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Somatic Symptoms

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9th Beijing/ Hong Kong Medical Exchange Psychological medicine in Community 3 - 4 November 2007 – PowerPoint PPT presentation

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Title: Somatic Symptoms


1
Somatic Symptoms Depression in General
Practice???????
9th Beijing/ Hong Kong Medical Exchange
??????????? Psychological medicine in
Community?????? 3 - 4 November 2007 Presidential,
Plaza Hotel, Beijing, China
  • David Wong ???
  • MB.,BS, PDip.Com.Psy Med
  • HONG KONG

S.1
2
What is this what do you see ? ???????
S.2
3
Somatic symptoms depression
Review of patients record in General
Practice ?????????????
Somatic symptoms????
  • Associated with medical causes and now found
    increasingly so with psychiatric disorders as
    well.
  • ????????????, ???????????????????.
  • Some medically unexplainable symptoms may be
    listed under well defined psychiatric disorders,
    the rest is grouped loosely as medically
    unexplained symptoms (MUS).
  • ???????????????, ???????????.
    ????????????(????)??????, ????????????????????
    (MUS).
  • Management of MUS, also not explainable by the
    present system of psychiatry, remains a
    challenge.
  • ???????????MUS??????.

S.3
4
Somatic symptoms depression
Somatic symptoms(????) in DSM IV HAM-D
Symptoms?? DSM I V HAM-D Others
Sleep ?? Insomnia/hypersomnia ??, ?? Early, middle late insomnia ?, ?, ????
General ?? Fatigue or loss of energy, ??/???? Fatigue and loss of energy, heaviness, aches ??, ??, ??,??
GI??-Appetite?? Weight?? Decrease/increase ??/???? significant weight gain/loss????????? Marked reduction ???? Weight loss????
Head, Neck, ?, ? Aches (ANS) ?? Aches, dizziness ??, ??
Mouth Throat ???? Globus hysteutus??, Spitting, pain ?, ??
Abdomen?? Stomach cramps??? , belching, diarrhoea??(ANS) Abdominal??? and pelvic pain???? , belching, vomiting??diarrhoea,??
S.4
5
Somatic symptoms depression
Somatic symptoms(????) in DSM IV HAM-D
Symptoms?? DSM IV HAM-D Others
Heart and Chest ?? Palpitation,?? hyperventilation????(ANS) pain, palpitation??,dyspnoea ???? , suffocation??, hyperventilation????
Genital ?? Urinary frequency?? (ANS)
Gynecology ?? Menstrual disturbance ????
Sex ?? Loss of libido ????
Limbs ?? Paranesthesia ??, tremor?? (ANS) Mild to severe pain ??????
Skin ?? Sweating??, Flushing ?? (ANS) Coldness, rash? , Urticaria???
Ear ? Tinnitus??, vertigo??
Proportion of somatic symptoms ???????? 3/9 8/21
S.5
6
Somatic symptoms depression
Significance of somatic symptoms ????????
  • Prevalent in depression???????
  • Number of published articles found in PubMed
  • ???????????????????
  • Up to 2000 1498 (2000???1498)
  • Up to 2007 Jan2718 (2007?????2718)
  • Diagnosis Implications ?????
  • higher no. of somatic symptoms predict
    depression.
  • ????,?????????
  • Medically unexplained symptoms associate more
  • frequently with depression.
  • ???????????,??????????

S.6
7
Somatic symptoms depression
Significance of somatic symptoms ????????
  • Treatment implications-higher no of SS delays
  • ??????
  • response, ????,?????,???????
  • remission,?????
  • increases recurrence ?????????

S.7
8
Somatic symptoms depression
Percentage of depressed patients presenting
with predominantly physical symptoms ????????????
  • 70-75 (Gps?????) 60-65 (psychiatrist???
    ???)
  • (Partners in Research,SA,04 ??Mitchell?????)
  • 45 to 95 (Gps) 69 (psychiatrist) present
    only with
  • somatic symptoms ??????
  • (Simon GE et al, N.Eng.J Med 19993411329-1335)
  • gt65 depressed patients report somatic symptoms
  • ?????????
  • (Bair MJ et al, Arch Intern Med.
    20031632433-2445.
  • Bair MJ et al, Psychosom Med. 2004 66 17-22.)

