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Somatoform Disorder or Medically Unexplained Symptoms

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Somatoform Disorder or Medically Unexplained Symptoms Bruce Slater, MD, MPH Associate Professor (CHS) University of Wisconsin School of Medicine Learning Objectives ... – PowerPoint PPT presentation

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Title: Somatoform Disorder or Medically Unexplained Symptoms


1
Somatoform Disorder or Medically Unexplained
Symptoms
  • Bruce Slater, MD, MPH
  • Associate Professor (CHS)
  • University of Wisconsin
  • School of Medicine

2
Learning Objectives
  • Discuss Several Theories of Somatoform Disorder
  • List Techniques for Recognizing Somatoform
    Disorder
  • Review Treatment Approaches for Patients With
    Medically Unexplained Symptoms

3
Financial Disclosure
  • No Financial Support

4
Case Presentation
  • 12 Visits Over 9 Months for Abdominal Pain
  • Apparently Unnecessary Treatment for Presumed
    Disease
  • Extensive Diagnostic Evaluation
  • Several Consultants

5
Clinical Features of Case
  • Slowly Evolving Nature of Symptoms
  • Contradictory Symptomatology
  • Minimal Secondary Gain
  • Underlying Anxiety Uncovered

6
Historical Origins
  • Dark Ages Organ Based Explanations of Disease
  • Uterus Frequently Blamed for MUS
  • Hysterical Symptoms
  • 1667 Thomas Willis - ? Brain Involvement
  • 1889 Charcot ?Nervous Center Lesion
  • Babinski/Freud Psychological Explanations

7
(Loose) Diagnostic Criteria
  • Several Non-specific Symptoms in Different Organ
    Systems
  • Chronic Course
  • Frequently Co-morbid for Psychiatric Disease
  • Ten Times More Common in Women
  • Fully Developed by Age 30

8
Diagnostic Criteria
  • Diagnostic and Statistical Manual (DSM IV)
  • Multiple Recurring Pains and Symptoms
  • Gastrointestinal
  • Sexual
  • Pseudoneurological
  • Occurring Over a Period of Years
  • Not Intentionally Induced
  • Significance
  • Result in Medical Attention
  • Functional Impairment

9
Therapeutic Approach
  • Empathy
  • Rational Reassurance
  • Evaluation of Equivocal Symptoms
  • Symptom Based Care
  • Emphasize Return to Normal Activities
  • Approach Psychiatric Disease Separately
  • Treat Psychiatric Disease Actively

10
Therapeutic Approach (Details)
  • Step 1 Set Stage, Intro, Ensure Comfort
  • Step 2 Agenda (Constraints, the List, Negotiate)
  • Step 3 HPI Open Ended, Non-focused, Gather Data
  • Step 4 Focus on Symptoms, Context, Emotion,
    Address Emotion
  • Step 5 Transition Summary, Check, Assess
    Readiness to Change Focus to Physician Centered

From RC Smith, et al. JGIM 2003
11
Interesting Findings and Theories
  • Patients With Irritable Bowel Are Sensitive to
    Distention in the Gut, but Not As Sensitive to
    Pain From Skin.
  • Increased Anxiety Is Associated With Increased
    Pain (Battlefield Versus Mva)
  • Adrenaline Released at Sympathetic Nerve Endings
    May Sensitize Nociceptors and Trigger Somatic
    Muscle Tension Reflexes

12
From Wilhelmsen, Gut 200047 (Suppl
4)iv5-iv7(December)
13
More Interesting Theories
  • Amplification of Bodily Sensations
  • Panic Attacks
  • Somatisation
  • Family Dynamics and the Identified Patient
  • The Need to Be Sick
  • Dissociation
  • (Sensory Experience in the Absence of Sensory
    Stimulation)

From D Servan-Schreiber AFP 2000
14
Summary
  • Evolving Concepts
  • Frequent in Minor Incomplete Form Frust
  • Rule Out Disease for Rational And/or Potentially
    Serious Symptoms
  • Understand the Patient With the Disease
  • Care Not Cure

15
Questions for Me?
Questions for You
  • Do You Enjoy Seeing Patients With Mus?
  • What Diagnostic Clues Can You Add?
  • What Have You Tried Therapeutically?

16
References
  • Brain-gut Axis As an Example of the
    Bio-psycho-social Model. I Wilhelmsen, Gut
    200047(Suppl IV)Iv5-iv7 (December)
  • Treating Patients With Medically Unexplained
    Symptoms in Primary Care. RC Smith. J Gen Intern
    Med 18478-488. June 2003
  • Somatizing Patients Part I. Practical Diagnosis.
  • D Servan-Schreiber, et al. Am Fam Physician
    61/4
  • pp. 1073-1079 2/15/2000.
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