1. Functional Somatic
Syndromes
Chris Stewart-Patterson, MD,
CCBOM, FACOEM
Program Director, Harvard Medical
School
Senior Lecturer Wellington Medical
School
Clinical Instructor, Faculty of Medicine
UBC

2. A Difficult Issue…
 Difficult encounters strongly
associated with MUS & high somatic
Sx counts
 Patients rated as difficult are 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)

3. Illness, Syndrome &
Disease
 Illness
− Subjective experience of Sx & suffering
 Disease
− Dx and demonstrated pathology
 Syndrome
− Association of several symptoms & signs
that often occur together

4. Definition of FSS
 Characterized more by symptoms,
suffering, & disability than by tissue
abnormality
 No defined pathophysiology to date
 Similar phenomenologies, high co-
occurrence, & psychiatric
comorbidities
 CFS, FMS, MCS, IBS, Chronic Lyme
Disease & many more…

5. Engel’s Biopsychsocial
Model
BiologicalSociological Psychological

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

7. Disability Cycle
Pain, fatigue & other Sx Fears & beliefLimitations DeconditioningSecondary Disability

8. 
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Somatoform Tool Box!
 Approach
 Interview
 Pearls
 Focus on
function
 Screening tools
 Communication
 Treatment review

9. Areas of Somatization
 “Everyday” somatization
 Functional Somatic Syndromes
 Somatized DSM IV depression &
anxiety
 DSM IV Somatoform disorders
− Exaggerating Sx & disability with a Dx
 DSM IV cultural “Idioms of distress"

10. Global Sx Pain &
Fatigue
 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

11. Canadian MDD
Somatization
 Canadian Primary Care presentation
 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.)

12. 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

13. Assessment of
Somatization
− History
− Examination
− Investigations
− Questionnaires
− Communication of diagnosis
− Treatment
− Secondary prevention of further disability

14. History
 High # of Sx likely indicates
somatization
− Caution with AIDS, SLE, TB
 Somatizers get sick too!
 Careful with pts age >50 & “red flags”
 Change in headache?
 History of cancer?
 Nocturnal back pain?
 Unexplained weight change?

15. Somatizing, Dissociation
& Panic Attacks
 ‘‘I was outside of myself’’, ‘‘I was
spaced out’’, ‘‘Things didn’t feel real’’
 Depersonalization and derealization
may also be described as ‘‘dizziness’’
 With dissociative Sx, consider PA
 (J Neurol Neurosurg Psychiatry 2005;76)
 DSM-IV PA criteria
− “derealization” or “depersonalization”

16. FSS & Panic Sx
 Greater frequency of panic
responses with MCS/IEI
 Environ Health Persp (2002)
 Fatigue OR Panic 8-13
 J Gen Intern Med 1993
 FMS & Panic disorder OR 5.0
 J Clin Psychiatry 2006
 46% pts with PD had IBS vs 3% CG
 Ann Clin Psychiatry 1996

17. Disability Misperception
in FMS
 60 pts AS, FMS, RA & 4 controls
− Pt self-rate disability with 7 activities
− Video of same 7 activities performed
− 6 OT & MDs (blinded to Dx) rate video
 Discordance?
− AS & RA not significant
− FMS is high (36%) p<0.01
 J Rheumatology 1994;21:5 p818

18. But Downplay
Psychiatric Questions…
Panic attack approach…
 ‘‘Do you ever have attacks where you
have lots of symptoms all at once?
 When do these happen?
 Is it when you’re outside or in certain
situations?’’

