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Somatoform disorders

Somatoform disorders






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    Somatoform disorders Somatoform disorders Presentation Transcript

    • Co mmon Psychiatric Problems in Family Practice Somatoform Disorders Saudi Diploma in Family Medicine Center of Post Graduate Studies i n F amily M edicine Dr. Zekeriya Aktürk [email_address] www.aile.net
    • Your most difficult patients ? Pain everywhere Not improving Comming every day
      • At the end of this session, the trainees will increase their knowledge in managing somatoform disorders
        • Explain the pathopysiology
        • List symptoms which might be somatic
        • List diagnostic criteria of somatoform disorders
        • Explain the management principles of somati s ation
        • Categorize the somatoform disorders
    • somatization desomatization resomatization
      • Bodily symptoms without any organic, physical cause
      Definition Lipowsky 1988
      • No explanatory organic cause can be found in 20-84% of patients presenting with bodily symptoms.
      Why important?
    • Epidemyology
      • More common among less educated and less income
      • I. Increased bodily sensitivity
      • Physical symptoms perceived are normal for most individuals
      • II. Defined patient
      • Stress within the family stabilizes after the member bocomes “ sick ”
      • III. Need to be sick
      • Becoming physically sick is less stressfull than being unsuccessfull
      Pathopysiology Barsky, 1997 “ There is no medicine or surgery to remove the need to be sick” BARSKY,1997
      • IV. Dissociation
      • Perceiving a stimulus which is not present
      • Phantom pain
      • Depersonalization
      • Flashback
      • Somatiza tion
      • Conversion disorder
      • Hypo chondriasis
      • Pain disorder
      • Body dysmorphic disorder
      Somatoform Disorders
      • Resemples a neurological problem
      • Motor or sensorial symptoms
      • Not explainable by neuroanatomy
      • “ La belle indiference”
      • Females 10-35 years,
      • Lower socioeconomic class
      • “ Disease of having disease”
      • Severe anxiety
      • M/F=1
      • No insight
      • Resistant, causing functional losses
      • Main symptom is pain
      • M/F=1/2
      • Pain increases with stress
      • Not explainable with nouroanatomy
      • Organic problem may be superimposed
      Pain disorder
      • Belives that there is a problem with appearance
      • Obsessive
      • M/F=1
      • Frequent cosmetic surgery
      Body Dysmorphic Disorder
    • Organic cause? Substance abuse? Other psychiatric dis.? Neurological symptom conversion Pain predominant Too busy with disease Hypochondriasis Pain disorder Somatization dis. Many symptoms Intentional symptoms Malingering yok I II III IV V VI
    • SYNDROMES Atipical chest pain Temporomandibular joint s. “ hypoglycemia” Premenstruel symdrome Unidentified “food allergy” Unidentified “vitamin deficiency” PSEUDONEUROLOGICAL Amnesia Swallowing difficulty Loss of voice Blurred vision, blindness Fainting Muscle weakness Difficulty in walking PAIN Generalized pain Extremity pain Back pain Joint pain Headache Dysuria UROGENITAL Burning Dysparonia Dysmenorrhea Irregular menstruation Vomiting CVS Chest pain Palpitations Dyspnea GIS Nausea Abdominal pain Diarrhea Belching Bloating Food intolerance SYMPTOMS WHICH MIGHT BE SOMATIC
      • At least three symptoms of uknown cause (generally in different systems)
      • Chronic course (more than two years)
      Diagnostic Criteria Since too long Too many systems Too many symptoms
    • Symptoms might be exaggerated and irrational for us but they are REAL for the patient!
    • Management – Discuss the diagnosis “ We counldn’t find anything serious after the exam or investigations. But htere is something bothering you. Although the reason is not clear, this is a situation we face frequently… ”
    • Management – Discuss the diagnosis “ Better we should discuss how we can help you instead of the name. However, although there are a lot of names given, we frequently call this situation as “Somatoform disorder” What is my diagnosis: Chronique fatigue syndrome Fibromyalgia
      • Frequent visits (15 min/month)
      • Short PE
      • Aim:
        • Prevent new symptoms
        • Decrease admissions to ER
      • Discuss open ended questions
      Management – Regular visits
      • Don’t try to loose the symptoms, better try to teach how to deal with them
      • Patients expect more “care” than “cure”.
      • Patients expect continuous relationship.
      Management – Regular visits
      • B ackground
      • How is your life going ?
      • A ffect
      • What do you feel ?
      • T rouble
      • What is the most important problem ?
      • H andle
      • What can help you ?
      • E mpathy
      • I understand you. This is a tough situation...
      Management – BATHE’ing the patient Stuart MR, Lieberman JA, 1993
      • No specific medicine
      • Treat concomittant psychiatric problem
      • Deal with domiant symptom:
        • Pain  Amitriptilline
        • Fatigue  Bupropion
        • Anxiety, sleep dist  SSRI, TCA
      Management - Pharmacological
      • Stress - somatic symptom relationship
      • Symptom diary
      • Group therapy
      Management - Psychotherapy
      • Light exercises (3x20 min/w)
      • Increases self esteem
      • Yoga, meditation, walks
      • Non harmful methods: cold-warm applications, acupuncture, vitamins…
      Management – Life style changes
      • Dont put goals you can not meet
      • Co-morbidity
      • Diagnositc requests
      • Emergency admissions
      • Phone calls
      Management - Problems
    • Concentrating on symptoms Unnecessary Referrals / cons.
        • Tests
        • or Rx without Dx
        • It’s just in your
        • mind, take it
        • easy..
    • Frequent, short visits Allow patient role Concentrate on functions Single doctor
    • What did we learn?