The Foundation for Medical Excellence 27th Annual Pain & Suffering Symposium http://tfme.org

1. Functional Somatic
Syndromes
Chris Stewart-Patterson MD
Program Director
Harvard Medical School
No disclosures

2. FSS Definition
• “FSS are characterised by
patterns of persistent bodily
complaints for which adequate
examination does not reveal
sufficiently explanatory structural
or other specified pathology.”
– The Lancet, Volume 369, Issue 9565, March 2007

3. Clinical Features of FSS?
• Sx of CFS, FMS, MCS, IBS, Chronic
Lyme Disease…
• No defined pathophysiology
• High rate of psychiatric comorbidities
• Contribution of psycho-social factors
• Barsky & Borus, Ann Int Med 1999.130:910-
921

4. FSS Psychosocial Factors
1. Belief of a serious disease
2. Expectations of worsening
disease
3. “Sick Role"
–including litigation & compensation
4. Stress & distress
– Barsky & Borus, Ann Int Med 1999.130:910-
921

5. Difficult Encounters
• MUS & high somatic Sx counts
• 2-3 times more likely to have a
depressive or anxiety disorder
• A stepped care approach may
improve care & enhance physician
satisfaction
• Kroenke. J Clin Psychiatry 2003;5 [suppl 7]: 11–
18)

6. “Can you check to
see if I have
hemosiderin laden
macrophages?”

8. Don’t miss pathology!

9. Somatoform Tool Box!
• Approach
• Interview
• Focus on
function
• Screening tools
• Communication
• Treatment
review

10. A Very Brief History
of Somatization &
Somatic Syndromes…

13. Fibromyalgia…
• 1838 spa Dr. Charles Despine
–Varying “Pointes hysteric”
• 1904 BMJ Dr. William Gowers
–“fibrositis”
–On biopsy: muscle tissue inflammation
• 1970’s increased media attention

14. 1990 ACR FMS Criteria
Wolfe, Smythe, Yunus et al
• Rheumatological & physical
emphasis
• Hx of widespread pain for at least 3
months
• In combination with at least 11/18
tender points being painful

15. FMS Literature Trends 1996
• If < 11 TPs may have FMS if
have widespread pain & many
other related sx
• Dx after longitudinal
observation & considering
….psychiatric symptoms
• No Dx validation in
compensation settings
– Wolfe F et al. Journal of Rheumatology 1996;23:S

16. FMS Literature Trends
1997-2003
• “…near epidemic proportions in
courts……mounting evidence that many
patients have major affective ,
somatization & personality disorders…”
• Wolfe F. J Rheumatology 24:7 1997
• “…By ignoring the central psychosocial
and distress …and choosing instead a
physical examination item, we allowed FM
to be seen as mostly a physical illness…”
»Wolfe F. J Rheumatology 2003; 30:8

17. FMS Literature Trends
2009
“Medically unexplained symptoms…
…the contention around FM should be
the extent to which it is socially
constructed and medicalized…the
extent to which psychosomatic
factors dominate.”
–Wolfe F. J. Rheumatology 2009 36:4:671-678

18. ACR FMS Screening 2010
• Does not require a physical or
tender point examination
• Combines 2 brief questionnaire
scales
–Symptom Severity (SS) scale
–Widespread Pain Index (WPI)
–Wolfe et al. Arthritis Care & Research
Vol. 62, No. 5, May 2010

19. Somatic Symptoms Scale
Muscle pain, irritable bowel syndrome, fatigue,
thinking or remembering problem, muscle
weakness, headache, pain/cramps in the
abdomen, numbness, tingling, dizziness,
insomnia, depression, constipation, pain upper
abdomen, nausea, nervousness, chest pain,
blurred vision, fever, diarrhea, dry mouth,
itching, wheezing, Raynaud’s phenomenon,
hives/welts, tinnitus, vomiting, heartburn, oral
ulcers, change in taste, seizures, dry eyes,
shortness of breath, loss of appetite, rash, sun
sensitivity, hearing difficulties, easy bruising,
hair loss, frequent or painful urination, bladder
spasms

20. DSM & FSS
• DSM IV TR Somatization Disorder (2000)
–“…so called functional disorders (e.g.
IBS) symptoms may count towards a Dx
of Somatization Disorder”
• DSM V Somatic Symptom Disorder (2013)
–“the Sx of IBS or FMS would not satisfy
the criterion necessary to Dx somatic
Symptom Disorder”

