Presented by: Ruth Tadesse, MS, RN
Date: 01/21/2016

• Identify 3 common types of somatization seen in primary care setting
• Know DSM-5 criteria used to diagnose Somatic
Symptom Disorder
• Identify at least 2 assessment tools used to diagnose somatic symptom disorder
• List at least 4 treatment methods used to manage somatic symptom disorder.
Disclosures: Ruth Tadesse has nothing to disclose.

(Dimsdale, J. E., et al. 2013)
Somatoform Disorder Somatic Symptom Disorder
First introduced 30yrs ago in DSM-III as Somatoform Disorder .
Somatoform didn’t translate to another language well.
DSM-IV – concept of medically unexplained symptoms were introduced .
Is it unexplained or unexamined medical condition?
DSM-5 replaced Somatoform Disorder with Somatic Symptom
Disorder and Related Disorders
The symptoms may or may not be medically unexplained. If the patient primarily had anxiety but not somatic complaints, the diagnosis would be Illness Anxiety Disorder.
http://www.dsm5.org/documents/somatic%20symptom%20disorder%20fact%20sheet.pdf
Somatic Symptom Disorder Fact Sheet.pdf

(Dimsdale, J. E., et al. 2013)
DSM-5 Somatic Symptom
DSM-IV
Somatoform Disorder
Disorder and related disorders
Somatization Disorder
Undifferentiated
Somatoform Disorder
Conversion Disorder
Pain Disorder
Hypochondriasis
Body Dysmorphic Disorder
Somatoform Disorder NOS
Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion Disorder
Psychological factors affecting a medical condition
Factitious Disorder
Other specific and nonspecific somatic symptom disorders

Somatic Symptom Disorder vs Illness Anxiety
Disorder
(Croicu, C., et al. 2014)
Approach to the patient with multiple somatic symptoms.pdf

http://emedicine.medscape.com/article/294908-overview

DSM-5 Criteria for Somatic Symptom Disord
A . One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
1) Disproportionate and persistent thoughts about the seriousness of one's symptoms.
2) Persistently high level of anxiety about health or symptoms.
3) Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent - more than 6 months.
American Psychiatric Association ((APA) (2013). Diagnostic and Statistical Manual of Mental
Disorders . (5 th ed.) Washington, DC: American Psychiatric Association Press. p. 309
–27.

Ms. B is a 37-year-old woman who presents to the
ED with abdominal pain. She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple abdominal surgeries, the most recent was for pain felt due to adhesions. These operations have failed to reduce her complaints of pain. Her physical examination, vital signs, and labs, including CBC, urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician for further examination.

• If you are her PCP, what more would you like to know?
• What additional tests/screenings would you like to do?
• What will you include under your differential diagnosis?
• What do you think her full mental status examination would look like?
• What will you prescribe to treat Ms. B’s chronic pain?

Somatic Symptom Disorder - Pathophysiology
Pathophysiology is poorly understood
Associated with a heightened awareness of normal bodily sensations which maybe paired with a cognitive bias to interpret any physical symptom as indicative of medical illness
Some tend to have autonomic arousal
Brain imaging shows reduced volume of amygdala
Comorbidity – depressive disorders, anxiety disorders, substance use, and personality disorders
Somatic complaints epidemiology and psychiatric co-morbidity.pdf
http://emedicine.medscape.com/article/294908-overview#a0104

Somatic Symptom Disorder - Epidemiology
Somatic Symptom Disorder Prevalence
Community sample – 0.1%
Medical chart review show prevalence rate in women as high as 2%
Liberal criteria rates as high as 11.6%
Hypochondriasis in primary care 4-6%
50% of patients presents in primary care with physical symptoms has no diagnosable disease
Female-to-Male ratio is 10:1
Symptoms usually begin in childhood, adolescence or early adulthood
Somatic complaints epidemiology and psychiatric co-morbidity.pdf
http://emedicine.medscape.com/article/294908-overview#a0199

(Croicu, C., et al. 2014)
1.
Acute somatization
Temporary phase of physical symptoms associated with transient stressors
2 . Relapsing somatization
Repeated episodes of physical symptoms associated with repetitive stressors & anxiety or depressive episodes
3 . Chronic somatization
Nearly continuous somatic focus, perception of ill health, development of disability
Approach to the patient with multiple somatic symptoms.pdf

Assessing for Somatic Symptom Disorder Using the 3-Ps
(Croicu C, et al. 2014)
Predisposing
Chronic childhood illnesses, childhood adversities, comorbid medical illness, lifetime psychiatric diagnosis, poor coping ability
Precipitating
Medical illness, psychiatric disorder, social & occupation stress, and changes in social support
Perpetuating
Chronic stressors, maladaptive coping skills, negative health habits, and disability payments
Approach to the patient with multiple somatic symptoms.pdf

Assessing Mental Health in Patients with SSD using S4 Model
(Jackson, et al., 2003)
1.
S tress recently (last week) (yes/no)
2.
S ymptom count (checklist of 15 somatic symptoms; scored as positive if more than 5 symptoms)
3.
S elf-rated overall health poor or fair on a 5-point-scale
(excellent, very good, good, fair, poor); scored as positive for fair or poor responses.)
4.
S elf-rated severity of symptoms from 0 (none at all) to
10 (unbearable) scale, scored as positive for responses greater than 5
Clinical predictors of mental disorders among medical outpatients.pdf
Validation of the S4 Model.pdf

Identifying Somatic Symptom Disorder
(Croicu C, et al. 2014)
• Do a thorough history and detailed physical assessment
• Rule out medical illness
• Consider medication side effects
• Identify ability to meet basic needs
• Identify secondary gains
• Identify ability to communicate emotional needs
• Determine substance use
• Build therapeutic alliance with the patient
• Use screening tools appropriate for somatic symptom disorder: SSS-8 and PHQ-15
Approach to the patient with multiple somatic symptoms.pdf

