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UNDERSTANDING AND OPERATIONALIZING THE SOMATIC SYMPTOM DISORDERS

Joel E. Dimsdale, M.D. UCSD jdimsdale@ucsd.edu

outline
Why do we need these changes? What are the criteria and why did we write them the way

we did?
Factitious Disorder Conversion Disorder (Functional neurological symptoms disorder) Psychological factors affecting another medical condition Somatic symptoms disorder (SSD) and illness anxiety disorder

How to assess SSD in clinical practice? How to operationalize in psychiatric epidemiology? How to convey to non-psychiatric colleagues? How to treat?

Why are psychosomatic illnesses important?


They are common Result in impairment Outcomes of

psychosomatic illnesses
Not death, but plenty of:
Disability Discomfort Dissatisfaction Destitution

comparable to depression Excessive health care use which costs US health care annually $100B Frustrating for clinicians to manage High levels of patient dissatisfaction

Kroenke, Psychosom Med 2007; Jackson, JGIM 2006

Why do we need changes to DSM?


Classification is

difficult It is always contentious, a tug of war between change and continuity DSM is not a Bible Changes driven by evolving data and utility

DSM IV TR status quo


Somatoform Disorders Somatization Disorder Undifferentiated Somatoform Disorder Conversion Disorder Pain Disorder (2 variants) Hypochondriasis Body Dysmorphic Disorder Other conditions that may be a focus of clinical

attention Psychological factors affecting medical condition (six variants: mental disorder, psych. symptoms, personality traits/coping style, stress-related physiological response, maladaptive health behaviors, other) Factitious Disorders With predominantly psychological signs & symptoms Factitious Dis. with predom. physical signs & symptoms Factitious Dis. with combined psych & physical symptoms Factitious Dis. NOS Appendix B Criteria sets and axes for further study Factitious Dis. By proxy

Problems with somatoform in DSM IV


Overlapping disorders Prevalence estimates are hazy Criteria are too sensitive and too specific Pejorative Mind-body dualism Over-emphasis on medically unexplained symptoms Disorders can occur with or without medical diagnoses Confusing to primary care doctors Physicians dont use

One third of neurology outpatients have symptoms unexplained by organic disease


Stone et al., Brain 2009
Study of 3781 newly

referred neurology outpatients in Scotland Of the not explained & somewhat explained
26% headache 18% conversion

% explained by organic disease

not at all somewhat largely completely

Prevalence of medically unexplained symptoms (MUS)


Primary care ~20% Specialty care ~40% MUS accounts for 60 million outpatient visits/y in

USA Thus, defining psychiatric disorder on MUS alone is too sensitive

Creed, Henningsen, & Fink, Medically unexplained symptoms, somatization and bodily distress, Cambridge, 2011

Out of 1,203,927 Virginia Anthem BC policy holders, only 569 somatoform cases were coded, Levenson
2011
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..

Figure portrays a 1% sample of data

Distribution of somatoform disorders in Virginia, Levenson, 2011

What are physicians and patients opinions of these diagnoses?

Assessing attitudes towards existing somatoform diagnoses


Focus groups in San Diego & Edinburgh General psychiatrists, child psychiatrists, forensic psychiatrists, psychopharmacologists, rural psychiatrists Internists, GI specialists, neurologists, pediatricians Insurance industry Anonymous internet polling in US and UK
Psychiatrists and non-psychiatrist physicians n = 332 respondents 2/3 psychiatrists
2/3 from USA

Clarity of diagnoses
Very clear Somatoform NOS Somatization Hypochondriasis Conversion Pain 5% 18 21 21 7 clear 22% 55 51 47 33 neutral 28% 15 15 14 23 unclear Very unclear 33% 11 11 16 26 12% 1 2 2 11

Utility of diagnoses
Very Useful useful Somatoform 6% NOS Neutral Not particularly useful Completely useless

26% 51 43 44 28

17% 16 18 17 21

42% 22 21 22 31

9% 2 5 1 12

Somatization Hypochondriasis

9 12

Conversion 17 Pain 7

What do patients think of these terms?


