Somatic Symptom Disorder

Douglas W. Martin, MD, FAAFP

ACTIVITY DISCLAIMER

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

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1 DISCLOSURE

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Douglas W. Martin, MD, FAAFP

Medical Director, UnityPoint Health–St. Luke’s Occupational Medicine, Sioux City, Iowa

Dr. Martin is a graduate of the University of Nebraska College of Medicine, Omaha, and completed his family medicine residency in Davenport, Iowa. He also completed a mini- residency in occupational medicine at the University of Cincinnati, Ohio. The majority of Dr. Martin’s practice is focused on musculoskeletal-related diagnoses. He has given numerous lectures on occupational medicine topics, with emphasis on upper-extremity repetitive motion injuries, disability medicine, and medical review officer functions. In addition, he has authored book chapters for AMA Guides on causation analysis, return to work, and how to navigate disability systems. Dr. Martin is an international expert on the construct of complex regional pain syndrome and has lectured at the Royal Society of Medicine in London. He is a former president of the Iowa Academy of Family Physicians and the American Academy of Disability Evaluating Physicians (AADEP). A Diplomate of the American Board of Family Medicine (ABFM), he is currently on the board of directors for both the American College of Occupational and Environmental Medicine (ACOEM) and the Interstate Postgraduate Medical Association (IPMA).

2 Learning Objectives

1. Use screening tools like PHQ-15 and Somatic Symptoms Scale-8 initially and then the American Psychiatric Association DSM-5 criteria to diagnose somatoform disorders.

2. Use tools like PHQ-9, 15, and DSM-5 to distinguish somatoform symptom disorder from co-morbid conditions like anxiety and .

3. Refer appropriately for cognitive behavioral therapy and mindfulness-based therapy.

Learning Objectives (Cont.)

4. Evaluate the safety and efficacy of amitriptyline, SSRI’s, and St. John’s Wort MOA inhibitors, bupropion, anticonvulsants, and antipsychotics in treating the symptoms of somatic symptoms disorder.

5. Appraise the efficacy of labs and studies used in differential diagnosis.

6. Recognize behavioral presentation of patients with somatoform symptom disorder and that the symptom complex is reproducible and not fictionalized by individual patients.

3 Audience Engagement System Step 1 Step 2 Step 3

Definitions • Somatic Symptom Disorder is a specific psychiatric diagnosis that is one of many listed under the general heading of “Somatic Symptom and Related Disorders”

4 Do Not Confuse With Other Dx In This General Class:

• Illness • • • (is not a medical condition)

Also Do Not Get Confused with DSM IV

• (Somatoform) Disorder • •

5 Definition of SSD • Somatic symptom disorder is characterized by one or more somatic symptoms that are accompanied by excessive thoughts, feelings, and/or behaviors related to the somatic symptoms • In addition, the symptoms cause significant distress and/or dysfunction. • The somatic symptoms may or may not be explained by a recognized general medical condition.

Epidemiology • 5-7 % of the general population • 20-25% of those will go on to a chronic somatic illness • Occurs in children at roughly the same rate as adults • Several studies suggest it accounts for up to 17% of primary care visits

6 Risk Factors and Predictability

AES Question #1

Which of the following statements is NOT a recognized medical condition?

A.Hypochondriasis B.Malingering C.Illness Anxiety Disorder D.Somatic Symptom Disorder

7 Diagnostic Criteria (DSM 5)

SOMATIC SYMPTOM DISORDER A. One or more somatic symptoms that are distressing or result in significant disruption of daily life. B. Excessive thoughts, feelings, or 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 (typically more than 6 months).

Specify if: With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain. Specify if: Persistent: a persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months). Specify if: Mild: Only one of the symptoms specified in Criterion B is fulfilled. Moderate: Two or more of the symptoms specified in Criterion B are fulfilled. Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

There Is Some Controversy

• DSM 5 revision compared to DSM IV R • Too inclusive ? (overinclusive with false +) • WHO still uses old terminology

8 There Are Some Positives • Focus shift from a diagnosis of exclusion to a BPSE model • Focus shift to primary care

AES Question #2

Which of the following is NOT a DSM 5 consideration for the diagnosis of somatic symptom disorder?

