Simposium Besar TIMA 2017, July 16th 2017

Anxiety & Somatization

Identification & Treatment in General Practice

Anastasia R.B
Rewarding Punishing
stimulus stimulus

EMOTION
 Stimulus Anxiety
Punishing Emotion

Behavior

Avoidance
Is anxiety = fear?

No, its different

How ?
 Fear Anxiety
Identifiable overtly Signals that predict
dangerous stimuli impending danger

Acute, immediate reaction Sustained, insidious

response to danger

Manifesting in abrupt Manifesting to fear-

encounter in highly salient conditioning experiment
threats
 A normal and adaptive response

Prepares the organism threatened by danger

Presence of impairments
Disruption in functioning
Presence of clinically significant distress
Core Key:
Excessive anxiety

Cognitive distortion

Autonomic arousals

Behavioral disturbances (mostly avoidance)

Lasting for a period of time ( 6 months or more)

Problems in functioning
 Its NOT OKAY to complain of
psychological distress or own up to
mental disorder

More acceptable
to complain of physical symptoms
(SOMATIZATION)
 Unconscious coping

Complaints of physical symptoms that remain

medically unexplained

Exposure to risk of:

Increased medical visit, unnecessary medical tests
and procedures (iatrogenic complications)
Financial and time loss
 A mechanism to experience, conceptualize
and/ or communicate psychological distress or
deep-seated neurosis as corporel sensations,
functional changes, or somatic metaphors

Physical symptoms that mask emotional distress

Core key: Its not about the physical

symptoms itself, but the way they were
presented and interpreted
 Recurring, multiple,
clinically significant
somatic complaints
Significant impairment in
social, occupational, or
other important areas of
functioning
The complaints can not be
fully explained by any
known general medical
condition or direct effects
of substance
The complaints are colorful,
exaggerated, but lacking
specific factual information
History of "doctor shopping
Prominent anxiety
symptoms or depressed
moods
Absence of objective
findings (objective signs or
specific laboratory findings)
 Dont say, Its all in your head
To them, the physical symptoms are real
Principles:

Good identification = more accurate treatment & better

prognostic

Differentiate between physical illness & somatization

Treat for any underlying anxiety disorder

Know the competency: when to treat and when to refer

Psychopharmacology

Anti-anxiety

Anti-depressant

Non-psychopharmacology

Cognitive behavioral therapy

Psychodynamic psychotherapy
 Lidbeck, 1997; Speckens et al, 1995

Patients with mild levels of somatization (at least one

psychosomatic symptom)

6 to 16 sessions of individually administered CBT

Result: significantly greater improvement in

psychosomatic complaints

Improvements maintained for 6 months after the

treatment
 Escobar et al., 2007

Patients presenting with more severe somatization (at

least four somatization symptoms

Involving patients spouse or other family member

Result: greater reduction in somatic complaints than

standard medical care, reduction number of physician
visits (Sumathipala et al, 2000)
Protocols:

Identifying dysfunctional cognitions

Restructuring dysfunctional cognitions

Re-engaging patients in avoided activities

Problem-solving training

Relaxation training
Recommendations:

Schedule appointments every 4 to 6 weeks, instead of as

needed setting boundary

Conduct a physical examination relevant to presenting

complaint

Avoid diagnostic procedures & surgeries unless clearly

indicated by underlying somatic pathology

Avoid making disparaging statements, such as your

symptoms are all in your head
 Patients with somatization typically have less capacity for
symbolic thought

Patients with somatization are less inclined to enter

psychotherapy, less likely to have meaningful
improvement

May benefit subjectively from a sympathetic listeners

Consideration: patients capacity & willingness to engage

in treatment
Recommendations:

Offer reassurance that the physical experiences is real

& understandably distressing (even though theres no
organic explanation)

Make clear that the goal of treatment is helping patient to

understand and cope, not removal of the symptoms

Identify complications determine the feasibility of

working with the patient
 Anxiety is negative emotion triggered by punishing
stimulus

Anxiety is normal, unless there's presence of

impairments, disruption in functioning, or presence of
'clinically significant' distress

Somatization is a more acceptable way to cope with

psychological distress
 Principles of treatment: good identification, differentiate
between physical illness & somatization, treat underlying
anxiety disorder, know when to refer

Treatment: multi modalities

Psychopharmacology anti-anxiety or anti-
depressant
Non-psychopharmacology CBT (first choice) or brief
psychodynamic psychotherapy