Very useful useful Somatoform NOS 0% 6% 10 6 18 34 neutral Dont Completely like unacceptable 59% 58 55 41 25 8% 10 29 10 6

27% 21 8 29 30

Somatization 1 Hypochondriasis Conversion Pain 1 2 4

The BIG question: should we be emphasizing medically unexplained symptoms as the core?

Problems with medically unexplained


Mind body dualism Does not foster doctor patient collaboration Patients hate it Defines disorders on the basis of negative criteria

rather than positive criteria Doctors disagree whether patients situation is medically unexplained

easy changes
DSM IV problems (10 codes)
Factitious disorders W psychological features W physical features W both Who is the proxy? PFAMC with 6 subtypes Mental disorder affecting Psychological symptoms affecting Personality traits or coping style Maladaptive health behaviors, Stress-related physiological response Other

DSM 5 solutions (3 codes)

Factitious disorder

imposed on self Factitious disorder imposed on another Psychological factors affecting other medical conditions- no subtypes

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Moderate changes
DSM IV problems
1. Body dysmorphic

DSM 5 solutions
1. BDD moved to obsessive

disorder (BDD) 2. Conversion 3. Location of factitious disorder (FD) and Psychological factors affecting other medical conditions (PFAMC) in the book 4. Hypochondriasis without somatic symptoms

compulsive and related disorders 2. Conversion (functional neurological symptom disorder)


Medically incompatible Stress not required

3. Include FD and PFAMC

with other somatic disorders 4. Illness anxiety disorder (IAD)

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Big changes Coalescing+and+dieren/a/ng+


Soma/za/on+disorder,+ undieren/ated+ somatoform+disorder,+ pain+disorders+

Soma/c+ symptom+ disorder+

+s With

oma

s+ ptom m y s /c+

hypochondriasis+
Without+soma/c+symptoms+

IAD+

Rationale for big changes


Overlapping diagnoses Medically unexplained

symptoms (MUS) Poor reliability Reinforces mind/body dualism Labels suffering as inauthentic Definition based on absence of criteria Diagnosis of a psychiatric disorder should not be based on unexplained medical symptoms Psychiatric disorders should focus on thoughts, feelings, and behaviors

Can occur in medical patients Pain Ambiguous distinction

between 2 different pain subtypes in DSM IV TR With new framework for SSD, that distinction less necessary. Pain is a logical specifier of SSD The more somatic symptoms, the worse the functioning, whether or not they are MUS Functioning is even worse when somatic symptoms combined with disproportionate thoughts, feelings, & behaviors

FACTITIOUS DISORDERS

Changes for DSM-V

Changes in criteria: DSM- IV to DSM-V


Eliminate the distinction between factitious

disorders involving physical vs. psychological symptoms. Clarify who is the patient in factitious disorder by proxy. This is now termed factitious disorder imposed on another. Emphasize objective identification rather than inference about intentionality or possible underlying motivation.

CONVERSION DISORDER

Changes for DSM-V

Conversion disorder
Describes a variety of clinical phenomena Weakness, attacks, sensory deficits A relatively common diagnosis but seen more by neurologists than psychiatrists Need for simpler diagnostic criteria, easier to use, suitable

for non-psychiatrists and more acceptable for patients

Changes to the name (a parenthetical)


Conversion Disorder (Functional Neurological Symptom

Disorder)
FNSD reflects current usage in neurology FNSD is probably more acceptable to patients

Criteria removed from DSMIV


Psychological factors judged to be associated Not always found in practice Still included as specifier and referred to in text The symptom is not feigned Not practical to detect not feigning (Wouldnt that also apply to all DSM

diagnoses?)

Criterion added to DSM5


Clinical findings that provide positive evidence of

incompatibility between the symptom and recognized neurological or medical conditions.


Examples: Hoovers sign Closed eyes with resistance to opening during an

attack Tunnel vision

PSYCHOLOGICAL FACTORS AFFECTING OTHER MEDICAL CONDITIONS

Changes for DSM-V

Psychological Factors Affecting Medical Condition


Controversies: 1. Is it a psychiatric disorder?
It is in DSM-III, III-R, IV, IV-TR, with counterpart in ICD-9 and 10. It is useful as a billing code, especially in CL and Health psychology

contexts.

