Anxiety and Psychosomatic

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Curriculum Vitae
 Dr. Andri,SpKJ,FAPM
 Lulus Dokter dari FKUI tahun 2003
 Lulus Psikiater dari FKUI tahun 2008
 Fellow of Academy of Psychosomatic Medicine (2013)
 Jabatan :
 Dosen FK UKRIDA
 Ketua Sub Kredensial Komite Medik Omni Hospitals Alam Sutera
 Kepala Klinik Psikosomatik OMNI Hospitals
 Sekretaris Seksi Consultation Liaison Psychiatry (CLP) PDSKJI
 Organisasi :
 Ikatan Dokter Indonesia (IDI)
 Perhimpunan Dokter Spesialis Kedokteran Jiwa Indonesia (PDSKJI)
 American Psychosomatic Society (Faculty Leader of Psychosomatic Medicine Interest Group in
Indonesia)
 Academy of Psychosomatic Medicine (Fellow Member)

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Psychosomatic Symptoms and
Anxiety Disorder
dr.Andri,SpKJ,FAPM
Psychiatrist, Fellow of Academy of Psychosomatic Medicine
Faculty of Medicine, UKRIDA
Psychosomatic Clinic Omni Hospitals Alam Sutera, Serpong

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What is Psychosomatic?
Somatic complaints in clinical practice
Somatic complaints in psychiatric disorder
Treatment strategy (Using Pharmacology and Non-
Pharmacology approach)
Conclusion
Outline for today’s talk

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What is Psychosomatic ?
• The term psychosomatic has been known for more than 50 years in the
field of psychiatry
• Mind and Body Connection
• George Engel : Biopsychosocial concept (1977)
• Since it was misunderstood by lay people as a disorder ―Only in Your
Head‖, since 1980, psychosomatic was not a diagnosis terminology in
DSM anymore
• Psychosomatic  Somatic symptoms
• The use of the term Psychosomatic for organization and journal until now
• Psychosomatic Medicine is a subspecialist in Psychiatry (APA,ABPN)
Kaplan and Saddock, Synopsis of Psychiatry, Psychosomatic
Medicine, Chapter 13, American Psychiatric Publishing 2015

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Historical Background and Changes from DSM III
to DSM 5 (Dimsdale, J. E., et al. 2013)
 Somatoform Disorder Somatic Symptom Disorder
- First introduced 30yrs ago in DSM-III as Somatoform Disorder.
Somatoform didn’t translate to another language well
- DSM-IV – concept of medically unexplained symptoms were introduced.
Is it unexplained or unexamined medical condition?
- DSM-5 replaced Somatoform Disorder with Somatic Symptom Disorder and Related Disorders
The symptoms may or may not be medically unexplained. If the patient primarily had
anxiety but not somatic complaints, the diagnosis would be Illness Anxiety Disorder.

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Case Illustration
A 29 years old man complaint discomfort feeling in his
left chest. He often felt palpitation that made him visit
ER more than once.
He also felt bloating and fear of losing control at the
same time. Physical examination and laboratory
workup found nothing was wrong. He had already done
ECG, Echo and Stress Test (Treadmil)
What was wrong with this patient?

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Somatic symptoms in Clinical Practice
 25-50% No serious medical cause found
 30-75% Remain medically unexplained
 16-33% ―bothered the patient a lot‖ but remain
unexplained
 Schneider R

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 A 39 years old woman complaint about her uneasy feeling in her stomach. She
frequently felt bloating, sometimes accompanied by palpitation and feeling
imbalance. She had already visited her internist and had done regular examination
and specific workup (gastroscopy). All the findings were normal. She was afraid of
her condition and still thinking about having severe disease related to her
complaints.
 She was a manager in one of the telecommunication company. A very strong and
persistent woman. She thought about her stress in her work but she thought they
were all regular stress until 6 months ago she started complaint about her stomach
Case Illustration

