Subtypes of Somatizaton

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Subtypes of Somatizaton

• Acute somatization
• Temporary production of physical symptoms
  associated with transient stressors
• Relapsing somatization
• Repeated episodes of physical symptoms associated
  with repetitive stressors
• Chronic somatization
• Nearly continuous somatic focus, perception of
  ill health, development of disability

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What psychiatric disorders are common among
somatizing patients?
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Case 1

• Mr. S is a 35 year old male who presented
  recurrently to the emergency room with chest
  pain, shortness of breath and palpitations. His
  vital signs revealed a resting pulse of 105 and
  blood pressure of 180/110. Workup over the last
  6 months revealed normal treadmill, Holter
  monitor, angiogram and pheochromocytoma screen.
  Mr S has a private law practice and has been
  married for 10 years and has two grade school
  children.

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1. Cost of Depression

• Data is based on computerized pharmacy,
  outpatient registration and cost-accounting data
  from a large staff-model HMO
• Compared mean annual health care costs of 4,289
  patients treated for depression with
  antidepressants vs. mean annual health care costs
  of 21,360 comparison enrollees

Simon and Von Korff, 1993
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II. Cost of Depression

• 2 to 3-fold differences in cost were seen for
  every category (outpatient, inpatient, specialty,
  pharmacy, laboratory)

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Prevalence of Mental Disorder in Chronic Physical
Illness
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Three Maladaptive Effects of Affective Illness on
Chronic Medical Illness

• Amplification of somatic symptoms (especially
  pain) and functional disability
• Decreased self-care and adherence to medical
  regimens
• Direct maladaptive physiologic effects
• Modulated by automatic neurons, hypothalamus and
  immunologic effects

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Depression Symptom Amplication in
Diabetes Ciechanowski et al., 2000

• After controlling for age, gender, education,
  medical comorbidity, the number of diabetic
  complications, and Type 1/Type 2 diabetes,
  patients with depression and diabetes compared to
  patients with diabetes alone, were significantly
  more likely to report having 8 out of 9 diabetic
  symptoms over the last week.
• These symptoms included several days of feeling
  abnormally thirsty, having blurred vision,
  passing a lot of water daily, feeling unusually
  hungry, feeling shaky, cold hands and feet,
  feeling sleepy during the day and having a
  feeling of pins and needles.

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Depression Impact on Self-Management of Chronic
Medical Illness

• Depressed patients with MI are more likely to
  drop out of exercise programs1
• Smokers with history of depression are 40 less
  likely to succeed in quitting smoking over a
  9-year period compared to nondepressed smokers2
• Patients with major depression and coronary
  artery disease are less likely to adhere to
  low-dose aspiring therapy than nondepressed
  controls3

• Blumenthal JA., et al. Psychosomatic Med. 1982
  44(6)529-536
• Anda RF, et al. JAMA 1990 264(12)1541-1545
• Carney RM, et al., Health Psychol. 199514(1)88-90

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Medical Specialties Their Problem Patients
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Research Methodology

• NIMH diagnostic interview schedule
• Medical control group
• Medical testing of patients and controls
• ? angiography, laparoscopy, upper and lower GI
  series, audiometric testing
• 4. Psychological distress
• ? SCL-90
• Amplification
• ? Somatization scale of SCL, DIS, Barsky,
  Whitely
• Social and occupational functioning
• ?CIPI, MOS

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Case 2

• Ms. T is a 45 year old with recurrent severe
  abdominal pain. She has made 4 ER visits in the
  last 4 months for acute pain and was hospitalized
  twice. She has had laparoscopy revealing
  moderate endometriosis and adhesions. She has
  required IM narcotic injections during each visit
  and conflict has arisen when ER attendings have
  been reticent about prescribing these
  medications. Prior history reveals multiple ER
  visits for migraines in the past, several back
  surgeries and disability for back pain and a
  history of domestic violence.

