Inova Health System IDEAS: Inova Digital e-ArchiveS Psychiatry Articles Psychiatry 2-2007 Resistant Somatoform Symptoms: Try CBT and Antidepressants. Preferred Strategy for ‘Mismatched’ Category of Illnesses. Michael J. Marcangelo MD Thomas N. Wise MD Inova Health System, [email protected] Follow this and additional works at: http://www.inovaideas.org/psychiatry_articles Part of the Psychiatry and Psychology Commons Recommended Citation Marcangelo, M.J. & Wise, T.N. (2007). Resistant somatoform symptoms: Try CBT and antidepressants. Preferred strategy for ‘mismatched’ category of illnesses. Current Psychiatry, 6(2), 101-115. This Article is brought to you for free and open access by the Psychiatry at IDEAS: Inova Digital e-ArchiveS. It has been accepted for inclusion in Psychiatry Articles by an authorized administrator of IDEAS: Inova Digital e-ArchiveS. For more information, please contact [email protected]. CP_0207_Marcangelo.FinalREV 1/21/07 3:15 PM Page 101 Resistant somatoform symptoms: Try CBT and antidepressants Preferred strategy for ‘mismatched’ category of illnesses Michael J. Marcangelo, MD Fellow in psychosomatic medicine Department of psychiatry ® Dowden Health Media INOVA Fairfax Hospital, Falls Church, VA George Washington University Washington, DC CopyrightFor personal use only Thomas Wise, MD Chairman, department of psychiatry INOVA Fairfax Hospital, Falls Church, VA Professor, department of psychiatry Johns Hopkins University Baltimore, MD reatment-resistant somatoform disorders T are chronic (duration >1 year), can cause significant functional impairment, and respond poorly to routine care. In the somatoform category, DSM-IV-TR in- cludes diverse diagnoses such as conversion disor- der, hypochondriasis, pain disorder, and body dys- morphic disorder. But like mismatched shoes, these disorders do not fit together well—one rea- son they are often misdiagnosed and ineffectively treated. This article describes: • debate about how to categorize somatoform disorders—as psychological or physiologic • evidence supporting psychotherapy and anti- depressants to help patients with treatment- resistant somatoform disorders. © 2007 IMAGE100/CORBIS continued VOL. 6, NO. 2 / FEBRUARY 2007 101 For mass reproduction, content licensing and permissions contact Dowden Health Media. CP_0207_Marcangelo.FinalREV 1/21/07 3:15 PM Page 102 Somatoform disorders Box 1 Somatoform disorders: Interacting psychiatric and biologic processes Psychobiologic causes of somatoform disorders conditions such as posttraumatic stress disorder are poorly understood. In a recent review, Rief —but other studies have found normal or even and Barsky1 emphasized that somatoform elevated cortisol. Although a relationship symptoms such as abdominal pain, headaches, between the HPA axis and somatoform disorders or dizziness “are not strictly mental events, but is likely, its nature remains unclear or may be are associated with a diversity of biological indirect. processes.” They propose that the following factors Serotonin is known to alter pain perception might contribute to somatoform disorders. in major depressive disorder, so this Autonomic physiologic arousal may lead neurotransmitter also probably plays a role patients to misperceive the meaning of normal in somatoform disorders. Low serotonin— bodily symptoms, but most studies have been mediated in part by alterations in branched- equivocal or correlate closely with changes in chain amino acid concentration—may be linked the cardiovascular system. For example, patients to increased pain perception. with somatoform spectrum disorders who Perception and filtering of body signals. A performed mentally distressing tasks did not signal-filtering model of somatoform symptoms have the same decrease in heart rate after proposes that physical sensations enter completing the task as normal controls did, consciousness influenced by numerous factors. suggesting a deficit in autonomic reactivity. These signals are then sent to a filter system, Hypothalamic-pituitary-adrenal (HPA) axis which itself is subject to factors that may studies also have been equivocal. Some have decrease its activity. Cortical perception found low cortisol in patients with somatoform of distress may occur and symptoms begin disorders—suggesting commonalities with to manifest if enough factors come into play. WHICH CATEGORY? numerous problems that complicate diagnosis Somatoform disorders are common in primary care. and treatment (Box 2, page 107). A medical utilization survey of 1,500 primary care Psychosomatic diad. Despite DSM-IV’s claims to patients found somatization symptoms in >20%.3 etiologic neutrality, the origin of somatoform disor- Controlling for comorbid psychiatric or medical ders’ physical symptoms