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Somatic Complaints
 Somatic complaint is a poorly understood ―blind spot‖ of medicine
 Somatic complaints and somatoform disorder (now is somatic
symptoms disorder based on DSM 5 ) remain neglected by
psychiatrist and also primary care physician
 It can be conceptualized in a variety of different ways but
fundamentally it appears to be a way of responding stress
 Not all somatizing patients have a diagnosis of somatoform
disorder, many have another Axis 1 disorder or transiently somatize
in the context of significant life stress
Abbey, Wulsin and Levenson in Somatization and Somatoform Disorder, Textbook
of Psychosomatic Medicine, 2nd ed, 2011

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Somatic Complaints
 Patients commonly present to their primary care physician
complaining of physical symptoms.
 More often than not, appropriate medical work-up fails to reveal
a clear underlying physical etiology
 The prevalence of somatic symptoms that are multiple, chronic,
and associated with medical help-seeking—but do not meet full
criteria for a DSM-IV somatization disorder :19.7% – 22%
Psychosomatics 42:3, May-June 2001

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 Survey bertween February 23rd 2013 until February 1st, 2014, patient with
depression and anxiety disorder were asked to fill the BSI (Bradford Somatic
Inventory)
 There were 1433 respondents who filled the BSI,704 (49.13%) were men ad 729
(50.8%) were women.
 Forty two point ninety seven percent (42.97%,N=617) respondents were between
21-30 years old, 29.60% (N=425) respondents were between 31-40 years old and
15.25% (N=219) below 21 years old.
Somatic Symptoms in Patients With Anxiety and
Depression
Unpublished data. Survey conducted by Andri from
Psychosomatic Clinic Omni Hospital (2014)

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1. palpitations (pounding heart) : 90.52%,
2. ache or discomfort in the abdomen : 84.94%
3. lack of energy (weakness) much of the time : 84.41%,
4. pain or tension in neck or shoulder : 82.86%
5. feeling giddy or dizzy : 81.88%
6. feeling tired even when are not working : 81.39%
7. suffered from excessive wind (gas) or belching : 73.6%
8. pain in the chest or heart : 73%
9. trembling or shaking : 72.7%
10. buzzing noise in ears or head : 71.34%.
Top 10 Somatic Symptoms
Unpublished data. Survey conducted by Andri from
Psychosomatic Clinic Omni Hospital (2014)

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Data 2009 di Puskesmas di Jakarta
Dan Hidayat, dkk. Majalah Kedokteran Indonesia, Vo. 60 No.10 Oktober 2010

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0
10
20
30
40
50
60
Panic
Dis
GAD Somatic MDD Schizo
% Diagnosis
Prevalensi Diagnosis Gangguan Jiwa Pada Pasien dengan
Keluhan Psikosomatik Jan– Des 2009
Panic Disorder 57.85 %
Generalized Anxiety
Disorder
21.07 %
Somatization Disorder 10.3 %
Major Depression
Disorder
9.5 %
Schizophrenia 2.07 %
Survey dilakukan di Klinik Psikosomatik RS OMNI,
Tangerang

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Common types of somatization seen in
primary care (Croicu, C., et al. 2014)
1. Acute somatization
Temporary production of physical symptoms associated with transient
stressors
2. Relapsing somatization
Repeated episodes of physical symptoms associated with repetitive
stressors & anxiety or depressive episodes
3. Chronic somatization
Nearly continuous somatic focus, perception of ill health,
development of disability

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Assessing for Somatic Symptom Disorder Using the 3-Ps
(Croicu C, et al. 2014)
Predisposing
Chronic childhood illnesses, childhood adversities, comorbid medical illness,
lifetime psychiatric diagnosis, poor coping ability
Precipitating
Medical illness, psychiatric disorder, social & occupation stress, and changes in
social support
Perpetuating
Chronic stressors, maladaptive coping skills, negative health habits

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Identifying Somatic Symptom Disorder
(Croicu C, et al. 2014)
• Do a thorough history and detailed physical assessment
• Rule out medical illness
• Consider medication side effects
• Identify ability to meet basic needs
• Identify secondary gains
• Identify ability to communicate emotional needs
• Determine substance use
• Build therapeutic alliance with the patient
• Use screening tools appropriate for somatic symptom disorder
: SSS-8 and PHQ-15

