Somatisation & Somatoform DisordersWhat are they,

What to tell patients and How?Professor George IkkosLiaison Psychiatry ConsultantMRCPsych MRCP

“And, poets, your brain is in your body.”

Mind Body and Psychosomatic ProblemsUseful websites for professionals recommended

by Professor George Ikkos

Mind and BodyA Psychiatric Summary by

Prof George Ikkos and Dr Susie Lingwood

• Depression is a broad and heterogeneous diagnosis

• Central to it is depressed mood and/or loss of pleasure in most activities

• A chronic physical health problem can both cause and exacerbate depression

• Depression can exacerbate the pain and distress associated with physical illnesses and adversely affect outcomes

Background (1)

Basic EmotionsJoseph E. LeDoux, Emotion Memory and the Brain

Scientific American, 2002

• Fear• Panic (and Care)• Rage• Seeking (and

Lust)• Play• (Disgust)• (Joy)

Copyright: Scientific American

Brain, Autonomic Nervous System

Integrative/ Psychosomatic Medicine

Stress, Brain and BodyWilkinson and Pickett, “The Spirit Level”, Allen Lane/ Penguin

Acute Stress

• Brain: acute alertness– Less perception of pain

• Immune tissues:– Readied for possible injury

• Circulatory system:– Heart beats fast and blood vessels

constrict: more oxygen to muscles

• Adrenal glands:– Secrete hormones to mobilise

energy supplies

• Reproductive organs:– reproductive functions

temporarily suppressed

Chronic Stress

• Brain: impaired memory– Increased risk of depression

• Immune tissues:– Deteriorated response

• Circulatory system:– Elevated blood pressure and

higher risk of cardiovascular disease

• Adrenal glands:– High hormone levels and slow

recovery from acute stress

• Reproductive organs:– Higher risk of infertility and

miscarriage

Subcortical Emotion

HypothalamusBasalForebrain

LocusCoeruleus

RapheNucleus

DorsalTegmentalArea

Tectum

HypothalamicNuclei

Septum

Amygdala

Thalamus

S.E.L.F.

InteroceptiveInput

THABody

MapRe-Map

BodyExperienc

e

dACCInteroceptive

Awareness

Emotions/Motor

Responses

AmygdalaHippocampu

s

(23) Insula

Medically Unexplained Symptoms

• http://www.rcpsych.ac.uk/expertadvice/improvingphysicalandmh/medicallyunexplainedsymptoms.aspx

• http://www.rcpsych.ac.uk/expertadvice

Medically Unexplained Symptoms

Mental Disorder Not Mental Disorder

Medically Unexplained Symptoms

Functional Mental Disorders Functional and Dissociative Neurological

Symptoms Functional Somatic Syndromes

• Including Various Pain Syndromes Somatoform Disorders (including Somatoform

Pain)

Clinical Somatisation

Medically Unexplained Symptoms

Organic Physical + Mental Disorders Functional Mental Disorders Functional and Dissociative Neurological

Symptoms Functional Somatic Syndromes

• Including Various Pain Syndromes Somatoform Disorders (including Somatoform

Pain)

Clinical Somatisation

Organic Mental Disorders

Medically Unexplained Symptoms

Mental Disorder Not Mental Disorder

Organic Mental Disorders

Organic Mental Disorders

Iatrogenic conditionsPsychotropic side effects of medicationOther side effects medication

• Which may be misunderstood for somatisation

Functional Mental Disorders www.rcpsych.ac.uk/expertadvice.aspx

Functional Mental Disorders

Medically Unexplained Symptoms

Mental Disorder Not Mental Disorder

Organic Mental Disorders

Functional Mental Disorderswww.rcpsych.ac.uk/expertadvice.aspx

Mood and anxiety disordersSchizophrenia and non-affective psychosesEating, Body Dysmorphic and

Hypochondriacal DisordersAutism Spectrum Disorders!!

