CPCP: Somatization; An Encore Performance by Dr. Aubrey Chan
So this is an encore performance Clinical Problems in Consultation Psychiatry (CPCP) presentation by Dr. Aubrey Chan, who authored the one on catatonia recently. It’s also his internal medicine noon conference talk. He’s an R2 in the UIHC Internal Medicine-Psychiatry combined residency program and these presentations are given in the William B. Bean Conference Room, which is named after Dr. Bean, who was the head of internal medicine here at Iowa decades ago. As a side note, Dr. Bean had a connection to what we now call the Somatic Symptom and Related Disorders category in the Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. One of the changes in the DSM-5 was to subsume Factitious Disorder under the somatic symptom disorder category.
It turns out Dr. Bean wrote a very long poem about Factitious Disorder, entitled “The Munchausen Saga,” published in 1959 in three journals that I know of, Perspectives in Biology and medicine, Perspectives of Biological Medicine, and Transactions of the American Clinical and Climatological Association. It goes on for several pages about a patient known as the Indiana Cyclone who was admitted to our hospital in 1954 and who had a florid case of Factitious Disorder…and who was also probably a malingerer. Bean’s poem was based on the case report by Chapman, published in JAMA in 1957:
Chapman, J. S. (1957). “PEREGRINATING PROBLEM PATIENTS-MUNCHAUSEN’S SYNDROME.” J Am Med Assoc 165(8): 927-933. Physicians in the United States may be unaware of the patient who spends his time going from place to place, resulting in wide travels, and presenting himself to hospitals, with a fanciful history and extraordinary complaints. It is not uncommon for these patients to have many surgical scars crisscrossing their abdomens, and willingly to allow further surgical procedures to be performed, regardless of the dangers. Publicizing case histories of such patients seems to be the only way of coping with the problem, which exploits medical services that could be put to better use.
Dr. Bean was renowned as a brilliant and colorful speaker and “…a masterful teller of tales…,” although not a teller of tall tales as are those with Factitious Disorder. In fact, we flatter ourselves as psychiatrists for our ability to distinguish between somatic symptom disorder, factitious behavior patterns, malingering, and conversion reactions–which would necessarily entail a miraculous talent for divining the motivation for each of these problems, a debatable presumption at best.
However, Dr. Chan tells us his story about somatoform illness with practicality, humility, and empathy–which are probably among the best attributes of all doctors, regardless of their erudition.
Returning to his R2 talk to the other internal medicine residents I mentioned earlier, I was happy to have an opportunity today to attend it. Of course I’m biased because I’m one of his teachers, but I think he did an outstanding job. When he finished, I noticed that his peers had excellent questions, most of them centering on how to communicate the diagnosis to the patient (especially in the era of the electronic health record to which the patient may have access) or how to tell them “no” when they ask for medications or other treatments which may not be indicated and not in their long-term best interests.
Aubrey had very good answers focusing on emphasizing a return to greater functional ability while validating concerns and instilling hope while eschewing the delivery of diagnostic labels that send mixed messages about whether or not the patient’s concerns are “real.”
At times, as his teacher, I felt like adding a comment or two but I stifled myself, not just because time was limited–but because Aubrey will be a leader and I needed to let him lead to allow him to grow in that role. Aubrey already has his own words for kindly telling the truth to patients and how to convey to his colleagues the importance of saying “no” to patients in order to ensure their safety, even at the possible cost of incurring their displeasure. He already knows how to tell residents and faculty that telling patients in plain language what is both wrong and right with them is hard but is a learnable skill and a powerful art.
Aubrey also tells me he doesn’t smile well for the camera. Judge for yourselves.
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Somatization disorder was in the DSM-IV and has been replaced in the DSM-5.
It was replaced by somatic symptom disorder. This talk touches on that disorder but focuses mostly on medically unexplained symptoms, which are common in primary care and generally difficult to treat.
Somatic symptoms, used her to mean physical symptoms without underlying structural disease, aside from causing distress to patients, account for large healthcare expenditures.
They also account for high rates of disability, can exacerbate co-morbid structural disease, and cause frustration and confusion for clinicians.
These were the somatoform disorders in DSM-IV. But these were changed because they were most often seen in medical specialities, and the criteria were too confusing and impractical for non-psychiatrists.
These are the new disorders listed in DSM-5.
