Published on

1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  1. 1. The Unexplained Physical Symptom Robert K. Schneider, MD Assistant Professor Departments of Psychiatry, Internal Medicine and Family Practice Virginia Commonwealth University The Medical College of Virginia Campus
  2. 2. Outline <ul><li>Unexplained symptoms </li></ul><ul><li>Definitions of conditions </li></ul><ul><li>Management </li></ul>
  3. 3. Unexplained symptoms <ul><li>25-50% No serious medical cause found </li></ul><ul><li>30-75% Remain medically unexplained </li></ul><ul><li>16-33% “bothered the patient a lot” </li></ul><ul><li>but remain unexplained </li></ul>
  4. 4. Somatization: Other Psychiatric Disorders <ul><li>Men: 3 unexplained symptoms </li></ul><ul><li>Women: 5 unexplained symptoms </li></ul><ul><li>Katon 1999 </li></ul>
  5. 5. Multiple unexplained physical symptoms <ul><li>Major Depression and Dysthymia </li></ul><ul><li>Panic Disorder </li></ul><ul><li>GAD </li></ul><ul><li>OCD </li></ul><ul><li>Somatoform Disorders </li></ul><ul><li>Substance abuse </li></ul><ul><li>Brown 1990 </li></ul>
  6. 6. Somatization: Definition <ul><li>Experiencing and reporting bodily symptoms that have no pathological basis, attributing them to disease and seeking medical attention for them </li></ul><ul><li>Lipowski 1988 </li></ul>
  7. 7. Somatization Disorder <ul><li>Symptoms begin before age 30 </li></ul><ul><ul><li>4 pain </li></ul></ul><ul><ul><li>2 GI </li></ul></ul><ul><ul><li>1 sexual </li></ul></ul><ul><ul><li>1 pseudoneurological </li></ul></ul><ul><li>DSM-IV </li></ul>
  8. 8. Undifferentiated Somatoform Disorder <ul><li>1 or more unexplained somatic symptom </li></ul><ul><li>6 month duration </li></ul><ul><li>DSM-IV </li></ul>
  9. 9. Symptom Amplification <ul><li>Belief one has a serious illness </li></ul><ul><li>Expectation that symptoms will worsen </li></ul><ul><li>The “sick role” </li></ul><ul><li>Condition is catastrophic and disabling </li></ul><ul><li>Barsky 1999 </li></ul>
  10. 10. Hypochondriasis <ul><li>Misinterpretation or amplification of bodily symptoms </li></ul><ul><li>Unreasonable fears or expectations of disease </li></ul><ul><li>6 months duration </li></ul><ul><li>Impairment of functioning </li></ul><ul><li>DSM-IV </li></ul>
  11. 11. Major Somatization <ul><li>Chronic </li></ul><ul><li>Multiplicity of symptoms </li></ul><ul><li>Refractory to reassurance </li></ul><ul><li>Absence of discrete stressor </li></ul><ul><li>Disproportionate disability and role impairment </li></ul><ul><li>Pursuit of medical care </li></ul><ul><li>Barsky 1997 </li></ul>
  12. 12. Conversion Disorder <ul><li>1 or more symptom affecting motor or sensory functioning that suggests a neurological or general medical disorder </li></ul><ul><li>Association with psychological stressor </li></ul><ul><li>Unconscious defense </li></ul><ul><li>DSM-IV </li></ul>
  13. 13. Malingering <ul><li>Intentional production of exaggerated or false symptoms </li></ul><ul><li>Motivated by secondary gain </li></ul><ul><li>Conscious </li></ul><ul><li>DSM-IV </li></ul>
  14. 14. Factitious Disorder <ul><li>Intentional production or feigning of symptoms </li></ul><ul><li>Motivation is to assume the sick role </li></ul><ul><li>No obvious secondary gain </li></ul><ul><li>DSM-IV </li></ul>
  15. 15. Six-step strategy <ul><li>Rule out major medical problem </li></ul><ul><li>Rule out major psychiatric problem </li></ul><ul><li>Build collaborative alliance </li></ul><ul><li>Barsky 1999 </li></ul>
  16. 16. Six-step strategy <ul><li>Improved functioning and coping are the goals </li></ul><ul><li>Provide limited reassurance </li></ul><ul><li>CBT if no success from above measures </li></ul><ul><li>Barsky 1999 </li></ul>
  17. 17. Rule out medical problem <ul><li>“ Reasonable” work up </li></ul><ul><li>Explain how the test results change the treatment (if they do at all) </li></ul><ul><li>Avoid “well if we don’t find anything then I’ll refer” </li></ul><ul><li>Barsky 1999 </li></ul>
  18. 18. Rule out psychiatric disorder <ul><li>MAPS-O is helpful in getting the spectrum of symptoms (MDD, Panic) </li></ul><ul><li>Symptom focus as opposed to disorder focus </li></ul><ul><li>Use Balint Agreement </li></ul>
  19. 19. Collaborative alliance <ul><li>Somatizing patients want medical care </li></ul><ul><li>Fear rejection or invalidation of symptoms </li></ul><ul><li>Validate dysfunction and suffering </li></ul>
  20. 20. Functioning is the goal <ul><li>Shift Expectations </li></ul><ul><li>Symptom reduction </li></ul><ul><li>Improved functioning </li></ul><ul><li>NOT </li></ul><ul><li>Diagnosis </li></ul><ul><li>Eradication of symptoms </li></ul>
  21. 21. Limited Reassurance <ul><li>Instill hope </li></ul><ul><li>Acknowledge that we may miss something, but this is very unlikely </li></ul><ul><li>More frequent non-emergent visits </li></ul>
  22. 22. CBT <ul><li>Good evidence supports its usage in the major somatization group or highly impaired functional disorders </li></ul><ul><li>Can be applied individually but groups are very effective and efficient </li></ul>
  23. 23. Case <ul><li>37 year old man with multiple somatic complaints </li></ul>