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Metaphors for Emotional Pain

• Broken Hearted
• Ripped Out My Heart
• Cut to the Core
• Deeply Crushed
• Emotionally Scared
• Wounded

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Anterior Cingulate Cortex (ACC)

• Pain affect (unpleasantness and suffering) but
  not pain intensity is associated with activation
  of ACC
• Social exclusion in an on-line ball-tossing game
  was shown to be associated with ACC and right
  prefrontal cortex increased activity on f-MRI
• Reactions to both physical and psychological pain
  are associated with activation of similar brain
  regions

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Descending ModulatoryNeurotransmitter Systems
5-HT and NElinks to paintransmissionneurons
Fields HL. Presented at 18th AAPM Annual
Meeting Feb 26-March 3, 2002 San Francisco,
Calif.
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Pain Modulatory Circuit

• Amydala, periaqueductal gray (PAG), dorsolateral
  pontine nucleus (Noradrenergic neurons) and
  Rostral-ventral medial medulla (Serotonergic
  neurons) in brainstem
• RVM has two types of cells
• on cells, which facilitate pain perception
• off cells, which inhibit pain perception
• These cells normally dampen perception of
  peripheral stimuli--depletion of serotonin and/or
  norepinephrine decreases this dampening effect

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The Link BetweenDepression and Chronic Pain

• Serotonin (5-HT) and norepinephrine (NE)are key
  mediators of mood in the brain
• 5-HT and NE arekey modulatory neurotransmitters
  inthe descending pain pathway and are part of
  the bodys endogenous analgesic system

CortexLateral HypothalamusThalamusAmygdalaMedu
lla
Opiates

GLUSubstance P
NE5-HT


A?
GABAInterneuron

Nociceptor
A?, c
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Shared Neurochemical Pathways in Pain and
Depression

• Involvement of 5-HT and NE in depression
• Involvement of 5-HT and NE in pain

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Problems in Treating Chronic Pain

• Dependence on narcotic analegesics and/or
  sedative-hypnotics
• Depression/anxiety
• Almost total physical inactivity leading to poor
  physical condition
• Family system is often reinforcing pain behavior
• Disability system
• Iatrogenic injury secondary to multiple surgeries

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Keys to Treatment of Chronic Pain in Primary Care

• Screen for preexisting psychiatric, alcohol and
  substance abuse problems
• Early return to work
• Avoidance of PRN analgesics, sedative-hypnotics-Rx
  at regular intervals with gradually decreasing
  dosages
• Physical therapy
• Antidepressant therapy
• Evaluate family reinforcers to pain behavior
• Pain Contract

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High Risk Patients for Chronic Opiate or
Benzodiazephines Treatment

• History of childhood sexual and/or physical abuse
• History of prior alcohol or substance abuse
• Personality disorder (multiple physicians and
  systems of care, poor relationships and work
  history)

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Red Flags

• Illness occurs in a psychologically meaningful
  setting
• Vague, inconsistent description of symptoms
• Much doctoring and little curing
• Patient denies possibility of psychological basis
  for symptoms
• Associated psychiatric illness
• Polysurgery, polypharmacy, polyallergy
• Positive review of systems

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I have chronic pain and its your job to fix me
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Important Facts for Patients

• There is no cure for chronic pain
• We can work together to help you adapt to chronic
  pain and optimize your functioning
• There are some responsibilities you will have
  (such as going to physical therapy or stress
  reduction treatment) and some I will have
  (prescribing medications, ordering tests)

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Increase in Activity

• ProblemTotal inactivity
• Operant Model
• Situation Training situationBehavior
  Physical activityConsequence Pain
• Situation PainBehavioral RestConsequence
  Pain reduction
• Gradually increasing exercise program (PT) with
  training only to quota following by rest
• Situation Training situationBehavior
  Training to quotaConsequence No pain

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Saying No

• My philosophy in treating chronic pain is to
  only use medications that are not potentially
  addictive such as narcotics and benzodiazepines.
• Are you saying I am an addict?
• No, Im saying my philosophy in Rx of chronic
  pain is to use treatments that are least harmful
  and apt to help people best adapt to their pain.
  There are doctors with different philosophies of
  Rx and you are welcome to seek care from them if
  you disagree with my philosophy.

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• Paradoxically, opioid treatment may be offered
  in an attempt to improve pain and functioning,
  and thereby reduce the burden of care, but the
  treatment may actually increase the burden of
  care because the management of opioid therapy in
  patients with complex problems is time consuming
  and difficult.