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Somatic Symptoms in Psychiatry Disorder
 Major Depression and Dysthymia
 Panic Disorder
 Generalized Anxiety Disorder (GAD)
 OCD
 Somatoform Disorders
 Substance abuse
 Delirium
 Dementia
 Schizophrenia and delusion disorder
Brown 1990

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Comorbid
psychological
conditions
often include:
Anxiety Disorders Are Chronic and Often Present
With Comorbid Psychological Conditions1-3
1.Baldwin DS, et al. J Psychopharmacol. 2014;28(5):403-439. 2. Katzman MA, et al. BMC
Psychiatry. 2014;14(Suppl 1):S1. 3. Fried EI. Front Psychol. 2015;6:309.
 Other anxiety disorders
 Major depressive disorder
 Bipolar disorder
 Schizophrenia
 Addictive disorders

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Somatic Comorbidities of Anxiety Disorders
Inflammatory
Bowel Disease
DiabetesHypertension
Cardiovascular
Disease
Anxiety
Disorders

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Pharmacotherapy
and
Cognitive-Behavioral Therapy
Effective Treatment of Anxiety Disorders Both
Removes Symptoms and Prevents Relapse
Anxiety Disorder Treatment
Bandelow B, et al. Int J Psychiatry Clin Pract. 2012;16(2):77-84.
Goals of treatment:
 Removal of symptoms
 Prevention of relapse

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Essential Treatment Approaches for Patients with
Somatic Symptom Disorder (Croicu, C., et al. 2014)
• Avoid the temptation to order unnecessary, repetitive, or invasive
investigations
• Educate the patient on how to cope with their symptoms instead of
focusing on a cure
• Evaluate somatic symptom burden
• Collaborate with the patient in setting treatment goals
• Screen for common psychiatric conditions associated with somatic
complaints such as depression and anxiety
• Treat identified comorbid psychiatric disorders

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Essential Treatment Approaches for Patients with
Somatic Complaints (Croicu, C., et al. 2014)
• Case management to minimize economic impact
• Medications to treat anxiety and depression (SSRIs :
Sertraline or SNRI : Venlafaxine ) : Need specific
competencies
• Short term use of anxiety medication (benzodiazepine, e.q
: diazepam, alprazolam)
• Non-pharmacological treatments
• *CBT – Shows promising evidence
• Psychodynamic therapy
• Integrative therapy

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Alprazolam Speed of Action to Remove Symptoms
of Anxiety
Sheehan DV, et al. Psychopharmacol Bull. 2007;40(2):63-81.
Magnitude
Average Benefit Observed 1 Hour
After Morning Dose
Hours
Average Time to
Peak Benefit
Percent(%)
Patients Achieving Peak
Benefit Within 1 Hour
Results from a 9-week, open-label, switch-over study in 30 patients with DSM-IV panic disorder. Patients stable on alprazolam compressed tablet for 3 weeks were
switched to alprazolam extended release. Analysis of profile data derived from the clinician and patient from daily diary records was used to determine magnitude of benefit.
 According to several measures, alprazolam demonstrated a rapid onset of action in the majority of patients
 In patients treated with alprazolam, 90% of the peak benefit occurred within
the first hour post-dose
64%
DSM=Diagnostic and Statistical Manual of Mental Disorders.

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Improvements in Anxiety and Panic Attacks
Pecknold J, et al. J Clin Psychopharmacol. 1994;14(5):314-321.
Data from a double-blind, placebo-controlled, flexible-dose (1-10 mg/d), multicenter, 6-week study (n=209) comparing regular alprazolam given four times per day with placebo in adult patients, evaluated with the
Structured Clinical Interview for DSM-III-R in order to establish a diagnosis of panic disorder
and extensive phobic avoidance (agoraphobia with panic attacks) or limited phobic avoidance. Results are calculated using LOCF.
ChangeFromBaseline(%)
HAM-A Score
P=0.03
Patients(%)
Freedom From Panic Attacks
P<0.04
P<0.01
 After 6 weeks of treatment, alprazolam was found to be significantly more effective than placebo, according to HAM-A
scores and the percentage of patients experiencing freedom from panic attacks
LOCF=last observation carried forward; HAM-A=Hamilton Rating Scale for Anxiety; DSM=Diagnostic and Statistical Manual of Mental Disorders.