2. How is it different from an Adjustment disorder?


Medical disorder leads to psychological distress=Adjustment

disorder Psychological state or behavior aggravates medical disorder=PFAMC

3. Which came first, the chicken or the egg? Still dont know!

Psychological Factors Affecting Medical Condition Six DSM IV Subtypes (eliminated in DSM 5):
Mental Disorder Affecting Psychological Symptoms Affecting Personality Traits of Coping Style Affecting Maladaptive Health Behaviors Affecting Stress-Related Physiological Response Affecting Other or Unspecified Psychological Factor Affecting

SOMATIC SYMPTOM DISORDER & ILLNESS ANXIETY DISORDER

Changes for DSM-V

REASONS FOR THE CHANGES (1)


Greater utility Decrease overlap Decrease emphasis on medically unexplained symptoms should not diagnose a psychiatric disorder simply because symptoms not medically explained Develop positive criteria for diagnosis Emphasize positive signs and symptoms: disproportionate and excessive thoughts, feelings and behaviors Somatization Disorder: criteria too stringent; insensitive Undifferentiated somatoform disorder: over inclusive,

diffuse, ill-defined Patients with medical illnesses can also have somatoform disorder

Reasons for changes (2)


Changes emphasize patients tolerance, coping, and

response to sxs, rather than cause of symptoms Extent and degree to which sxs are disruptive, disabling, distressing, bothersome Presence of medical disease does not rule out psychiatric dx; sxs could have medical basis if response disproportionate Difficulty determining definitive somatic sx etiology Mind-body dualism; sxs not either medically explained or unexplained

Assessing overwhelming concerns and preoccupations


From observation
appears apprehensive about health despite repeated reassurance alarmed by bodily sensations that would be ignored by most people

(e.g. muscle twitches) symptoms are viewed as signs of severe disease expects the worst outcome regardless of the evidence preoccupied by health concerns which dominate his/her life
From interview

Do you worry a lot about your health? If you notice a new bodily sensation, do you often fear that it is caused by a serious disease? When you feel your symptom, do you feel overwhelmed by it and worry it is never going to go away? Do you get the feeling that people are not taking your illnesses seriously enough? Is it hard to forget about your health and think about other things?

ILLNESS ANXIETY DISORDER (IAD)


25% DSM-IV hypochondriacal pts: belief in undiagnosed

illness; high health anxiety but minimal or no somatic sxs; and do not qualify for anxiety disorder dx Designated IAD; negative connotations of hypochondriasis Precise relationship to existing literature on hypochondriasis unclear, source of concern and debate Somatic sx disorder section rather than anxiety disorder Focus is limited to health concerns Typically encountered in medical settings

CLINICAL APPLICATIONS OF DSM5 SOMATIC SYMPTOM DISORDER

Changes for DSM-V

Assessing Somatic Symptom Disorder in clinical practice


A One or more somatic symptoms distressing / disruptive Single symptom distress is usually clear Ask questions about all bodily systems not just one
Headaches Pain/soreness in back, joints, limbs, chest and abdomen Nausea Fatigue / weakness of muscles Faintness or dizziness Lump in throat /difficulty swallowing Numbness or tingling in part of the body

DSM-5 Somatic Symptom Disorder


B i Persistent thoughts about seriousness of somatic symptoms ii Persistent anxiety re health or symptoms iii Excessive time and energy devoted to these symptoms or health concerns. Ask relevant questions: Do you think your symptoms are serious? Does your doctor under-estimate the severity of your condition? Do they preoccupy you so much that you cannot enjoy other things? Are they taking over your life? How much do you worry about this symptoms(s) Assess patients behaviour (directly or get history from informant and referring physician)

C Symptomatic for > 6 months

Summary

Assess criteria of Somatic Symptom Disorder

(SSD) history from patient, relative, previous physicians Accept that SSD may occur in presence of other psychiatric disorders and general medical conditions. Treat SSD because it is an independent predictor of poor outcome. Even if concurrent depression is treated, patient may need CBT for health concerns