Functional and Dissociative Neurological Symptomswww.neurosymptoms.org

Organic Mental DisordersFunctional Mental Disorders

Functional Neurological SymptomsFunctional Dissociative Symptoms

Medically Unexplained Symptoms

Mental Disorder Not Mental Disorder

Functional and Dissociative Neurological Symptoms

www.neurosymptoms.org• This website is about symptoms which are:

– Neurological (such as numbness, blindness and blackouts)

– Real (and not imagined)– But not due to neurological disease

• Symptoms like these are surprisingly common but are difficult for patients and health professionals to understand

• Its like having a software problem rather than a hardware problem

www.neurosymptoms.orgFunctional and dissociative neurological symptoms have been given many different names over the years: e.g.

conversion, hysteria Many of these labels are 'psychiatric' and are based on the

idea that the symptoms are 'all in the mind'. Psychological factors are often important to look at in

relation to functional and dissociative neurological symptoms but the symptoms are not 'made up'.

Most experts believe that these symptoms exist at the interface between the brain and mind, between neurology and psychiatry, which is why it is difficult when people (and patients) ask "is it neurological or psychological?".

The evidence suggests it is both, and that actually this question doesn’t really make sense given what we know about how movement and emotion pathways work in the brain.

www.neurosymptoms.orgDoes anyone make up these symptoms?

The answer to this question is undoubtedly (and unfortunately) yes, but it seems to be rare.

For example, one man was filmed playing football when he said he was in a wheelchair. Another was filmed lifting heavy bins when he said that he couldn’t carry anything. In another case, a man who claimed he was blind and was suing for damages was arrested for speeding on a motorway.

When patients who are malingering like this are examined, they can have some of the same positive signs as patients with functional symptoms but there are important differences. They tend to have very inconsistent stories (because they are making up that too). They don’t have the same kind of stories to patients genuinely experiencing symptoms and there may be a legal case or other obvious reason for the symptoms. (although this does not mean that everyone with a legal case is making up their symptoms)

There are also some people who make up symptoms in order to gain admission to hospital or have an operation. When this happens it is called factitious disorder and by general consensus, its also a rare condition. Its best thought of as a form of behaviour like deliberate self harm.

So, occasionally, people do make up symptoms and it can be difficult to tell. Some doctors (and sometimes patients) make a terrible mistake in thinking that most patients with functional symptoms are ‘making up’ their symptoms or ‘swinging the lead’.

Functional Somatic Syndromeshttp://www.nhs.uk/Conditions

Organic Mental DisordersFunctional Mental Disorders

Functional Neurological SymptomsFunctional Dissociative Symptoms

Functional Somatic SyndromesPain Syndromes

Medically Unexplained Symptoms

Mental Disorder Not Mental Disorder

Functional Somatic Syndromeshttp://www.nhs.uk/Conditions• Atypical Facial Pain• TMJ Pain + Burning

Mouth Syndrome• Migraine• Hyperventilation• Non-cardiac/ atypical

chest pain• Functional Dyspepsia• Irritable Bowel Syndrome• Irritable Bladder• Chronic Pelvic Pain• Multiple Chemical

Sensitivity

• Chronic Fatigue Syndrome• Fibromyalgia• Non-specific lower back

pain• Joint Hypermobility

Syndrome (Ehler-Danlos)

Functional Somatic Syndromes - Different?

The British Journal of Psychiatry (2004) 185: 95-96 Peter White There is a five-fold risk of chronic fatigue syndrome in patients suffering from

infectious mononucleosis (White et al, 1998), whereas there is no evidence that fibromyalgia is caused by infections (Rea et al, 1999).

The risk factor of childhood sexual abuse varies six-fold across different functional somatic syndromes (Romans et al, 2002).

A recent systematic review showed that ‘... psychosocial treatments have not yet been shown to have a lasting and clinically meaningful influence on the physical complaints of polysymptomatic somatisers’ (Allen et al, 2002). A recent large trial of treatment of Gulf War syndrome found no significant differences

between CBT and control treatments (Donta et al, 2003). An accompanying editorial by Hotopf (2003) correctly attributed this lack of efficacy of CBT to not using an illness-specific model for CBT. In contrast, CBT is effective when specifically designed to help improve the physical functioning of patients with chronic fatigue (Whiting et al, 2001).

the concept of a general functional somatic syndrome does not predict prognosis, which varies by specific functional somatic syndrome. Fibromyalgia runs a persistent and chronic course, whereas irritable bowel syndrome runs an intermittent course with recovery being more common.