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Extended-Release Alprazolam Provides
Additional Safety
1. Susman J, et al. Prim Care Companion J Clin Psychiatry. 2005;7(1):5-11. 2. Rickels K. Expert Opin Pharmacother. 2004;5(7):1599-1611.
 Patients taking alprazolam XR exhibit a reduction in peaks and troughs in plasma concentrations that in turn reduces the
occurrence of side effects1
 The bioavailability and pharmacokinetics of alprazolam XR are similar to those of alprazolam
IR tablets, with the exception of a prolonged absorption time1
07:00 09:00 11:00 13:00 15:00 17:00 19:00 21:00 23:00 01:00 03:00 05:00 07:00
AlprazolamConcentration(ng/mL)
Time of Day
Alprazolam IR 1.5 mg q.i.d.
Alprazolam XR 6 mg every morning
Comparison of the plasma concentrations of the original formulation of alprazolam administered four times daily with that of
alprazolam XR (administered once in the morning) over a 24-hour period
Alprazolam Plasma Concentrations1,2

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Non-Pharmacological Approach :
The BATHE Technique
 B: Background - What is going on in your life? And What brings you in
here today?
 A: Affect – How do you feel about that?
 T: Trouble – What bothers you the most about this situation?
 H:Handling - How are you handling that?
 E: Empathy – That must be very difficult for you.

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PHQ-15 - Screening for Somatic Symptom Presence
and Severity Not bothered
at all
(0)
Bothered a
little (1)
Bothered a
lot (2)
a. Stomach pain   
b. Back pain   
c. Pain in your arms, legs, or joints (knees, hips, etc.)   
d. Menstrual cramps or other problems with your periods   
WOMEN ONLY
e. Headaches   
f. Chest pain   
g. Dizziness   
h. Fainting spells   
i. Feeling your heart pound or race   
j. Shortness of breath   
k. Pain or problems during sexual intercourse   
l. Constipation, loose bowels, or diarrhea   
m. Nausea, gas, or indigestion   
n. Feeling tired or having low energy   
o. Trouble sleeping   

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Somatic Symptom Scale – 8 [SSS-8]
(Table is hyperlinked)

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High prevalence and impact on patient and society
Effective treatment of anxiety disorders may be useful in the
management of psychological and medical comorbidities
Diagnostic and rating criteria are useful in clinical practice
Necessity for accurate diagnosis to ensure appropriate treatment plan
Effective treatment reduces symptoms and leads to remission
of anxiety disorders
Recognizing and Managing Anxiety Disorders in
Clinical Practice
✔

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Essential Treatment Approaches for Patients with Somatic
Symptom Disorder (Croicu, C., et al. 2014)
• Schedule time-limited regular appointments (e.g. 4-6 weeks) to address
complaints
• Explain that although there may not be a reason for their symptoms, you will
work together to improve their functioning as much as possible
• Educate patients how psychosocial stressors and symptoms interact
• Avoid comments like ―Your symptoms are all psychological.‖ or ―There is
nothing wrong with you medically.‖
• Relief their symptoms with appropriate and effective drug. Consider to ask
about drug history and alcohol use

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Summary
• Acknowledge the patients symptoms
• Non-pharmacological interventions such as CBT has shown evidence in
decreasing somatic symptom disorder.
• Initial treatment must be effective and relief patient’s symptoms
• Therapeutic alliance with the patient with somatic complaints improves
outcomes.
• Know our competencies, refer the patients with somatic symptoms if you think
they need further assessment and therapy

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Buku PSIKOSOMATIK

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Twitter : @mbahndi
Facebook : Andri Andri
IG : andripsikosomatik
Journal : https://www.researchgate.net/profile/Andri_Andri
Slides : http://www.slideshare.net/AndriAndri2
Website : www.psikosomatik.net
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