2nd CME

Psychosomatic disorders

Headache

Insomnia

Pain Disorder Doct. Jean-louis Aillon04-11-10

Psychosomatic disorders (Psychological factors affecting medical condition)

A general medical condition (coded on Axis III) is present.

B. Psychological factors adversely affect the general medical condition in one of the following ways:

• the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from the general medical condition

• the factors interfere with the treatment of the general medical condition

• the factors constitute additional health risks for the individual• Stress-related physiological responses precipitate or exacerbate

symptoms of the general medical condition

Our datas

Association with Depression

Association with Mental disorders

Prevalence of sintomsGastric pain/problems: 58 pz:19,3 %Headache: 40pz 13,3%

Pain how long? 29,2 months

Headache

Clinical assesment

• TIME: onset, frequency, patterns, duration• CHARACTER: site, intensity, nature of pain• CAUSES: predisposition, triggering,

aggravating, releaving factors• RESPONSE: patient actions and limitations

during an attack, medications used• INTERVALS: how does patient feel between

attacks; concern, anxieties and fears about attacks

Chronic Headache

1.Migraine

2.Tension-type Headache

Migraine

World prevalence of migraine:A disorder of First World

1-year prevalence rates1-year prevalence rates Population-based Population-based studiesstudies IHS criteria (or modified)IHS criteria (or modified)

USA USA 12%12%

Chile 7%Chile 7%

Japan 8%Japan 8%Italy 16%Italy 16%

Denmark 10%Denmark 10%

France 8%France 8%††

Switzerland 13%Switzerland 13%

Rasmussen and Olesen (1994); Rasmussen (1995);Rasmussen and Olesen (1994); Rasmussen (1995);Lipton Lipton et al (et al (1994); Lavados and Tenhamm (1997); 1994); Lavados and Tenhamm (1997);

Sakai and Igarashi (1997)Sakai and Igarashi (1997)††Prevalence measured over a few yearsPrevalence measured over a few years

Recognizing Migraine

• Pounding unilateral headache

• Preceded by visual or other aura

• Nausea, vomiting

• Light and sound sensitivity

What is migraine?Migraine without aura (MO)

Migraine with aura (MA)

Headache Classification Committee of IHS (1988)Headache Classification Committee of IHS (1988)

At least five attacks fulfilling these criteria:

• Headache lasting 4–72 h (2–48 h in children)

At least two attacks fulfilling these criteria:

• At least three of the following:

– one or more fully reversibleaura symptoms

– gradually developing orsequential aura symptoms

– no one aura symptom lastslonger than 1 h

– headache shortly follows or accompanies aura

• Accompanied by at least one of:– nausea – vomiting– photophobia and/or

phonophobia

• No evidence of organic disease

• With at least two of:– unilateral location– pulsating quality– moderate/severe intensity– aggravated by activity

• No evidence of organic disease

Aura

• Transient hemianopic disturbances prior to headache, lastin 10-30 minutes (occasionally up to 1 hour)

• A spreading scintillating scotoma (patiens may draw a jagged crescent)

• Other reversibile focal neurological disturbances (e.g. unilateral paraesthesiae of hand, arm or face)

Cady (1999); Warshaw Cady (1999); Warshaw et alet al (1998) (1998)

Diagnosis of migraine

• Diagnosis depends on patient history• No specific tests or clinical markers

• Positive diagnosis if attack history fulfils IHS criteria for migraine

• Other pointers include:– family history of migraine– age of onset <45– presence of aura– menstrual association

• Organic disease must be excluded

StressDepressionAnxietyMenopauseHead or neck trauma

Trigger

• Relaxation after stress

• Change in habit: sleep, travel etc..

• Bright lights/ loud noise

• Diet: alcohol, cheese, citrus fruits, possibly chocolate, missed or delayed meals

• Strenuous unaccustomed exercise

• Mestruation

WORRISOME HEADACHE RED FLAGS

“SNOOP”

Older: new onset and progressive headache, especially in middle-age >50 (giant cell arteritis)

Systemic symptoms (fever, weight loss) or

Secondary risk factors (HIV, systemic cancer)

Neurologic symptoms or abnormal signs (confusion, impaired alertness, or consciousness)

Onset: sudden, abrupt, or split-second

Previous headache history: first headache or different (change in attack frequency, severity, or clinical features)

subarachnoid hemorrhage (SAH) venous sinus thrombosis, arterial dissection, or raised intracranial pressure.