S.8
9
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Analysis of total 437 patients 437?????
S.9
10
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Analysis of 429 patients presenting with somatic
symptoms 429???????????
S.10
11
Somatic symptoms depression
Unexplained Somatic Symptoms Mood
Disorders ???????????????
  • 32 to 62 of such patients are depressive
  • 32 to 62??????
  • 24 to 50 have anxiety disorders
  • 24 to 50??????
  • (Kroenke K et al Arch Fam Med 19943-774-9)
  • More frequent association with anxiety disorders
    and depression
  • MUS ??????????????
  • (Katon W et al. Ann Intern Med
    2001134-971-925)

S.11
12
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Analysis of 91 patients with medically
unexplained symptoms (MUS) 91?????????????????
Mood dominant somatic symptoms
(mss) ????????? ??????? Somatic symptoms
dominant, some mood symptoms (mss) ??????? ????
????? Somatic symptoms only (ss) ?????
A
7
(7.7)
B
30
(33)
C
54
(59)
S.12
13
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Analysis of 99 patients (91 patients with MUS 8
patients with mood symptoms) 99 ???(91 ????? 8
?????)???
A (Total15,?15 ?) A (Total15,?15 ?) B (Total30,?30 ?) C (Total54?54 ?)
m mss mss ss
Depressed Group(Total 53)- ???(?53 ?) -Depression,?? -Depression comorbid with anxiety,???? -Low mood with MUS?????? ???? 2 16 35
Anxiety?? (Total 13?13?) 1 0 3 9
Bipolar I II?????(Total 25?25?) 2 3 10 10
Psychosis????? (Total 4?4?) 2 1 1 0
ADHD?????,????? (Total 3?3?) 2 1 0 0
Others?? (Total 1?1?) 1 0 0 0
S.13
14
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Diagnosis of depressed group of patients (53
patients) 53 ????????
S.14
15
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Prevalence of somatic symptoms in 53 depressed
group of patients (depression, depression
comorbid with anxiety, low mood with MUS)
S.15
16
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
  • Conclusion I ?? (I)
  • 12.1 of 437 patients suffer from depression.
  • 437????? 12?????
  • 21 of 429 patients with somatic symptoms
    present with
  • medically unexplained symptoms.
  • 429???????????????? 21
  • ????????????
  • 58.2 of patients presenting with medically
    unexplained
  • symptoms suffer from depression.
  • ????58.2?????
  • All depressed patients have somatic symptoms.
  • ??????????????

S.16
17
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Treatment for the depressed group of patients
(53 patients) 53????????
  • All patients were receiving antidepressant drugs
    when surveyed (with or without
    atypical antipsychotics)
  • ???????????SSRls
  • 4 patients discontinued subsequently.
  • 4?????
  • 49 patients remained on antidepressant treatment
  • 49??????SSRls
  • Number of somatic symptoms per patient between
    1 to 9.
  • ?????????????????

S.17
18
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Outcome of treatment in depressed grouppatients
(53 patients) ????
S.18
19
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Outcome of treatment in depressed group
patients (53 patients)????
Number of patients
S.19
20
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Conclusion II???
  • Antidepressants are useful in the treatment of
    somatic symptoms associated with depression.
  • ??????????????????
  • Antidepressants are useful in the treatment of
    somatic symptoms in the patients with medically
    unexplained symptoms(MUS).
  • ?MUS,???????????,????????
  • A systemic review of 96 randomized trials found
    antidepressants to be moderately effective. Odd
    Ratio comparing with placebo 3.4 (OMalley, PG
    et al. Antidepressant therapy for unexplained
    symptoms and symptom syndromes. J Fam Pract.
    199948980-990).
  • ??(OMalley)?????96?????????????????MUS????
    ??