A. One or more somatic symptoms that are distressing B. Persistent high level of anxiety about one’s health C.Symptoms last greater than 3 months D.The determination of mild, moderate, or severe

9 Screening Tools • PHQ-15 – Most commonly used •PHQ-9 • SSS-8 – Probably does the best job

10 A Difficult Differential Dx • Generalized Anxiety Disorder • Major Depressive Disorder • • Chronic Fatigue Syndrome • • ……….and a host of others

Development of

11 CARE MD Approach Strategy

Cognitive Behavioral Therapy

• CBT directs patients to re-examine their health beliefs and expectations, to look at how the sick role affects their symptoms, and to change dysfunctional thoughts (engage in cognitive restructuring). • Behavioral techniques are used to improve role functioning and minimize sick role behaviors; these techniques include response prevention, systematic desensitization, progressive muscle relaxation, and graduated exercise programs. • The use of CBT is limited when patients are unable to rationally discuss their illness perceptions and beliefs, or when patients are wedded to the sick role because of secondary gain (eg, missing work, disability payments, or obtaining prescription drugs).

12 CBT is Useful in Other Arenas

Schröder A, Sharpe M, Fink P. Medically unexplained symptom management. Lancet . 2015 Jul;2(7):587‐8.

13 AES Question #3 Which of the following statements is false regarding the CARE MD approach to SSD? A. Family physicians should limit referrals to specialists B. Schedule short interval regular visits C.Most of the clinical encounter time should be spent listening D.Limit the number of diagnostic tests ordered

Mindfulness Based Cognitive Therapy

• Being aware of the moment • Recognizing behaviors • Instead of trying to “attack and change” them, “develop a new relationship” with them

14 CBT MBCT

Medications • Please note that in the treatment of SSD, non-medication strategies are the most successful. • Medication initiation alone without anything else will almost always fail • Perhaps more important is the taper and discontinuation if ineffective and inappropriate medications

15 Prescription Medications Helpful for SSD (Cochrane / AAFP / UTD) • Amitriptyline – fatigue, functional symptoms, global improvement, morning stiffness, pain, sleep, and tender points • Fluoxetine (and probably escitalopram, duloxetine, venlafaxine, paroxetine) – functional status, global well-being, morning stiffness, pain, sleep, and tender points • SSRI and atypical antipsychotic (paliperidone or quitiapene) – Slightly better outcome than SSRI alone

Big Problem with Study Groups • Substantial drop out rate due to reported medication side effects and intolerances • This should not be surprising given the disorder’ features

16 Medications that Do NOT Work • Monoamine oxidase inhibitors • Buproprion • Anticonvulsants • Antipsychotics alone

Non-Prescription Supplements • St. John’s Wort – More effective than placebo for improvement in self-reported somatic symptoms; well- tolerated and safe

17 AES Question #4

Which of the following medication strategies are incorrect when considering SSD?

A. Atypical antipsychotics can be helpful in some cases B. St. John’s Wort has shown promise C.Continuation of pain medications are recommended D.SSRIs are usually helpful

Practice Pearls • Think of three types of clinical encounters: – Contested Illness – Elusive Illness – Chaotic Illness • Each can be approached a bit differently

18 Contested Illness • When every consultation becomes a battleground • Acknowledge what you can and cannot accept • Focus on the “do no harm” principle

Elusive Illness • Where a significant biomedical diagnosis seems to be ‘just around the corner’ • Focus on what medical tests can and cannot do • Focus on the commonality of the disorder (more common that many of the differential being considered)

19 Chaotic Illness • Where problems ‘go way down to the bottomless depths’ • Acknowledge life is hard and survival is good • Differentiate the physical from the mental as a framework

Prognosis • THIS IS A CHRONIC DISEASE • 50-75% of patients do show improvement • 10-30% deteriorate

20 Favorable Prognostic Indicators • Strong therapeutic alliance with physician • Fewer symptoms at time of diagnosis • Fewer number of medications at time of diagnosis

Evidence Based Practice Change Recommendation SORT Reference

In addition to a comprehensive clinical interview and assessment for diagnostic criteria, the use of screening instruments, such as the Patient Health Questionnaire‐15 or the Somatic Symptom Scale‐8, should be considered in patients with suspected somatic symptom disorder. C 1,2

Cognitive behavior therapy and mindfulness‐based therapy are effective for the treatment of somatic symptom disorder. B 3‐10

Amitriptyline, selective serotonin reuptake inhibitors, and St. John’s Wort are effective pharmacologic treatments for somatic symptom disorder. B 15‐17

Other antidepressants (monoamine oxidase inhibitors, bupropion [Wellbutrin], anticonvulsants, and antipsychotics) are ineffective for the treatment of somatic symptom disorder and should be avoided. B 15

A = consistent, good‐quality patient‐oriented evidence; B = inconsistent or limited‐quality patient‐oriented evidence; C = consensus, disease‐oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