21. Current FMS Pathophysiology Theories
• Central sensitization
• Neurohumoral abnormalities
• Psychiatric comorbidity
–Ann Int Med 2007;146:762-734
• Likely FMS originates in the CNS
–IASP Pain Clinical Updates Volume XVI, Issue
4 June 2008

22. Neuronal correlates of symptom
formation in FSS: An fMRI study

23. • NeuroImage Volume 41, Issue 4, 15 July 2008

24. Hypothetical Somatizing Cascade
• Dysfunctional early & current relationships
• Experience of bodily stress
• Interpretation as disease
• Increased anxiety & depression
• Chronic bodily Symptoms
• Seeking medical help
• Interpretation as severe disease
• Emotional distress
• Loss of functioning
• The Lancet, Volume 369, 17 March 2007

25. Barsky’s 6-Step Approach
1. Search for a medical disorder
2. Search for psychiatric disorder
3. Collaborative therapeutic alliance
4. Restoration of Fx is goal of Tx
5. Provide limited reassurance
6. Cognitive Behavioral Therapy if no response
to steps 1-5
Barsky, Borus 1999 Ann Int Med 130; 11

26. Psychiatric Somatic Sx
• Most frequent worldwide somatized Sx
of depression & anxiety are MSK pain &
fatigue
– (Kirmayer et al. J Clin Psychiatry 2001;62.)
• Globally 45%-95% of pts with depression
initially report somatic Sx
–11% deny psychological Sx of depression on
direct questioning
– NEJM 1999, 341; 18: 1329-1335

27. Canadian Primary Care MDD
• High CES-D (depression) scores
–“Psychologizers” (15%)
–Initial somatization (34%)
–Facultative somatization (26%)
–Persistent somatization (24%)
• Recognized by PCP = 23%
–(Kirmayer et al. J Clin Psychiatry 2001;62.)

28. Group Exercise
• Take a minute to remember a FSS
case and jot down a note
• Group in 2 or 3s and one of you
quickly discuss your case

29. History
• High # of Sx likely indicates
somatization
• Caution with AIDS, SLE, TB
• Careful with pts age >50 & “red flags”
• Change in headache?
• History of cancer?
• Nocturnal back pain?
• Unexplained weight change?

30. Sleep Screening
• HS Medication
• Sleep onset
• Nocturnal wakenings
• Time get up
• Refreshed
• Nap times
• +/- OSA screen

31. Past Medical History
• “The more functional symptoms they have
had in the past, the more likely it is that the
current symptom is also functional”
(J Neurol Neurosurg Psychiatry 2005;76)

32. Focus on Function!
• Change focus of treatment from
symptoms to improving functioning
• Prevent deconditioning & secondary
disability
• Assessment of capacity for
SAW/RTW
• Assessment of malingering

33. Focus on Function!

34. Functional Assessment
• Stated activity tolerances
• Current roles
• House and yard chores
• Hobbies and recreational
activities
• Functional physical examination

35. Disability Self Perception
• 60 pts AS, FMS, RA & 4 controls
–Pt self-rate disability with 7 activities (VAS)
–Video of same 7 activities performed
–6 OT & MDs (blinded to Dx) rate video (VAS)
• Discordance in VAS
–AS & RA not significant
–FMS is high (36%) p<0.01
• Hidding et al. J Rheumatology 1994;21:5, p 818

36. Physical Examination
• Full physical exam
• Functional physical exam
–Sit, arise, stand, walk, bend,
squat…
–Look for evidence of impairment
• MSE: depressed or anxious

37. Exam Screening for FMS
BP Cuff invoked allodynia
• Inflate 10mmHg/sec to 180
mmHg or to pain
• Say “Tell me if the cuff’s pressure
brings forth pain”
• 69% FMS report pain vs. 2% normals
–70% sensitive & 96% specific for
FMS
–J Clin Rheum 2006;6

38. PHQ-15 Questionnaire
PHQ-15 Severity PHQ-15 Score
Screen
• Score the 15 Sx as
• 0 “not bothered at all”
• 1 “bothered a little”
• 2 “bothered a lot”
• 5, 10, 15 are cut points for low,
medium & high somatic Sx severity
– Kroenke, Spitzer et al. Psychosomatic Medicine
64:258–266 (2002)
• www.phqscreeners.com

39. Disability Days in Last 3 months
• (Kroenke J Clin Psychiatry 2003;5[suppl 7]: 11–18)

40. When to stop the investigations?
• Reasonable workup for common
conditions
• No “red flags”
• +/- specialist consultation
• Patient is counselled & educated
• You are comfortable
• Workup is well documented

41. Somatization Tx Structure
• One designated physician
• Brief, regular visits not contingent on
new Sx
• Engage or lose!
• Focus on function not chronic Sx
• Provide & assess measurable goals
• Prevent secondary disability

42. Provide Limited Reassurance
1. Hurt vs harm
2. Care rather than cure
–“You do not have any life-threatening
illness. You do, however, have a medical
condition that is incompletely
understood. Though no treatment is
available that can cure it completely,
there are a number of interventions
that can help you deal with the
symptoms better than you have so far.”