S.20
21
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Review of records of patients for January 07
Analysis of somatic symptoms in 53 patients with
depression 53????????????
A (Total2, ?2 ?) B (Total16,?16 ?) C (Total35,?35 ?) Prevalence ???
m mss mss ss
Sleep?? 2 14 30 87
pain?? 2 13 26 77
GI upset ?? 1 10 24 66
Tiredness?? 1 10 16 51
Dizziness?? 1 3 14 34
Blood Pressure??(???) 0 2 8 19
Others?? Malaise??, hotness chills??, numbness??, palpitation??, urgency, shortness of breath Malaise??, hotness chills??, numbness??, palpitation??, urgency, shortness of breath Malaise??, hotness chills??, numbness??, palpitation??, urgency, shortness of breath Malaise??, hotness chills??, numbness??, palpitation??, urgency, shortness of breath
S.21
22
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Analysis of 41 depressed patients with
pain ??????(4l?)
A (Total2, ?2 ?) B (Total13,?13 ?) C (Total26,?26 ?) Prevalence ???
m mss mss ss
General ?? 1 9 14 59
Head?? 1 9 8 44
Chest?? 1 3 13 42
Neck Shoulder ???? 0 4 6 24
Limbs?? 0 2 5 17
Back?? 0 1 3 9.8
Others?? pain of tongue,soles, joints, heaviness of lower limb ??, ??, ??, ???? pain of tongue,soles, joints, heaviness of lower limb ??, ??, ??, ???? pain of tongue,soles, joints, heaviness of lower limb ??, ??, ??, ???? pain of tongue,soles, joints, heaviness of lower limb ??, ??, ??, ????
S.22
23
Somatic symptoms depression
Review of records of patients for January
07 ??2007?????????
Analysis of 35 patients with GI upset ???????(35?)
A (Total1, ?1 ?) B (Total10,?10 ?) C (Total24,?24?) Prevalence???
m mss mss ss
Pain?,???? 0 10 22 91
IBS???? 0 0 4 11.4
OGD??(????) 0 3 8 31
Colonoscopy????(????) 0 0 5 14
Gastrectomy????(???) 0 1 2 8.5
Tenesmus???? 0 0 1 2.8
Abdominal mass???? 0 0 1 2.8
Others?? Swallowing difficulty, constipation ????????? Swallowing difficulty, constipation ????????? Swallowing difficulty, constipation ????????? Swallowing difficulty, constipation ?????????
S.23
24
Somatic symptoms depression
Questions to be answered ???????
  • Why How are antidepressants effective in the
    treatment of somatic symptoms?
  • ???????????????
  • Are all patients with medically unexplained
    symptoms psychiatric?
  • ??????????, ????????,??????????????

S.24
25
Somatic symptoms depression
Questions to be answered ???????
  • How does the mind generate symptoms of the body?
  • ??(???????)??????????
  • Is the pathophysiology producing the psychiatric
    medical somatic symptoms the same biological
    mechanism?
  • ??????,????????????????????????????????

S.25
26
Somatic symptoms depression
The body and the mind?????
  • Are doctors feeling different parts of
  • the same depressed elephant?
  • ????????????????????????

S.26
27
Psychiatrists, researchers GPs seeing
different parts of a depressed elephant
  • Non-psychiatric doctors in general practice
  • other specialities
  • e.g. Dr. David Wong
  • ???????????,?????

The Body??
???????
A depressed elephant
S.27
28
Psychiatrists?????
Psychiatrists e.g. Prof. S W TANG ????? e.g.
?????
???????
A depressed elephant
S.28
29
Researchers???
???????
A depressed elephant
Researchers Psychopharmacologists e.g. Prof.
Brian Leonard e.g.?????
S.29
30
Mind Body is One??????????
A depressed elephant
???????
S.30
31
Acknowledgment??
I would like to thank Professor SW Tang
Professor Brian Leonard for their encouragement
and inspiration to make this project
possible. ???????????????????????????????????????
????????????????
S.31
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