21 Practice Recommendations • These patients are difficult. Do not think you will make and impact in one or two visits • You MAY need to learn to provide CBT in your practice if you elect to treat these patients • Although some medications can be helpful, do not think they will “hit a home run”

Questions

22 Contact Information Douglas W Martin MD FAAFP FACOEM FIAIME 4230 War Eagle Drive Sioux City, IA 51109 712-224-4300 [email protected] @OccDocDMMD

Reference List 1. Gierk B, Kohlmann S, Kroenke K, et al. The Somatic Symptom Scale-8 (SSS-8): a brief measure of somatic symptom burden. JAMA Intern Med. 2014;174(3):399-407.

2. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64(2):258-266.

3. Tyrer P, Cooper S, Salkovskis P, et al. Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet. 2014;383(9913):219-225.

4. Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. 2007;69(9):881-888.

5. Sumathipala A. What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies. Psychosom Med. 2007; 69(9): 889-900.

6. Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom. 2000; 69(4): 205- 215.

7. Lakhan SE, Schofield KL. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One. 2013;8(8):e71834.

8. Segal ZV, Williams JM, Teasdale JD, Kabat-Zinn J. Mindfulness-Based Cognitive Therapy for Depression. 2nd ed. New York, NY: Guilford Press; 2013.

9. Williams JM, Kuyken W. Mindfulness-based cognitive therapy: a promising new approach to preventing depressive relapse. Br J Psychiatry. 2012;200(5):359-360.

10. Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. 2007;69(9):881.

11. Sumathipala A. What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies. Psychosom Med. 2007;69(9):889.

12. Kurlansik SL, Maffei MS. Somatic Symptom Disorder. Am Fam Physician. 2016 Jan 1;93(1):49-54.

13. Stone L. Managing medically unexplained illness in general practice. Aust Fam Physician. 2015 Sep;44(9):624-9.

14. Schröder A, Sharpe M, Fink P. Medically unexplained symptom management. Lancet Psychiatry. 2015 Jul;2(7):587-8.

23 Reference List

15. O’Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract. 1999; 48(12):980-990.

16. Müller T, Mannel M, Murck H, Rahlfs VW. Treatment of somatoform disorders with St. John’s wort: a randomized, double-blind and placebo-controlled trial. Psychosom Med. 2004;66(4):538-547.

17. Volz HP, Murck H, Kasper S, Möller HJ. St John’s wort extract (LI 160) in somatoform disorders: results of a placebo-controlled trial [published correction appears in Psychopharmacology (Berl). 2003;167(3):333]. Psychopharmacology (Berl). 2002;164(3):294-300.

18. van Geelen SM, Rydelius PA, Hagquist C. Somatic symptoms and psychological concerns in a general adolescent population: Exploring the relevance of DSM-5 somatic symptom disorder. J Psychosom Res. 2015 Oct;79(4):251-8.

19. Katz J, Rosenbloom BN, Fashler S. Chronic Pain, , and DSM-5 Somatic Symptom Disorder. Can J Psychiatry. 2015 Apr;60(4):160-7.

20. Lee S, Creed FH, Ma YL, Leung CM. Somatic symptom burden and health anxiety in the population and their correlates. J Psychosom Res. 2015 Jan;78(1):71-6.

21. Mayou R. Is the DSM-5 chapter on somatic symptom disorder any better than DSM-IV somatoform disorder? Br J Psychiatry. 2014 Jun;204(6):418-9.

22. Rief W, Martin A. How to use the new DSM-5 somatic symptom disorder diagnosis in research and practice: a critical evaluation and a proposal for modifications. Annu Rev Clin Psychol. 2014;10:339- 67.

23. Creed FH, Davies I, Jackson J, Littlewood A, Chew-Graham C, Tomenson B, Macfarlane G, Barsky A, Katon W, McBeth J. The epidemiology of multiple somatic symptoms. J Psychosom Res. 2012 Apr;72(4):311-7.

24. Cochrane Review : Medication as a treatment for long-term medically unexplained physical symptoms (somatoform disorders): a review of the evidence @ http://www.cochrane.org/CD010628/DEPRESSN_medication-as-a-treatment-for-long-term-medically-unexplained-physical-symptoms-somatoform-disorders-a-review-of-the-evidence

25. UpToDate: Somatic Symptom Disorder Treatment @ https://www.uptodate.com/contents/somatic-symptom-disorder-treatment?search=somatic%20symptom%20disorder&source=search_result&selectedTitle=1~25&usage_type=default&display_rank=1

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