Prevalence of migraine by sex and age

FemalesFemalesMalesMales3030

2525

2020

1515

1010

55

002020 3030 4040 5050 6060 7070 8080 100100

Migraine prevalence (%)Migraine prevalence (%)

Age (years)Age (years)

Lipton and Stewart (1993)Lipton and Stewart (1993)The American Migraine Study (The American Migraine Study (nn=2479 migraine =2479 migraine sufferers)sufferers)

Physiology

• Vasospasm – Lance

• Spreading Wave of Depression – Leao

• Trigeminocentric

• Allodynia

Trigeminal Theory

• Serotonin again

• Trigeminal Afferents: sensory function of face and meninges

• Trigeminal efferents to vessels

• Cause vessel spasm and sensitivity

• This theory primarily explains action of Triptans: 5-HT 1b,d agonists

Vasospasm

• I. Aura: Arteries Spasm– Visual and focal neurological symtoms– Pial and Occipital small artery branches

• II. Headache: Compensatory Vasodilation– Pounding unilateral sick headache

• III. Inflammation and muscle spasm: second pain phase

Treatment

• Effective treatment of attack

• Prevention

• Address comorbidities

1 step

• Oral Analgesics ± Antiemetic

Paracetamol Metoclopramide

Aspirin Domperidone

Ibuprofen

Naproxen

2 Step

Parenteral Analgesics ± Antiemetic

Diclofenac Metoclopramide

DomperidoneAlso suppositories

Paracetamol 1 g Tid

3 Step

• Rizatriptan

• Contraindication:

Uncontrolled Hypertension

Risk factors for CHD or CVD

Children under 12Diagnose ad-exiuvantibus

Mechanisms for treatment

CGRPCGRPNKNKSPSP

5-HT5-HT1F1F5-HT5-HT1D1D

5-HT5-HT1B1B

Blood vesselBlood vessel

Trigeminal Trigeminal nervenerve

Adapted from Goadsby (1997)Adapted from Goadsby (1997)

CGRPCGRP calcitonin genecalcitonin gene related peptiderelated peptide

NKNK neurokinin Aneurokinin A

SPSP substance Psubstance P

triptantriptan

CONSTRICTIONCONSTRICTION

INHIBITIONINHIBITION

Emergency

• Diclofenac IM

Or

• Clorpromazine IM

Prophilaxys

Depression, another chronic pain, Disturbed Sleep, TTH

Atenolol

Even combined in serious cases

Tension-type headache (TTH)

• Episodic

• Chronic

• Bilateral

• Also every day

• No nausea or photophobia

• No pulsation

Treatment

1) infrequent episodic TTH (-2 days/week)

Paracetamol, aspirine, ibuprofen

or Codeine

2) Chronic TTH

Sintomatic treatment only for short time

Consider a course of Naproxen

Prophilaxis with Amitriptiline (10-75 mg nocte)

Non drug intervention for Migraine and TTH

• Improving physical fitness

• Physiotherapy

• Acupunture

• Psychological therapy

• Relaxation

• Stress reduction

• Coping Strategies

• Biofeedback

Phisiotherapy and CBT

Visual feedbackPlace colored labels in strategic sites to remind to keep muscle contraction at a normal level.

Relaxation exercise (once or twice a day)

Sit down on a comfortable armchair in a quiet room. Let the mandible drop in a position of maximum relaxation for about 10-15 minutes. Apply warm pads on cheeks and shoulders.

3) After having cupped the hands behind the neck, performs stretching movements of the head backward, with forward counterpressure from the hands. Relax after 2-3 seconds.

2) While body and head are kept against the wall, make horizontal movements of thehead, forwards and backwards

1) Keep an erect position with the tallons, the hips and the nape against the wall. While the rest of the body does not move bring the shoulders into contact with the wall and release, rhythmically

Posture exercises 8-10 times every 2-3 hours

An Insomnia Typology

• Difficulty falling asleep

• Difficulty staying asleep

• Waking too early

• Non-restorative poor quality sleep

anxiety

Depression, PTSD

Insomnia Mechanisms

• Disorders of circadian rhythms• Disordered homeostatic drive for sleep• Disordered sleep mechanisms• Dyssomnias & Parasomnias• Disordered arousal mechanisms• Medical & psychiatric disorders• Substance/medication-induced disorders

Sleep Disorder Classification

• Dyssomnias are disorders of initiating & maintaining sleep, with Excessive Daytme Somnolence (EDS) – 3 types: intrinsic, extrinsic, and circadian

• Parasomnias - characterized by abnormal behavior or physiological events at specific stages or sleep-wake transitions, involving inappropriate activation of autonomic & motor systems – usually with both normal restful sleep & REM Latency, and without EDS