Ballantyne Mao, 2003.
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• Primary Care
• Monthly appointment
• 30-day supply of medications
• Variability of counseling
• Variability of Tox screen if at all
• Practitioners often have limited time and
  knowledge regarding addiction

• Methadone Maintenance Clinic
• Daily appointments
• One-day supply of medications
• Individual counseling supplemented with NA AA
  groups
• Regular urine Tox screens
• Practitioners often in recovery from addictions

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Biology of Neuropathic Pain Analogous Changes
with Long-Term Opiate Use

• Neuropathic pain Marked by increased pain from
  noxious stimuli (hyperalgesia) as well as pain
  from previously innocuous stimuli (allodynia)
• Long-term use of opiates is associated in
  clinical and preclinical studies with abnormal
  pain sensitivity (sensitization results from
  NMDA-receptor changes in spinal dorsal horn cells
  in patients with opiate Rx similar to changes
  seen with neuropathic pain)

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Medication Dependence

• Pain patients often have chronic emotional pain
  as well as physiologic somatic pain.
  Overconsumption of analgesics is frequently a
  problem due to the PRN use of medication and
  resultant operant conditioning.
• Situation Pain (emotional and/or somatic)
• Behavior Pill taking
• Consequence Pain reduction
• Due to the pain reduction, the probability for
  pill taking increase. Opiates are the most potent
  pharmacologic agents for both emotional and
  somatic pain.

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Chronic Pain Medication Management

• Acute pain medications not appropriatetolerance,
  dependence, withdrawal, problems increase,
  benefits diminish, apathy, lethargy, depression
• Diagnose and Rx psychiatric diagnoses, substance
  abuse history, depression/anxiety disorders
• Change and treat with timed long-acting
  medications such as TID methadone avoid PRN
  medication

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Pain Contract

• Only 1 doctor will prescribe pain medication
• Pain medication will not be refilled earlier than
  prescribed
• Patient will not miss appointments
• Patient will have regular counseling with mental
  health professional to learn alternatives to deal
  with stress
• Patient will take part in regular physical
  therapy or prescribed exercise
• Functional goals (i.e. increased walking)
• Urine toxicology screens

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Treatment of Chronic Somatization/Pain

• Regular, nonsymptom-dependent visits
• Conservative intervention
• Defined responsibilities
• Tolerate symptoms and uncertainty
• Reinforce emotional and personal expression
• Nonmedical therapy
• Avoid referral unless objective signs are seen

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Treatment Essential Concepts and Goals

• Doctor-patient relationship is paramount trust,
  empathy, respect
• Understand patient perspective
• Negotiate realistic goals
• Optimize function
• Acknowledge difficult aspects
• Treat comorbid conditions
• Formal and informal consultation
• Physician self-care
• Long-term relationship

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Typical Features of Noncompliance with Opioid
Therapy-I

• Unexpected results on toxicologic screening
• Frequent requests for dose increases
• Concurrent use of nonprescribed psychoactive
  substances
• Failure to follow the dosage schedule
• Failure to adhere to concurrently recommended
  treatments
• Frequently reported loss of prescriptions or
  medications

Ballantyne JC et al., NEJM, 2005
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Typical Features of Noncompliance with Opioid
Therapy-II

• Frequent visits to the emergency room for opioid
  therapy
• Missed follow-up visits
• Frequent extra appointments at the clinic or
  office
• Prescriptions obtained from a second provider
• Tampering with prescriptions

Ballantyne JC et al., NEJM, 2005
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Antidepressant Analgesia in Chronic, Nonmalignant
Pain

• Summary of 28 studies
• More effective than placebo
• A median of 58 of patients reported at least 50
  pain reduction
• Response is greater when a specific pain
  diagnosis is made
• Greater response for pain in the head region
• Response not dependent on presence of depression
• Doses similar to those used for depression

Onglena and Van Houdenhove Pain 1992
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Antidepressants and Neuropathic Pain

• Dual Serotonin and Norepinephrine Uptake
  Inhibitors have been found most effective in
  treating neuropathic pain
• These agents include tricyclic antidepressant as
  well as newer agents such as venlafaxine,
  buproprion and duloxetine