients with MUS seek recognition of their
distress

• External authority other people, usually
  family, vouch for severity of symptoms
• Invalidating doctors explanations by giving
  additional symptoms or complexity of problems
• Invalidating doctors explanations by giving
  patients own alternative explanation for
  symptoms
• Invalidating doctors explanations by emphasizing
  the ineffectiveness of previous treatments

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What doesnt work

• GP withholds important information from physical
  examination or investigations (including normal)
• GP denies the reality of the patients concerns
  (its all in the head)
• GP passively accepts the patients own
  explanation for symptoms without discussion
• GP gives a double message that there is on reason
  for concern while giving the patient medication
  or precautionary advice e.g. there is nothing
  wrong with your heart but next time you get chest
  pain slip this tablet under your tongue

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What doesnt work

• GP gives rudimentary reassurance without
  explanation (reduces distress for less than 24
  hours)
• GP gives reassurance with ineffective explanation
  unrelated to patients expressed concerns
• GP ignores patients attempts to discuss
  emotional or social issues by reasserting a
  physical health agenda

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What works in specialist settings

• Antidepressant drugs provide short-term
  improvement for pain and gastrointestinal
  symptoms but not other MUS.
• Graded aerobic exercise or increasing physical
  activity shows short-term efficacy for chronic
  fatigue, chronic back pain or chronic widespread
  pain
• Emotional disclosure of problems is ineffective.
• Cognitive behaviour therapy can be effective but
  is suitable for and acceptable to relatively few
  patients with MUS.
• Patients are too numerous for existing number of
  specialists to see, and difficult to engage in
  therapy and patients prefer to see their GPs.

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Routine care

• Doctors usually talk to patients with MUS about
  their symptoms in an unstructured way,
• investigate,
• provide reassurance
• prescribe symptomatic relief
• exercise
• psychotropic drugs (usually antidepressants,
  sedatives and hypnotics)
• refer to physiotherapy
• community nursing and counseling services, and
  hospital medical and surgical care.
• There is little short-term evidence of improved
  symptoms or function with such an approach.

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Important properties of symptom beliefs

• Nature physical, psychological, normalizing
  (part of everyday experience)
• Cause e.g. germ, body part work out
• Severity trivial, potentially catastrophic or
  catastrophic consequences
• Timeline short-lasting or long lasting
• Controllability by patient, by others including
  health professionals, out of control
• Perceived exacerbating factors e.g. harmful
  effects of exercise on fatigue or body pain
• Perceived relieving factors e.g. benefits of
  complete rest on fatigue or body pain
• Fixity of beliefs degree of certainty with
  which symptom belief is held

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Four Stage Model for managing MUS

• Feeling understood
• Establishing the agenda through negotiation
• Action
• Termination of consultation

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Stage 1 Feeling understood

• Doctor takes history of presenting physical
  symptoms,
• other associated physical symptoms,
• emotional problems and psychosocial factors,
• symptom beliefs,
• past similar problems, symptoms and management,
• relevant physical examination

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Stage 2 Establishing the agenda through
negotiation

• Doctor acknowledges distress or symptoms,
• feeds back results of any physical examination
  and any investigations (including no or minor
  abnormalities).
• Establishes patients needs
• clarification of the problem,
• acknowledgement of the problem and the concern it
  raises,
• specific action to help patient to manage
  themselves
• explanation for the symptoms,
• further management when physical problems have
  been ruled out,
• explain that doctor is happy to reconsider the
  problem if further symptoms arise.

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Stage 3 Action

• Clarification of the problem what is due to
  physical health problems, what might be due to
  stress or lifestyle
• Discussion and acknowledgement of distress and
  problems patients symptoms have
• Negotiate any specific requests patients has
  what this will or will not reveal for the patient
• Explanation of symptoms in three stages
• Symptoms stress or lifestyle
• how they are linked in time or physiologically
  e.g. headache each time there is an argument or
  when in a rush feel tense and muscles in forehead
  tighten up
• Treatment symptomatic, watchful, waiting or
  underlying depression, anxiety

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Stage 4 Termination of consultation

• Determine whether follow-up is required or not.
• Again acknowledge current distress and offer to
  review
• if there is a physical health problem
• if further symptoms appear

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Approaches for chronic MUS involving frequent
attendance

• One doctor to organise management
• Clarify areas you and the patient agree/disagree
  on
• Regular scheduled appointments
• Clear agenda setting during consultation
• Limit diagnostic tests
• Provide clear model for the patient
• Involve colleagues in primary care team
• Involve the patients family
• Dont expect a cure

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Role of the Family

• Central in maintaining symptoms - what do the
  family want?
• Involve family in
• limiting further investigations
• reinforcing explanation
• provision of effective treatment
• explore needs of carers

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Cultural Competence in clinical formulation

• Multidimensional, culturally relevant assessment
• Social and cultural context of patient and family
• Language, etiquette, power, identity, racism
• Flexible roles and boundaries
• Questioning Stance
• Awareness of differences in cultural norms
• individualism vs. collectivism

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Cultural Competence in clinical formulation

• Negotiate a problem definition and therapeutic
  strategy meaningful and acceptable to patient,
  family and clinician
• Mobilise personal, family and community resources
• Culturally consonant interventions to address the
  most flexible or accessible levels at which
  problems can be addressed
• Listen, renegotiate in response to needs and
  concerns.

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Problems with the Health Service

• Disincentives for continuity of care
• Shortage of skilled professionals (liaison
  psychiatrists, health psychologists)
• Iatrogenic disease defensive practice
• Lack of sophisticated psychological therapy
• Benefit system mitigates against successful
  rehabilitation