Co mmon Psychiatric Problems in Family Practice  Somatoform Disorders Saudi Diploma in Family Medicine   Center of Post Gr...
Your most difficult patients ? Pain everywhere Not improving Comming every day
<ul><li>At the end of this session, the trainees will increase their knowledge in managing somatoform disorders </li></ul>...
somatization desomatization resomatization
<ul><li>Bodily symptoms without any organic, physical cause </li></ul>Definition Lipowsky 1988
<ul><li>No explanatory organic cause can be found in 20-84% of patients presenting with bodily symptoms. </li></ul>Why imp...
Epidemyology <ul><li>More common among less educated and less income </li></ul>
<ul><li>I. Increased bodily sensitivity </li></ul><ul><li>Physical symptoms perceived are normal for most individuals </li...
 
<ul><li>II. Defined patient  </li></ul><ul><li>Stress within the family stabilizes after the member bocomes “ sick ”  </li...
<ul><li>III. Need to be sick </li></ul><ul><li>Becoming physically sick is less stressfull than being unsuccessfull </li><...
<ul><li>IV. Dissociation   </li></ul><ul><li>Perceiving a stimulus which is not present </li></ul><ul><li>Phantom pain </l...
<ul><li>Somatiza tion   </li></ul><ul><li>Conversion disorder  </li></ul><ul><li>Hypo chondriasis </li></ul><ul><li>Pain d...
<ul><li>Resemples a neurological problem </li></ul><ul><li>Motor or sensorial symptoms </li></ul><ul><li>Not explainable b...
<ul><li>“ Disease of having disease” </li></ul><ul><li>Severe anxiety </li></ul><ul><li>M/F=1 </li></ul><ul><li>No insight...
<ul><li>Main symptom is pain </li></ul><ul><li>M/F=1/2 </li></ul><ul><li>Pain increases with stress </li></ul><ul><li>Not ...
<ul><li>Belives that there is a problem with appearance </li></ul><ul><li>Obsessive </li></ul><ul><li>M/F=1 </li></ul><ul>...
Organic cause? Substance abuse? Other psychiatric dis.? Neurological symptom conversion Pain predominant Too busy with dis...
SYNDROMES Atipical chest pain Temporomandibular joint s. “ hypoglycemia” Premenstruel symdrome Unidentified “food allergy”...
<ul><li>At least three symptoms of uknown cause  (generally in different systems) </li></ul><ul><li>Chronic course  (more ...
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 som...
Management – Discuss the diagnosis “ Better we should discuss how we can help you instead of the name. However, although t...
<ul><li>Frequent visits (15 min/month) </li></ul><ul><li>Short PE  </li></ul><ul><li>Aim:  </li></ul><ul><ul><li>Prevent n...
<ul><li>Don’t try to loose the symptoms, better try to teach how to deal with them </li></ul><ul><li>Patients expect more ...
<ul><li>B   ackground </li></ul><ul><li>How is your life going ?  </li></ul><ul><li>A   ffect </li></ul><ul><li>What do yo...
<ul><li>No specific medicine </li></ul><ul><li>Treat concomittant psychiatric problem </li></ul><ul><li>Deal with domiant ...
<ul><li>Stress  -  somatic symptom relationship </li></ul><ul><li>Symptom diary </li></ul><ul><li>Group therapy  </li></ul...
<ul><li>Light exercises (3x20 min/w) </li></ul><ul><li>Increases self esteem </li></ul><ul><li>Yoga, meditation, walks </l...
<ul><li>Dont put goals you can not meet </li></ul><ul><li>Co-morbidity </li></ul><ul><li>Diagnositc requests </li></ul><ul...
Concentrating on  symptoms Unnecessary  Referrals / cons. <ul><ul><li>Tests  </li></ul></ul><ul><ul><li>or Rx without Dx <...
Frequent, short visits Allow patient role Concentrate on  functions Single doctor
What did we learn?
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Somatoform disorders