(J Neurol Neurosurg Psychiatry 2005;76)

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

20. 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)

21. Physical Examination
 Full physical exam
 Functional physical exam
− Sit, arise, stand, walk, bend, squat…
− Look for evidence of impairment
 Decreased AROM, atrophy, neurological
deficits
 MSE: depressed or anxious

22. 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

23. Focus on Function!
 Spectrum of disability with a given Dx
 Change focus of treatment from
symptoms to improving functioning
 Prevent deconditioning & secondary
disability
 Assessment of capacity for SAW/RTW
 Assessment of malingering

24. Focus on Function!

25. Clinical Data Base for
Functional Assessment
 Symptom severity
 Stated activity tolerances
 Current roles
 House and yard chores
 Hobbies and recreational activities
 Accommodations at home
 Functional physical examination

26. Screening
Questionnaires
 Prime MD (Somatoform Module)
 PHQ-15
 Tampa Kinesiophobia Scale
 Pain Catastrophization Scale
 Illness Behavior Questionnaire

27. Prime MD Somatoform
Module 3/15 Sx that “bother a lot” & lack
medical or psychiatric explanation
− Dx multisomatoform disorder or SD NOS
− Sensitivity 100% & specificity 37%
 Spitzer et al. JAMA 1994. 272; 22: 1749-1756
 Or 7/15 Sx in total
− Dx MSD or SD NOS
− Sensitivity 76% & specificity 79%
− PPV 35% & NPV 96%
− Kroenke, Spitzer. Psychosomatics 1998;39:263-

28. PHQ-15 Severity Score
Screen PHQ-15 = the 15 Prime MD somatic
Sx
 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

29. S-4 Predictors of
Depression & Anxiety
1. Recent stress (yes/no)
2. Sx count greater than 5/15 PHQ-15
3. Self-rated health of poor/fair on a
5-point scale (excellent, very good,
good, fair, poor)
4. Severity of Sx 6/10 or greater
 17% with 1/4 & 94% of those with all
4 had depression and/or anxiety
− (Kroenke J Clin Psychiatry 2003;5 [suppl 7]:11–18)

30. PHQ-15 & Disability
 Greater role & ADL disability
 Work limitation (OR 3.2)
 Disability equal to or greater than
chronic medical disorders
 Not due to depression or anxiety
 More absence, disability & job loss
 J Occup Rehabil 2010 20:264–273
 J Gen Intern Med 2008 24(2):155–61

31. Disability Days in Last
3/12 & PHQ-15 Results

(Kroenke J Clin Psychiatry 2003;5[suppl 7]:
11–18)

32. Comprehensive Scales
 Tampa Kinesiophobia Scale
 Pain Catastrophization Scale
 Illness Behavior Questionnaire
− Hypochondriasis
− Disease conviction
− Somatization
− Disease affirmation

33. Psychiatric Comorbidity
 Primary Care pts
− Depression 6.6%
− GAD 8.0%
− “Somatization” 9.5%
 >50% of pts with somatization have
comorbid depression or anxiety
 Functional impairment of comorbidity
exceeds individual contributions of
Dxs

34. Psychiatric Comorbidity
(Lowe, Spitzer et al. 2008)

35. 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

36. Barsky’s 6-Step
Approach
1. Search for a medical disorder
2. Search for a 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

37. 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
 CBT if poor response
 Prevent secondary disability

38. Lose! MD Explanation of
Somatization Sx
 Rejection of Sx
− Denies reality of symptoms
− Implies imaginary disorder or stigmatizing
psych problem
− Doctor distrusted with future symptoms
 Collusion
− Acquiescence to patient’s explanation
− Question MD’s openness & competence
 BMJ Volume 318, 6 February 1999

39. Engage! MD Explanation
of Somatization Sx
Empowerment
− Tangible mechanism
− Exculpation
− Self management & control
− Legitimizes patient’s suffering
− Pt understands & owns the explanation
− Allies doctor and patient
− BMJ Volume 318, 6 February 1999

40. Engage!
BATHE Technique
 (Background) “What is going on in your
life?”
 (Affect) “How do you feel about it?”
 (Trouble) “What troubles you most about
that situation?”
 (Handling) “How are you handling that?”
 (Empathy) “This is a tough situation to be in.
Anybody would feel [down, stressed, etc.].
Your reaction makes sense to me...”
 Primary Care Clinics 1999 Vol. 26, No. 2

41. 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.”