Will not discuss illness anxiety disorder in this talk. But the major difference is that there are no symptoms, but the patient remains concerned about being ill.
DSM-5 criteria. To get away from the biased notion of mind-body duality, and in acknowledgement that medical tests are essentially infinite, the “medically unexplained” criteria has been removed.
DSM-5 criteria of conversion disorder.
An abbreviated and more practical definitions. The picture is of Jean Martin Charcot, who studied hypnotism to treat hysteria. Hysteria is the historic and misogynistic former name of conversion disorder, going back to ancient Greek physicians. Hysteria was attributed to the movement of the uterus throughout the body. Hysteria led to the development of the modern day vibrator, as genital stimulation was used as a treatment, and vibrators were adopted for this purpose after initially having been invented to treat musculoskeletal pain.
Aside from an underlying structural disease, the major differential diagnoses are factitious disorder and malingering, both of which centrally feature deceit (either intentionally produced or feigned symptoms), with the purpose of obtaining some other gain. The picture is that of the new McDonald’s Hamburglar, who represents deceit and a frequent feature of malingering: asking for food immediately upon arriving in the emergency department. The major difference between these and somatic disorders is that in people with somatic symptoms, the symptoms are real and distressing to the patient and not under their conscious control.
These are not scientifically validated or studied, but these are some clues that a patient may be presenting with somatic symptoms.
These are examples of somatic symptoms/disorders, which are also called functional disorders, as there is no established structural pathology underlying.
Continued list. Pictures are of the fibres seen in Morgellon’s disease and Mary Tudor (Queen Mary I of England), who was daughter of Henry VIII and his first wife, Catherine of Aragon, and was queen before Elizabeth I. She suffered from pseudocyesis.
These are illnesses that have some underlying structural pathology, but are also worsened by psychological distress (Takotsubo’s cardiomyopathy, migraines, chronic back pain), or else it is unclear how the structural elements produce the various systemic symptoms people experience (chronic Lyme disease).
The picture here is of the Boston Marathon bombing in 2013. A study was published that found that shortly after this event, the number of children presenting to the ED with functional neurological disorders tripled.
Research is being conducted to look into the underlying mechanisms of somatic illnesses, with some leads on altered neuronal sensitivity and possible links to inflammatory or hormonal disturbances. This may in part explain why somatic illnesses are more common in women, as women’s immune systems must be able to accommodate pregnancy which is very similar to having a foreign organism in the body. Additionally, it may relate to the stresses of living within a patriarchal society. I did not find any research that looked into primarily matriarchal societies to determine whether somatic symptom frequency was different. In the end, the difficulty with defining these illnesses may simply like in our poor understanding of the underlying mechanisms.
A common and damaging response to these symptoms is to characterize them as “not real” or “all in your head” which is not helpful to the patient and also damaging to the therapeutic relationship. The most important factor in treatment is that the patient feels heard and have their concerns validated. Then, education and reassurance are necessary to explain that there is no structural illness requiring intervention, and that this could be an effect of stress on the body. Engaging and empowering the patient in his/her own treatment is a big part of treatment. The emphasis should be on function, e.g. “what things ARE you able to do?” and “how can you adapt to function with these symptoms present?” This is a generally more successful approach than for the patient to adopt a passive “fix me” role and to focus on losses and dysfunction.
Because of the natural inclination for clinicians to perform tests and interventions, it is critical to limit tests and procedures only to those necessary (eg to rule out a serious illness) to limit potential harm and medical expenses for the patient. Schedule regular follow-up with the same provider who knows the patient and the symptoms well, so that changes can be taken into account to see if it is more of the same or something new and different. Additionally, the patient will also feel reassured that they are being well-cared for and that their symptoms are being monitored and not dismissed. Physical, occupational, and/or speech therapy can be helpful to maximize function. Generally, healthy lifestyles help to relieve stress, and mindfulness/body awareness helps people understand and change how they experience their symptoms so they are less distressing, although this must be proposed carefully to avoid conveying the “it’s all in your head” message which can harm therapeutic alliance.
Depression and anxiety are strongly co-morbid with somatic disorders, and these should be treated accordingly. However, in the absence of these, antidepressants are not effective for the somatic symptoms. Again, minimize intervention to minimize adverse effects and harm, and certainly limit dangerous and/or habit-forming medications.