clearly is meant to be psy- illness did not change the study’s findings, which chological. As Lipowski4 said, somatization is “a suggests that somatization is a distinct entity and tendency to experience and express somatic distress not a symptom of another underlying disorder. and symptoms unaccounted for by pathological Little is known about somatoform disorders’ findings, to attribute them to physical illness, and pathophysiology (Box 1),1 but their unifying theme to seek medical help for them. It is often assumed is that psychological factors contribute to, amplify, that somatization becomes manifest in response to or alter the presentation of physical illness. Not psychosocial stress brought about by life events that only do these disorders not form a coherent DSM are personally stressful to the individual.” category, but—as described by Mayou et al2— Kroenke and others,5,6 however, have pointed the lack of clearly defined thresholds between out 2 shortcomings of this definition: normal and pathologic behaviors is one of • the difficulty in knowing when a physical continued on page 107 102 VOL. 6, NO. 2 / FEBRUARY 2007 CP_0207_Marcangelo.FinalREV 1/21/07 3:15 PM Page 107 continued from page 102 symptom truly is unexplained, especially Box 2 5 in patients with comorbid medical illness Problems with DSM categorization • the instability of somatoform diagnoses of somatoform disorders (in a cohort examined with the same questionnaire 12 months apart, 43% of • Somatoform disorders lack clearly defined “lifetime somatic symptoms” patients thresholds that establish a difference between reported at the first screening were not normal and pathologic behaviors reported at the second).6 • Somatoform disorders do not form a coherent Kroenke5 suggests using “physical symp- category, and exclusion criteria are ambiguous tom disorder” as an etiologic-neutral descrip- • By existing, the category suggests that some tor of unexplained physical symptoms. He disorders are physical and others are mental, would place this category on Axis III and shift leaving little room for intermediate or mixed the causal emphasis from psychological to conditions unexplained. This category would replace som- • Patients reject the term “somatoform” atization disorder, undifferentiated somato- because it conveys doubt about the reality form disorder, and pain disorder in DSM. of their conditions Similarly, Mayou et al2 contend that • Somatoform disorders are incompatible with because most patients with somatoform disor- some cultures’ views of mental illness (for example, the DSM translation used in China ders are treated by primary care physicians, does not include the somatoform category) having their disorders understood as psychi- • Nonspecific somatoform illness subcategories atric does not serve them well. cannot achieve established reliability standards Psychiatric component. Conversely, patients in studies examining diagnoses with somatization disorder often have psycho- • Medical-legal cases and insurance entitlements logical symptoms, and many have personality are complicated by unclear descriptions disorders. The number of somatic symptoms of somatoform disorders with unexplained cause may be a normally dis- Source: Reference 2 tributed trait, with somatization disorders at the extreme end of the spectrum. Thus: • Hypochondriasis could be reconsidered as this diagnostic category. Tyrer8 reviewed his clini- health anxiety disorder because it features cal experience and reported shifting from a view anxiety about potential illness.2 that people with excessive pain had a psychiatric • Conversion disorders might be regrouped disorder to the view that living with chronic pain with other disorders focused on dissociation.2 produces a profile similar to that of a person with a • Body dysmorphic disorder might be re- psychiatric disorder. grouped with obsessive-compulsive disorder.7 Physiologic component. Others recommend caution These changes would shift focus away from before radically altering DSM’s categorizations. the disorders’ physiologic presentations, empha- Rather than shift symptoms to Axis III—as size the psychiatric disorders to which they likely Kroenke suggests—Starcevic9 would use unex- are related, and provide insight into treatments plained physical symptoms as an organizing prin- and clinical investigations. ciple and group disorders with common features, Pain disorder could be removed from DSM such as somatization disorder, conversion disorder, because of persistent concerns about the validity of pain disorder, and undifferentiated somatoform VOL. 6, NO. 2 / FEBRUARY 2007 107 CP_0207_Marcangelo.FinalREV 1/21/07 3:15 PM Page 108 Somatoform disorders Box 3 Consultation letters. Sending a consultation letter to Treatment