Somatic Symptom Disorder in Primary
Care Setting - Part II
Presented by: Ruth Tadesse, MS, RN
Date: 5/21/2015
Disclosures and Learning Objectives
Learning Objectives:
•Review DSM 5 criteria used to diagnose somatic
symptom disorders.
•Identify best practice treatment methods used to
manage somatic symptom disorders.
•Know how to provide patient education to
increase insight about mind-body dichotomy.
Disclosures: Ruth Tadesse has nothing to disclose.
Background: Why should we care?
• One in three people who come to primary care setting
have medically unexplained physical symptoms
(MUPS) that have no clear cause.
• Somatic symptom disorders and MUPS may lead to:
- Functional impairment
- High levels of psychological distress
- Troubled doctor-patient relationship
- Fragmented care
- High utilization and cost of health care
- Reduced quality of life
(Konnopka, 2012).
Differences from DSM IV to DSM 5
(Dimsdale, J. E., et al. 2013)
DSM IV
Somatoform Disorder
-Somatization Disorder
-Undifferentiated
Somatoform Disorder
DSM 5 - Somatic
Symptom Disorder and
related disorders
-Somatic Symptom Disorder
-Illness Anxiety Disorder
-Somatoform Disorder NOS
-Conversion Disorder
-Pain Disorder
-Psychological factors affecting
a medical condition
-Hypochondriasis
-Conversion Disorder
-Psychosocial factors
affecting medical condition
- Factitious Disorder
-Factitious Disorder
-Other specific and nonspecific
somatic symptom disorders
Differences from DSM IV to DSM 5
(Dimsdale, J. E., et al. 2013)
DSM IV
Somatoform Disorder
DSM 5 - Somatic
Symptom Disorder and
related disorders
-Somatization Disorder
-Somatic Symptom Disorder
-Undifferentiated
Somatoform Disorder
-Pain subtype
-Illness Anxiety Disorder
-Somatoform Disorder NOS -Conversion Disorder
-Psychological factors affecting
-Pain Disorder
a medical condition
-Hypochondriasis
-Factitious Disorder
-Conversion Disorder
-Other/unspecific somatic
-Psychosocial factors
symptom disorders
affecting medical condition
-Factitious Disorder
From negative to positive symptoms
- DSM-IV – defines symptoms negatively
– by absence of core features
Medically
unexplained
conditions
- DSM-5 – defines symptoms positively
– by presence of core features
The symptoms may or may not be medically unexplained.
http://www.dsm5.org/documents/somatic%20symptom%20disorder%20fact%20sheet.pdf
Somatic Symptom Disorder Fact Sheet.pdf
DSM 5 Criteria for Somatic Symptom Disorder
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. (5th ed.) Washington, DC: American Psychiatric Association Press. p. 309–27.
MUPS = SAD
Medically
Unexplained
Physical
Symptoms
Kroenke K., (1997; 2003)
Somatization
Anxiety
Depression
Beyond the SAD triad
Medical
Unexplained
Physical
Symptoms
Stressanxietydepression
Somatic Symptom Disorder –
Essential Features
Somatic Symptom Disorder
Essential features – Somatic symptom burden
Illness Anxiety Disorder
Essential features – preoccupation with being ill
Conversion Disorder
Essential features
- functional pattern of sensory-motor symptoms & signs
- Still incompatibility with neurologic disorder
- Not psychological or presumed trauma
Core Features of Somatic Symptom Disorder
- Somatic symptom burden
- Total number of symptoms
-
Continuous number, no threshold
Explained vs unexplained doesn’t matter
- Distress and impairment
- Associated with several adverse outcomes
-
Disability
Increased health care utilization
http://medprofvideos.mayoclinic.org/videos/somatic-symptom-disorders-part-ii-corefeatures-and-treatment
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
Assessing Mental Health in Patients with SSD
using S4 Model (Jackson, et al., 2003)
1. Stress recently (last week) (yes/no)
2. Symptom count (checklist of 15 somatic symptoms;
scored as positive if more than 5 symptoms)
3. Self-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. Self-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
Treatment for Somatic Symptom Disorder
Treatment for Somatic Symptom Disorder
Specific DX=Specific Intervention=Better Outcome
Review of 34 Controlled Trials;
Variable Size and Quality
-** Identifying and diagnosing somatic symptom
disorder makes a difference
- CBT – decreases symptoms and disability
- Antidepressants – TCA/SNRIs - greater than
SSRIs
(Stabb, 2014)
Psychopharmacotherapy of somatic
symptoms disorders (Somashekar, 2012)
Five principal groups of drugs:
- Tricyclic antidepressants (TCA)
- Serotonin reuptake inhibitors (SSRIs)
- Serotonin and noradrenalin reuptake
inhibitors (SNRIs)
- Atypical antipsychotics
- Herbal medication
Case Study – Ms. B
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.
Case Study – Ms. B
•
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?
PHQ-15 - Screening for Somatic Symptom
Presence and Severity
Not
Bothered
Bothered
bothered
at all
(0)
a
little
(1)
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.



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



Chest pain
http://www.phqscreeners.com/instructions/instructions.pdf
http://www.phqscreeners.com/pdfs/04_PHQ-15/English.pdf
Somatic Symptom Scale – 8 [SSS-8]
(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
Summary
•
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.
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental
disorders. 5th 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 (SSS8). A Brief Measure of somatic symptom burden. JAMA Internal Medicine. 174(3): 399407.
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)
References Cont.
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
The End!
Next Week
Topic TBD
05/28/15