B : Background - What is going on in your life? And What brings you in here today?
A : Affect – How do you feel about that?
T : Trouble – What bothers you the most about this situation?
H : Handling - How are you handling that?
E : Empathy – That must be very difficult for you.
The BATHE Method.pdf
Approach to the patient with multiple somatic symptoms.pdf

Not bothered at all
(0)

Bothered a little
(1)

Bothered a lot
(2)
 a.
Stomach pain
   b.
Back pain
   c.
Pain in your arms, legs, or joints (knees, hips, etc.) d.
Menstrual cramps or other problems with your periods
WOMEN ONLY e.
Headaches






   f.
Chest pain
   g.
Dizziness
   h.
Fainting spells
   i.
Feeling your heart pound or race
   j.
Shortness of breath
   k.
Pain or problems during sexual intercourse
   l.
Constipation, loose bowels, or diarrhea
   m.
Nausea, gas, or indigestion
   n.
Feeling tired or having low energy
   o.
Trouble sleeping http://www.phqscreeners.com/instructions/instructions.pdf
http://www.phqscreeners.com/pdfs/04_PHQ-15/English.pdf

(Table is hyperlinked)

Essential Treatment Approaches for Patients with Somatic Symptom Disorder
(Croicu, C., et al. 2014)
• Schedule time-limited regular appointments (e.g. 4-6 weeks) to address complaints
• Explain that although there may not be a reason for their symptoms, you will work together to improve their functioning as much as possible
• Educate patients how psychosocial stressors and symptoms interact
• Avoid comments like “Your symptoms are all psychological.” or “There is nothing wrong with you medically.”
Approach to the patient with multiple somatic symptoms.pdf

Essential Treatment Approaches for Patients with Somatic Symptom Disorder
(Croicu, C., et al. 2014)
• Avoid the temptation to order unnecessary, repetitive, or invasive investigations
• Educate the patient on how to cope with their symptoms instead of focusing on a cure
• Evaluate somatic symptom burden
• Collaborate with the patient in setting treatment goals
• Screen for common psychiatric conditions associated with somatic complaints such as depression and anxiety
• Treat identified comorbid psychiatric disorders
Approach to the patient with multiple somatic symptoms.pdf

Essential Treatment Approaches for Patients with Somatic Symptom Disorder
(Croicu, C., et al. 2014)
• Case management to minimize economic impact
• Medications to treat anxiety and depression
(SSRIs, SNRIs)
• Short term use of anxiety meds (dependence is a risk)
• Non-pharmacological treatments
• * CBT – Shows promising evidence
• Psychodynamic therapy
• Integrative therapy
Approach to the patient with multiple somatic symptoms.pdf

• Scheduling a regular visit with the patient reduces or eliminates unnecessary ED visits.
• Identifying risks such as childhood trauma can suggest screening for somatic symptom disorders using appropriate assessment tools (PHQ-15 & SSS-8).
• Identifying, screening for and treating common psychiatric comorbidities such as depression (PHQ-9) and anxiety
(GAD-7) can decrease somatic symptom burden.
• Non-pharmacological interventions such as CBT has shown evidence in decreasing somatic symptom disorder.
• Therapeutic alliance with the patient with somatic complaints improves outcomes.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. 5 th edition. American Psychiatric Association Press.
Croicu, C., Chwastiak, L., & Katon, W. (2014). Approach to the patient with multiple somatic symptoms. Medical Clinics of North America . 98 (5): 1079-1095.
Dimsdale, J. E., Creed F., Escobar, J., …Levenson, J. (2013). Somatic symptom disorder: An important change in DSM. Journal of Pscyhosomatic Research . 75(3): 223-228.
DSM V Somatic Symptom Disorder Fact Sheet available online http://www.dsm5.org/documents/somatic%20symptom%20disorder%20fact%20sheet.pdf
Glerk,B., Kohlmann,S., Kroenke, K., …Lowe, B. (2014). The Somatic Symptom Scale-8 (SSS-
8). A Brief Measure of somatic symptom burden. JAMA Internal Medicine. 174 (3): 399-
407.
Gierk, B., Kohlmann, S., Toussaint, A. …Lowe, B. (2014). Assessing somatic symptom burden. A psychometric comparison of the Patient Health Questionnaire – 15 (PHQ-15) and the Somatic Symptom Scale- 8(SSS-8)

Jackson, J.L., O’Malley, P., & Kroenke, K. (1998). Clinical Predictors of Mental Disorders
Among Medical Outpatients: Validation of the S4 Model. The Journal of Consultation and Liaison Psychiatry. 39( 5): 431 –436.
Kroenke K., (2003). Patients presenting with somatic complaints epidemiology, psychiatric comorbidity and management . International journal of methods in psychiatric research .
12 (1): 34-43
Kroenke, K., Jackson, J.L., & Chamberlin, J. (1997). Depressive and anxiety disorders in patients presenting with physical complaints. The American Journal of Medicine.
103( 5): 339 –347.
Martin, A., Rauh, E., Fichter, M., & Rief, W. (2007). A One-session treatment for patients suffering from medically unexplained symptoms in primary care: A randomized clinical trial. Psychosomatics . 48(4): 294-303.
Ravesteign, H., Wittkampf, K., Lucassen, P., …,Weel, C. (2009). Detecting somatoform disorders in primary care with the PHQ-15. Annals of Family Medicine . 7: 232-238.
Van Dessel, N., den Boeft, van der Wouden, J.C. …van Marwijk, H. (2014). Nonpharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane Database Systematic
Review .11(1): Vol.11, p.CD011142-CD011142

Next Week Topic:
Personality Disorders in the Primary Care
Setting