Dyssomnias - Intrinsic

• Primary Insomnia – Psychophysiologic and Idiopathic

• Narcolepsy

• Sleep Apnea

• Periodic Limb Movements

• Restless Legs Syndrome

Dyssomnias - Extrinsic

• Inadequate sleep hygiene

• Environmental sleep disorder

• Secondary to toxins & substance dependence

Dyssomnias - Circadian

• Time zone changes (jet lag)

• Shift work

• Changes in sleep phase – advanced & delayed

Parasomnias

• Sleep Terrors

• Somnambulism

• Nightmares

• REM Sleep Behavior Disorder

• Jactatio Capitis Nocturna

• Bruxism

• Enuresis

• Hyperthyroidism• Arthritis or any other painful condition• Chronic lung or kidney disease• Cardiovascular disease (heart failure, CAD)• Heartburn (GERD)• Neurological disorders (epilepsy, Alzheimer’s, headaches, stroke,

tumors, Parkinson’s Disease)• Diabetes• Menopause• Major Depression• Bipolar Disorder• Seasonal Affective Disorder• PTSD, anxiety

Pain SyndromesCluster Headaches

Medical & Psychiatric Causes of Sleep Disorders

Common drugs that can cause insomnia

• Alcohol• Caffeine/chocolate• Nicotine/nicotine patch• Beta blockers• Calcium channel

blockers• Bronchodilators

• Corticosteroids• Decongestants• Antidepressants• Thyroid hormones• Anticonvulsants• High blood pressure

medications

Therapy of insomnia

1) Non-drug treatments

• Cognitive-behavioral therapy (CBT)– Stimulus control– Cognitive therapy– Sleep restriction– Relaxation training– Sleep hygiene

How to keep track of your sleep

• Daily sleep diary or sleep log– Bedtime– Falling asleep time– Nighttime awakenings– Time to get back to sleep– Waking up time– Getting out of bed time– Naps

Cognitive Therapy

• Identify beliefs about sleep that are incorrect

• Challenge their truthfulness

• Substitute realistic thoughts

False beliefs about insomnia

• Misconceptions about causes of insomnia– “Insomnia is a normal part of aging.”

• Unrealistic expectations re: sleep needs– “I must have 8 hours of sleep each night.”

• Faulty beliefs about insomnia consequences– “Insomnia can make me sick or cause a mental

breakdown.”

• Misattributions of daytime impairments– “I’ve had a bad day because of my insomnia.” – I can’t have a normal day after a sleepless night.”

More common myths about insomnia

• Misconceptions about control and predictability of sleep– “I can’t predict when I’ll sleep well or badly.”

• Myths about what behaviors lead to good sleep– “When I have trouble getting to sleep, I should

stay in bed and try harder.”

Sleep Restriction - best if done with a professional

• Cut bedtime to the actual amount of time you spend asleep (not in bed), but no less than 4 hours per night

• No additional sleep is allowed outside these hours

• Record on your daily sleep log the actual amount of sleep obtained

Sleep Restriction (cont’d)

• Compute sleep efficiency (total time asleep divided by total time in bed)

• Based on average of 5 nights’ sleep efficiency, increase sleep time by 15 minutes if efficiency is >85%

• With elderly, increase sleep time if efficiency >80% and allow 30 minute nap.

Stimulus Control - You can do this on your own

• Go to bed only when sleepy

• Use the bed only for sleeping

• If unable to sleep, move to another room

• Return to bed only when sleepy

• Repeat the above as often as necessary

• Get up at the same time every morning

• Do not nap

Relaxation training

• More effective than no treatment, but not as effective as sleep restriction

• More useful with younger compared with older adults• Engage in any activities that you find relaxing shortly

before bed or while in bed– Can include listening to a relaxation tape, soothing music,

muscle relaxation exercises, a pleasant image

Exercise relaxion for insomnia and anxiety

1) Take a deep breath. Breathe in through your nose and visualize the air moving down to your stomach. Breathe out slowly through your mouth. As you breathe in again, silently count to four. Purse your lips as you exhale slowly. This time count silently to eight.Repeat this process six to ten times.

2)Lay on your back on the floor with your feet slightly apart, your hands by your sides, and your palms turned upward. Close your eyes and concentrate on every part of your body.Begin at the top of your head and work your way down to your toes.Start by feeling your forehead tense, then your eyes, face, and jaw. Tense and release each muscle group, such as your shoulders and neck.Pay attention to each area of your body from the top of your head, down through the trunk of your body, along your legs, and ending at the tips of your toes.Stay in this relaxed condition for a few minutes. Concentrate on your breathing and let all worry and stress dissipate from your mind and body. Make sure that your breathing comes from deep in your stomach and flows slowly and evenly.Stretch slowly before standing up.

