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.
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
Perceiving a stimulus which is not present
Body dysmorphic disorder
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”
Resistant, causing functional losses
Main symptom is pain
Pain increases with stress
Not explainable with nouroanatomy
Organic problem may be superimposed
Belives that there is a problem with appearance
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)
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
How is your life going ?
What do you feel ?
What is the most important problem ?
What can help you ?
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:
Anxiety, sleep dist SSRI, TCA
Management - Pharmacological
Stress - somatic symptom relationship
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
Management - Problems
Concentrating on symptoms Unnecessary Referrals / cons.
or Rx without Dx
It’s just in your
mind, take it
Frequent, short visits Allow patient role Concentrate on functions Single doctor