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Somatoform disorders

  1. 1. 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
  2. 2. Your most difficult patients ? Pain everywhere Not improving Comming every day
  3. 3. <ul><li>At the end of this session, the trainees will increase their knowledge in managing somatoform disorders </li></ul><ul><ul><li>Explain the pathopysiology </li></ul></ul><ul><ul><li>List symptoms which might be somatic </li></ul></ul><ul><ul><li>List diagnostic criteria of somatoform disorders </li></ul></ul><ul><ul><li>Explain the management principles of somati s ation </li></ul></ul><ul><ul><li>Categorize the somatoform disorders </li></ul></ul>Aim-Objectives
  4. 4. somatization desomatization resomatization
  5. 5. <ul><li>Bodily symptoms without any organic, physical cause </li></ul>Definition Lipowsky 1988
  6. 6. <ul><li>No explanatory organic cause can be found in 20-84% of patients presenting with bodily symptoms. </li></ul>Why important?
  7. 7. Epidemyology <ul><li>More common among less educated and less income </li></ul>
  8. 8. <ul><li>I. Increased bodily sensitivity </li></ul><ul><li>Physical symptoms perceived are normal for most individuals </li></ul>Pathopysiology
  9. 10. <ul><li>II. Defined patient </li></ul><ul><li>Stress within the family stabilizes after the member bocomes “ sick ” </li></ul>Pathopysiology
  10. 11. <ul><li>III. Need to be sick </li></ul><ul><li>Becoming physically sick is less stressfull than being unsuccessfull </li></ul>Pathopysiology Barsky, 1997 “ There is no medicine or surgery to remove the need to be sick” BARSKY,1997
  11. 12. <ul><li>IV. Dissociation </li></ul><ul><li>Perceiving a stimulus which is not present </li></ul><ul><li>Phantom pain </li></ul><ul><li>Depersonalization </li></ul><ul><li>Flashback </li></ul>Pathopysiology
  12. 13. <ul><li>Somatiza tion </li></ul><ul><li>Conversion disorder </li></ul><ul><li>Hypo chondriasis </li></ul><ul><li>Pain disorder </li></ul><ul><li>Body dysmorphic disorder </li></ul>Somatoform Disorders
  13. 14. <ul><li>Resemples a neurological problem </li></ul><ul><li>Motor or sensorial symptoms </li></ul><ul><li>Not explainable by neuroanatomy </li></ul><ul><li>“ La belle indiference” </li></ul><ul><li>Females 10-35 years, </li></ul><ul><li>Lower socioeconomic class </li></ul>Conversion
  14. 15. <ul><li>“ Disease of having disease” </li></ul><ul><li>Severe anxiety </li></ul><ul><li>M/F=1 </li></ul><ul><li>No insight </li></ul><ul><li>Resistant, causing functional losses </li></ul>Hypochondirasis
  15. 16. <ul><li>Main symptom is pain </li></ul><ul><li>M/F=1/2 </li></ul><ul><li>Pain increases with stress </li></ul><ul><li>Not explainable with nouroanatomy </li></ul><ul><li>Organic problem may be superimposed </li></ul>Pain disorder
  16. 17. <ul><li>Belives that there is a problem with appearance </li></ul><ul><li>Obsessive </li></ul><ul><li>M/F=1 </li></ul><ul><li>Frequent cosmetic surgery </li></ul>Body Dysmorphic Disorder
  17. 18. 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
  18. 19. 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
  19. 20. <ul><li>At least three symptoms of uknown cause (generally in different systems) </li></ul><ul><li>Chronic course (more than two years) </li></ul>Diagnostic Criteria Since too long Too many systems Too many symptoms
  20. 21. Symptoms might be exaggerated and irrational for us but they are REAL for the patient!
  21. 22. 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… ”
  22. 23. 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
  23. 24. <ul><li>Frequent visits (15 min/month) </li></ul><ul><li>Short PE </li></ul><ul><li>Aim: </li></ul><ul><ul><li>Prevent new symptoms </li></ul></ul><ul><ul><li>Decrease admissions to ER </li></ul></ul><ul><li>Discuss open ended questions </li></ul>Management – Regular visits
  24. 25. <ul><li>Don’t try to loose the symptoms, better try to teach how to deal with them </li></ul><ul><li>Patients expect more “care” than “cure”. </li></ul><ul><li>Patients expect continuous relationship. </li></ul>Management – Regular visits
  25. 26. <ul><li>B ackground </li></ul><ul><li>How is your life going ? </li></ul><ul><li>A ffect </li></ul><ul><li>What do you feel ? </li></ul><ul><li>T rouble </li></ul><ul><li>What is the most important problem ? </li></ul><ul><li>H andle </li></ul><ul><li>What can help you ? </li></ul><ul><li>E mpathy </li></ul><ul><li> I understand you. This is a tough situation... </li></ul>Management – BATHE’ing the patient Stuart MR, Lieberman JA, 1993
  26. 27. <ul><li>No specific medicine </li></ul><ul><li>Treat concomittant psychiatric problem </li></ul><ul><li>Deal with domiant symptom: </li></ul><ul><ul><li>Pain  Amitriptilline </li></ul></ul><ul><ul><li>Fatigue  Bupropion </li></ul></ul><ul><ul><li>Anxiety, sleep dist  SSRI, TCA </li></ul></ul>Management - Pharmacological
  27. 28. <ul><li>Stress - somatic symptom relationship </li></ul><ul><li>Symptom diary </li></ul><ul><li>Group therapy </li></ul>Management - Psychotherapy
  28. 29. <ul><li>Light exercises (3x20 min/w) </li></ul><ul><li>Increases self esteem </li></ul><ul><li>Yoga, meditation, walks </li></ul><ul><li>Non harmful methods: cold-warm applications, acupuncture, vitamins… </li></ul>Management – Life style changes
  29. 30. <ul><li>Dont put goals you can not meet </li></ul><ul><li>Co-morbidity </li></ul><ul><li>Diagnositc requests </li></ul><ul><li>Emergency admissions </li></ul><ul><li>Phone calls </li></ul>Management - Problems
  30. 31. Concentrating on symptoms Unnecessary Referrals / cons. <ul><ul><li>Tests </li></ul></ul><ul><ul><li>or Rx without Dx </li></ul></ul><ul><ul><li>It’s just in your </li></ul></ul><ul><ul><li>mind, take it </li></ul></ul><ul><ul><li>easy.. </li></ul></ul>
  31. 32. Frequent, short visits Allow patient role Concentrate on functions Single doctor
  32. 33. What did we learn?

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