Healthy sleep habits (sleep hygiene)

• Avoid alcohol, nicotine, caffeine, chocolate– For several hours before bedtime

• Cut down on non-sleeping time in bed– Bed only for sleep and satisfying sex

• Avoid trying to sleep– You can’t make yourself sleep, but you can set the stage for sleep

to occur naturally

• Avoid a visible bedroom clock with a lighted dial– Don’t let yourself repeatedly check the time!– Can turn the clock around or put it under the bed

More healthy sleep habits

• Expose yourself to bright light at the right time– Morning, if you have trouble falling asleep at night– Night, if you want to stay awake longer at night

• Establish a regular sleep schedule– Get up at the same time 7 days a week– Go to bed at the same time each night

• Exercise every day - exercise improves sleep!• Deal with your worries before bedtime

– Plan for the next day before bedtime– Set a worry time earlier in the evening

More healthy sleep habits

• Adjust the bedroom environment– Sleep is better in a cool room, around 65 F.– Darker is better– If you get up during the night to use the bathroom, use

minimum light– Use a white noise machine or a fan to drown out other

sounds– Make sure your bed and pillow are comfortable– If you have a partner who snores, kicks, etc., you may have

to move to another bed (try white noise first)

Farmacotheraphy for sleep disorders

Benzodiazepine

1) Difficult fall asleep, no anxiety during day

Ultra short-acting: Zolpidem 5-10 mg PO nocteLess Dependence, Sedation

Short-acting: Alprazolam: 0,25 mg nocte, up to 2 mg

2) Early weakening:Long acting: Diazepam: 2,5 mg PO nocte, up 5-10 mg .Lowest effective dose for as short a period as possible (maximum 4

weeks) better only when need it

Lower doses are generally advised in children and adolescents.

Contraindications: 1) VALIUM: Pregnancy and Breast feeding, Miastenia gravis, respiratory insufficiency2) ALPRAZOLAM, ZOLPIDEM: Pregnancy and Breast feeding

Somatoform disorders

Somatization Disorder

Conversion Disorder

Pain Disorder

Hypochondriasis

Body Dysmorphic Disorder

“Hysteria”

Dissociative Disorders (Amnesia,Fugue, identity, depersonalization

Histrionic Personality Disorder

Somatoform symptoms

• Symptoms suggest a physical disorder

• Symptoms cannot adequately be explained physiologically

• Symptoms are often (but not always) described in dramatic ways

• Other disorders, such as anxiety disorders, mood disorders, and personality disorders, often co-exist

Pain Disorder

• Main symptom is pain• May be exacerbated by psychosocial factors• May be maintained by gain: Eugene

– Primary gain– Secondary gain

• Theraphy: Psychological TherapyAmitriptiline low dosage: 25 mg nocte

Unconscious conflict?

Somatization Disorder (Briquet’s syndrome)

• Many physical complaints• Beginning before age 30• Must include

– Four different pains– Two gastrointestinal symptoms– One sexual symptom– One pseudoneurological symptom

• Symptoms are unfounded or exaggerated

Conversion Disorder

• Physical symptoms suggesting neurological problems– Sensory impairment: Any modality– Paresthesias and paralysis (demonstrate)

• Sudden onset, sudden termination, sudden reappearance

• Mostly women; men in combat• Often misdiagnosed: Overpathologized• La belle indifference: 1/3 of cases

Sometimes like epilectis convulctions

Hypochondriasis

• No physical symptoms are necessary• Preoccupied with the possibility that normal

sensations are symptoms of serious disease• Frequent visits to physicians• Persists despite medical reassurance• Over-report bodily sensations

Body Dysmorphic Disorder

• Excessive concern with real or imagined defects in appearance, especially facial marks or features.

• Frequent visits to plastic surgeons• Culturally-influenced, but not culture-bound• May be a symptom of more pervasive

disorders: Obsessive-compulsive or delusional disorder, for example.

Utopia lies at the horizon. When I draw nearer by two steps, it retreats two steps. If I proceed ten steps forward, it swiftly slips ten steps ahead. No matter how far I go, I can never reach it. What, then, is the purpose of utopia? It is to cause us to advance.” Eduardo Hughes Galeano

Asante sana for your attention

For any suggestion: jean.84@libero.it 0735525429

http://www.who.int/mental_health/management/psychotropic/en/index.html