Functional Somatic Syndromes

Chris Stewart-Patterson MD

Program DirectorHarvard Medical School

No disclosures

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

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

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

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)

“Can you check to see if I have

hemosiderin laden macrophages?”

Don’t miss pathology!

Somatoform Tool Box!

• Approach• Interview• Focus on

function• Screening tools• Communication• Treatment review

A Very Brief History of Somatization &

Somatic Syndromes…

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

1990 ACR FMS CriteriaWolfe, 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

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

FMS Literature Trends1997-2003

• “…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

FMS Literature Trends2009

“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

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

Somatic Symptoms ScaleMuscle 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

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”

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

Neuronal correlates of symptom formation in FSS: An fMRI study

• NeuroImage Volume 41, Issue 4, 15 July 2008

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

Barsky’s 6-Step Approach

1. Search for a medical disorder2. Search for psychiatric disorder3. Collaborative therapeutic alliance4. Restoration of Fx is goal of Tx 5. Provide limited reassurance6. Cognitive Behavioral Therapy if no response

to steps 1-5Barsky, Borus 1999 Ann Int Med 130; 11

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

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.)

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

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?

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

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)

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

Focus on Function!

Functional Assessment• Stated activity tolerances• Current roles• House and yard chores • Hobbies and recreational

activities• Functional physical examination

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

Physical Examination

• Full physical exam• Functional physical exam

–Sit, arise, stand, walk, bend, squat…

–Look for evidence of impairment• MSE: depressed or anxious

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

PHQ-15 QuestionnairePHQ-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

Disability Days in Last 3 months

• (Kroenke J Clin Psychiatry 2003;5[suppl 7]: 11–18)

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

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

Provide Limited Reassurance1. Hurt vs harm2. 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.”

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

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

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

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

Poor Response to Tx? • Illness beliefs & misinformation• Poor integration in treatment• Personality disorders• Opioid or other SUD• Workplace or interpersonal

conflict• Compensation seeking behavior

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

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)

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)

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)

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

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

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

Summary1. Search for a medical disorder2. Search for psychiatric disorder3. Therapeutic alliance4. Restoration of Fx is goal of Tx 5. Provide limited reassurance6. CBT if no response to steps 1-5