HOW TO OPERATIONALIZE SOMATIC SYMPTOM DISORDERS IN PSYCHIATRIC EPIDEMIOLOGY

Changes for DSM-V

Somatic Symptom Inventories


Diagnostic Interview Schedule (DIS) (N= >30 Somatic

Symptoms) Composite International Diagnostic Interview (CIDI)(N= >30 Somatic Symptoms Physicians Health Questionnaire (PHQ-15) = 15 Somatic Symptoms past month NLAAS Somatic Symptoms (14 symptoms past year plus severity probe) SCL-12 (Hopkins Symptom Checklist) (12 symptoms, past week) SCAN-PSE Somatic Symptom Items (>80 items exploring physical symptoms).

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PHQ Somatic Symptom Short Form (PHQ-SSS)*


During the past SEVEN (7) DAYS how much have you been bothered by. 1. 2. 3. 4. 5. 6. 7. 8. Not at all Stomach or problems going to the toilet? 1 Pain in your back? 1 A li)le bit 2 2 2 2 2 2 2 2 Somewhat 3 3 3 3 3 3 3 3 Quite a bit 4 4 4 4 4 4 4 4 Very much 5 5 5 5 5 5 5 5

Pain in your arms, legs, or joints 1 Headaches? Chest pain or geGng out of breath? Dizziness? Feeling Lred or having low energy? Trouble sleeping? 1 1 1 1 1

*Kroenke K, Unpublished, 2010 Adapted from PHQ-15

Somatic Symptoms in Psychiatric Epidemiology


ECA Study (DIS Somatic Symptom Module) CIDI Somatic Symptoms were not included in National

Comorbidity Study and other recent, large, Epidemiological Studies (NIAAA Study, World Mental Health Survey) NLAAS Included an Abridged Somatic Symptom Module Similar to the PHQ-15 with Probes for Severity

Problems in Interpreting Epidemiological Data on Mental Disorders


They are Surveys, not diagnostic Examinations. Use brief or abridged instruments Systems of probing are not very elaborate. Lay interviewers with little clinical experience Complete dependency on respondents answers or reports. Little or no objective information. There is no Gold Standard to confirm or deny the diagnosis And yet, these surveys can be influential

DSM5 FOR NONPSYCHIATRISTS

DSM5 must work for non-psychiatrists, psychiatrists, and mental health researchers
A wedding cake type of

DSM?
Each layer for a different use DSM PC- still on the drawing

board (fewer disorders, briefer, guidance on stepped care) harmonization with ICD 11PC?

Treating psychosomatic disorders


Primary care interventions Referral interventions Psychotherapy Pharmacotherapy

Nine pointers on Primary care interventions Levenstein, Psychosom Med 2007; Sapira, Ann Int
Med 1972; Smith NEJM 1986
1. 2. 3. 4. 5. 6.

Importance of patience; this is a chronic illness Elicit detailed description of symptom as well as patients worries about its significance Importance of hands on physical, even if brief and focused Avoid extensive tests Reassurance is tricky (cf Sapira, Ann Int Med 1972) Legitimize & explain symptoms:
a) b)

c)
7. 8. 9.

Its not in your head but it is real pain, but fortunately its not cancer either Sometimes these symptoms come on under stress, like a headache does, and sometimes we just dont know why they happen Some people are just more tuned into their body than others a blessing and a curse

Dont miss depression; consider antidepressants Regularly scheduled f/u appointments With established patients, selective referral in presence of distress

Referral Interventions
Specialist interventions Typically group outpatient Discussion of stress, how to recognize it and stress effects on body Homework on observing and rating stress and symptoms Learning how to communicate frustrations Exercise & relaxation
Mayou, Treatment of functional somatic symptoms, Oxford Press, 1995

Results 34 RCTs in last 40 y 4000 patients on clinical trials CBT effective in 11/13 trials Antidepressants effective in 4/5 trials Effective in terms of QoL, health care utilization
Kroenke, Psychosom Med 2007

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Next steps
Broader testing Setting the right

threshold Helping clinicians determine B criteria Defining co-occurrence with other disorders Emphasizing treatment options

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