42. Focus on Function
 Activity Rx
− 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

43. Focus on Function
Sleep Hygiene Basics
 Limit coffee intake to two cups/day &
no caffeine 8 hours before sleep.
 No alcohol for 3 hrs before bed.
 Bedroom is dark when sleeping.
 Bed is for sleep or sex. Do not read or
watch television in bed.
 Get up at same time & no naps.

44. Provide Measurable
Goals
 S.M.A.R.T. Rehabilitation Goals
− Specific
− Measurable
− Achievable
− Relevant
− Time bound
 Clin Rehabil April 2009 vol. 23, no. 4 352-361

45. CBT if Required
 CBT is indicated in
− Somatization disorder
− Major depression
− GAD
− Panic Attacks
− Fibromyalgia
− CFS
− IBS
− Insomnia

46. 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

47. WSBC & Progressive Goal
Attainment Program (PGAP)
 Target psychosocial risk factors for
chronic pain and disability
 Once a wk for a maximum of 10 wks
 Significant reductions in psychosocial
risk factors
 Decreases pain-related disability in
chronic pain, depression, or FMS
− BCMJ VOL. 54 NO. 3, APRIL 2012

48. Vigilance for Secondary
Disability Cascade
1. Deconditioning can lead to…
2. Increased weight can lead to …
− Diabetes, Hypertension associated with
…
− OSA leads to…
1. Disrupted sleep can lead to…
2. Depression can lead to…
3. Substance
misuse/abuse/dependence

49. Poor Response to Tx?
 Illness beliefs & misinformation
 Poor integration in treatment
 Personality disorders
 Workplace or interpersonal conflict
 Job dissatisfaction
 Compensation seeking behavior
 Opioid or substance dependence

50. DSM Pain Disorder &
SUD
 Substance Dependence/Abuse may occur
in Pain Disorder in up to 25% of individuals
− DSM-IV-TR
 So screen…
− “How many times in the past year have you used
an illegal drug or used a medication for
non-medical reasons?”
 82% sensitive & 73.5% specific for SUD
 Arch Intern Med. 2010;170(13):1155-1160
− CAGE, AUDIT

51. Chronic Non-cancer
Opioid Guides
 R20 Patients with a psychiatric
diagnosis are at greater risk for
adverse effects from opioid treatment
 Opioids should be reserved for well-
defined somatic or neuropathic pain
conditions
 Canadian Guidelines for Safe and Effective Use of Opioids for
Chronic Non-Cancer Pain, published by National Opioid Use
Guideline Group April 30, 2010 “McMaster Guidelines”

52. DSM-IV Diagnostic Criteria
 Somatization Disorder
− Criteria D: “The symptoms are not
intentionally produced or feigned (as in
Factitious Disorder or Malingering)”
 Pain Disorder
− Criteria D: “The symptom or deficit is not
intentionally produced or feigned (as in
Factitious Disorder or Malingering)”

53. Malingering Prevalence?
 AMA: Probable prevalence DI, PI & WCB
− 25%-30%
(Melhorn & Ackerman, 2008; Genovese & Galper, 2009)
 33,000 neuropsychological testing cases
− Probable malingering or exaggeration
 Fibromyalgia/chronic fatigue 35%
 Chronic pain 31%
(Mittenberg, W. et al., J Clin Exper Neuropsychology, 2002)

54. DSM-IV Malingering
 Intentional false or grossly exaggerated
presentation motivated by external incentives
 Strongly suspected if any combination of:
− Medico-legal context
− Marked discrepancy between stated disability and
observations
− Lack of cooperation with evaluation & Tx
compliance
− Antisocial Personality Disorder
− APA DSM-IV-TR

55. Focus on Function…
 Marked discrepancy between stated
disability and observations
 (DSM-IV)
 “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)

56. 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)

57. But remember …
 Inconsistency is evidence that signs
are functional
− 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

58. Also remember...
Somatization & Culture
 25% of socially disadvantaged
immigrants accessing primary care
used somatization to express their
distress
 Ethnicity & Health 2012;17:5 477-491
 Some very atypical presentations
− DSM-IV “idioms of distress”

59. 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

60. Case Studies?