Functional Somatic Syndromes- Same?Functional Pain Disorders: Time for a Paradigm Shift

Ch 25; E A Mayer and M C Bushnel

• Hypersensitivity to experimental stimuli

• Compromised DNIC• Evidence of structural brain

abnormalities• Evidence of altered neuro-

cognitive function• Evidence of increased activity

in central arousal circuits and sympathetic nervous system

• Evidence of common genetic susceptibility (endophenotypes)

2009

HypothalamusBasalForebrain

LocusCoeruleus

RapheNucleus

DorsalTegmentalArea

Tectum

HypothalamicNuclei

Septum

Amygdala

Thalamus

S.E.L.F.

InteroceptiveInput

THABody

MapRe-Map

BodyExperienc

e

dACCInteroceptive

Awareness

Emotions/Motor

Responses

AmygdalaHippocampu

s

Integration of Interoceptive Information

InteroceptiveInput

THA pINSmIN

SaINS

Interoceptive awareness and emotional responses

Emotions/Motor

Responses

InteroceptiveInput

THA pINSmIN

SaINS

Orbitofrontal PFC

dACCAmygdala

Hippocampus

InteroceptiveAwareness

Body Loops

Insula:Aversive Learning

Cingulate Gyrus:

Limbic Motor Cortex

Attention!!

InteroceptiveExpectation

MIS-MATCH!!!

ICD 10 F45 Somatoform disorders

Organic Mental DisordersFunctional Mental Disorders

Functional Neurological SymptomsFunctional Dissociative Symptoms

Functional Somatic Syndromes

Somatoform DisordersPain Syndromes

Somatoform Pain DisorderMedically Unexplained Symptoms

Mental Disorder Not Mental Disorder

• The main feature is repeated presentation of physical symptoms together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis.

• If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient.

ICD 10 F45 Somatoform disorders

ICD 10 F45.0 Somatization disorder

• A definite diagnosis requires the presence of all of the following:(a) at least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found(b) persistent refusal to accept the advice or reassurance of several doctors that there is no physical explanation for the symptoms(c) some degree of impairment of social and family functioning attributable to the nature of the symptoms and resulting behaviour

ICD10 F45.4 Persistent somatoform pain disorder

http://www.britishpainsociety.org/pub_patient.htm The predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences.

The result is usually a marked increase in support and attention, either personal or medical.

Pain presumed to be of psychogenic origin occurring during the course of depressive disorders or schizophrenia should not be included here.

Psychalgia Psychogenic: · backache · headache

Somatoform pain disorder

Personal Tips on Clinician Behaviour Comprehensive psychosocial assessment; INCLUDE MEANING!

Impeccable consultation skills; DON’T MAKE IT WORSE! Validate Patient Experience

• “Showing courage and resilience”/ “Body can’t keep up with the mind”• “Sensitive body”/ “sensitive body + mind”

• Possible evolutionary advantage!!! Discuss risk of iatrogenic harm

• Analgesic Dependence and abuse• Analgesic exacerbated pain

Use pictures Provide information Refer to websites “RE-ATTRIBUTION”- Target unhelpful cognitions;

• Focus on unnecessary or unhelpful health anxiety ACTIVITY SCHEDULING- with appropriate pacing and encourage fun Follow-up Consider further specific treatment:

• rehabilitation, psychological and psychiatric approaches, including medication

Organic Physical Disorders

Organic Mental DisordersFunctional Mental Disorders

Functional Neurological SymptomsFunctional Dissociative Symptoms

Functional Somatic SyndromesSomatoform Disorders

Pain SyndromesSomatoform Pain Disorder

Medically Unexplained Symptoms

Mental Disorder Not Mental Disorder

Organic Physical + Functional Mental Disorders

Organic Physical + SomatoformMental Disorders

Organic Physical + Mental Disorders

Organic Physical + Medically Unexplained Symptoms