43. Activity Rx: Focus on Function
–What pts should be doing for recovery
and to preserve well-being
–What pts should not do because of
medical risk (harm self or to others)
–What pts can & cannot do given their
medical condition & functional ability
–Whether or not they are willing to
tolerate the activity

44. Fibromyalgia & Lifestyle Physical
Activity
• Recorded daily steps & types of LPA’s
– Tx group is to Increase LPAs
– Control group education only
• LPA group increased daily steps from
3,788 to 5,837 (± 1,770) over 12/52
• LPA group reported significantly less
perceived functional deficits & pain
– Fontaine et al. Arthritis Research & Therapy 2010, 12:R55

45. CBT & Stress Management Resources
• Vancouver CBT
–www.vancouvercbt.ca
–www.changeways.com
• Relaxation Response Instructions
–www.massgeneral.org/bhi/basics
• Behavior treatment for insomnia
–www.cbtforinsomnia.com

46. Discuss your case…
• Search for a medical disorder
• Search for psychiatric disorder
• Collaborative therapeutic alliance
• Restoration of Fx is goal of Tx
• Provide limited reassurance
• CBT if no response to steps 1-5

47. Poor Response to Tx?
• Illness beliefs & misinformation
• Poor integration in treatment
• Personality disorders
• Opioid or other SUD
• Workplace or interpersonal
conflict
• Compensation seeking behavior

48. DSM-IV & V Diagnostic Criteria
• DSM-IV Somatization Disorder & Pain
Disorder
–“The Sx are not intentionally produced
or feigned (as in …Malingering)”
• DSM V Somatic Symptom Disorder
–No mention of malingering

49. Malingering Prevalence?
• AMA: Probable prevalence DI, PI & WCB
is 25%-30%
(Melhorn & Ackerman, 2008; Genovese & Galper, 2009)
• 33,000 neuropsychological testing cases
–Probable malingering or exaggeration
• Fibromyalgia/chronic fatigue 35%
(Mittenberg, W. et al., J Clin Exper Neuropsychology, 2002)

50. Focus on Function…
• Marked discrepancy between stated
disability and observations
• (DSM-IV & V)
• “Cross validation” of reported functioning
with observation
• (Rondinelli, 2007)
• One of the most common incongruencies
– Discrepancy in reported level of functioning &
observed level of functioning
• (Rogers, 2008)

51. Video Surveillance & FMS
194 B. C. court judgments & video
• Credibility Complete congruent =
28%
–Mean award = $189,981
• Credibility Partial congruent = 63%
–Mean award = $114,245
• Credibility incongruent= 9%
–Mean award =$10,613
• Le Page, J.A. et al., Int J Law Psychiatry 2008 Jan-Feb;31(1)

52. FMS Office Congruency Screen
• Sites that should not be painful to
palpation with FMS
–3rd digit between DIP & PIP
–Medial third of the clavicle
–Medial malleolus
»Wolfe F., Rheum Dis Clin NA
1994;20:2

53. Malingering Screen
• Vague and evasive
• Exaggerated symptoms
• Inconsistent symptoms & findings
• Endorses improbable symptoms
» Knoll J., Resnick P.J., Psychiatr Clin N Am 2006;
29:629
• Multiple lawsuits
• Unstable work history
• Recreational activities justified but
not working
» Hall R., Hall C.W., Gen Hosp Psych 2006;28:525

54. But remember …
• Inconsistency is evidence that signs are
likely non physiological
–But does not tell you if consciously or
unconsciously produced
• A functional sign does not exclude the
possibility that the patient also has
disease
–They may have both
• J Neurol Neurosurg Psychiatry 2005;76

55. Summary
1. Search for a medical disorder
2. Search for psychiatric disorder
3. Therapeutic alliance
4. Restoration of Fx is goal of Tx
5. Provide limited reassurance
6. CBT if no response to steps 1-5