Module: Health Psychology Lecture: Chronic illness and somatisation Date: 16 March 2009 Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick Tel: +44(24) 761 50222 Email: [email protected]www.warwick.ac.uk/go/hpsych
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Module: Health Psychology Lecture:Chronic illness and somatisation Date:16 March 2009 Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick.
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Module: Health Psychology
Lecture: Chronic illness and somatisation
Date: 16 March 2009
Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick
Medical Specialties and TheirPatients with Problems
Specialty Problem / Symptom
Orthopedics - Low back pain
Obs/Gyn - Pelvic pain, PMS
ENT - Tinnitus
Neurology - Dizziness, headache
Cardiology - Atypical chest pain
Pulmonary - Hyperventilation, dyspnea
Rheumatology - Fibromyalgia
Internal Medicine - Chronic Fatigue Syndrome
Gastroenterology - Irritable Bowel Syndrome
Rehabilitation - Closed head injury
Endocrinology - Hypoglycemia
Patients with a wide range of somatoform symptoms are
encountered not only in primary care, but throughout
the specialities also
Characteristics of Somatoform Disorders
A class of disorder defined by
presence of physical symptoms that are not fully explained by the presence of a medical condition;
symptoms cause clinically significant distress and impairment;
psychological factors judged important in symptom onset, severity, and/or maintenance;
symptoms are chronic, independent of one another and not intentionally produced.
Somatoform Disorders
Somatisation disorder (Briquet's syndrome): A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought
Conversion disorder (conversion hysteria): Symptoms or deficits affecting voluntary motor or sensory function
Hypochondriacal disorder (hypochondriasis): Preoccupation with fears of developing or having a serious disease, based on (mis)interpretation of bodily symptoms, which persist despite medical reassurance
Somatoform pain disorder (psychogenic pain): Disabling pain of sufficient severity to cause treatment being sought
Body dysmorphic disorder (dysmorphophobia): Preoccupation with an imagined defect in appearance, or if real / present, concern is markedly excessive
Somatisation Disorder
Description: A history of many physical complaints beginning before age 30 years that occur over a period of several years and results in treatment being sought or significant impairment in social, occupational or other areas of functioning
Epidemiology: 10 X> females, familial pattern for 10-20% of 1st degree female relatives;
Course: Chronic, fluctuating and rarely remits. Diagnostic criteria usually met before age 25 yrs.
Cues: Symptom onset / progression following loss; symptom amplification with stress
Other features: Complicated medical history; numerous (12+) somatic complaints; Dr shopping
Date (Age)
Symptoms(life event)
Referral Investigation Outcome
1990 (21)
Abdominal painGP to surgical
outpatientsAppendicectomy Normal
1992 (23)
Nausea(boyfriend in prison)
GP to Obs/Gyn outpatient
PregnantTermination of
pregnancy
1994 (25)
Bloating, abdominal pain, (divorce)
GP to gastro outpatient
All testsnormal
IBS diagnosis; treat with Fybogel
1995 (26)
Pelvic pain(wants sterilisation)
GP to O&G outpatient
SterilisedPelvic pain for 2yrs
post-surgery
1997 (28)
Fatigue (dissatisfied at work)
GP to infectious disease clinic
Alltests normal
Self-diagnosed ME, joins self-help group
1998 (29)
Aching,painful muscles
GP torheumatology clinic
Mild cervical spondylosis
Tryptizol 50 mg,pain clinic referral
1999 (30)
Chest pain(lost job)
A&E tochest clinic
Normal; probable hyperventilation
Refer topsychiatric services
Somatisation Disorder: A 10-Year Example
Conversion Disorder
Description: Symptoms or deficits affecting voluntary motor or sensory function
Epidemiology: Rare condition; acute onset in adolescence or early adulthood; twice as prevalent in females; more common in rural populations and lower SES
Course: Recurrent symptoms with short duration
Cues: Traumatic events; stress; inability to cope
Other features: high suggestibility; prone to seizures and convulsions; unaware of retained functions
Samuel Pepys recorded conversion disorder after the Great Fire of London in 1666
Hypochondriacal Disorder
Description: Preoccupation with fears of developing or having a serious disease based on (mis)interpretation of bodily symptoms, which persists despite medical reassurance
Epidemiology: About 3% and 5% prevalence among general population and primary care outpatients, respectively
Course: Onset at any age, but typically early adulthood; familial deaths and illness; media
Cues: Heightened awareness of physical self; symptom amplification when stressed
Other features: Dr Shopping; background expertise
Somatoform Pain Disorder
Description: Pain of sufficient severity to cause clinically significant distress or impairment and treatment being sought
Epidemiology: Precise prevalence unknown but likely to be fairly common; small female bias possible; variable onset age
Course: Chronic, fluctuating and rarely remits
Cues: Often develops from illness or accidental injury; symptom amplification when exposed to illness, accident cues and stress
Other features: Dr shopping (often precipitated by maximum dose); risk for multiple registrations; pharmacologically informed; initiated and discontinued various CAM formulations
Body Dysmorphic Disorder (BDD)
Description: Preoccupation with an imagined defect in appearance, or if present, concern is markedly excessive
Epidemiology: Prevalence unknown in general population; 10-30% in mental health settings
Course: Onset early adulthood; increasingly distressing; potential for suicidal ideation
Cues: Unclear; possible sensitivity / bias to facial feature priming
Other features: Typically remain single; examined potential for plastic surgery
BDD?
What causes somatisation, and when?
What?
Aetiology is poorly understood, but biological, psychological and social factors are (likely to be) involved
Biopsychosocial contribution will vary between people and across somatoform disorders - size and interaction
Clinician factors may contribute to somatisation, i.e. iatrogenic harm
When?
Predisposing factors increase the chance that particular symptoms may develop and/or become important