Management of Somatoform Pain Disorders and Chronic Pain Management PDF

Management of Somatic Symptom and Related Disorders  Introduction Everyone experiences somatic symptoms, and most can cope with them effectively. However, some people’s lives are overwhelmed by their somatic concerns. Sometimes the somatic concerns stem from well-...

Management of Somatic Symptom and Related Disorders  Introduction Everyone experiences somatic symptoms, and most can cope with them effectively. However, some people’s lives are overwhelmed by their somatic concerns. Sometimes the somatic concerns stem from well- established major medical illnesses; sometimes, the origins of the concerns are never quite clear. What is common in both situations are the pervasive and overwhelming thoughts and behaviors centered on these sensations.  Somatic Symptom Disorder Patients believe that they have some severe yet undetected disease, and evidence to the contrary does not persuade them otherwise. They may maintain a belief that they have a particular disease or, over time, may transfer their belief to another disease. They are fixated on one or more somatic symptoms that they are convinced are evidence of illness. Often experience symptoms of depression and anxiety, in addition to their somatic symptoms.  Illness Anxiety Disorder Patients with illness anxiety disorder, like those with somatic symptom disorder, believe they have a serious but undiagnosed disease despite evidence to the contrary. They may maintain a belief that they have a particular disease or, as time progresses, they may transfer their belief to another disease. Their convictions persist despite negative laboratory results, the benign course of the alleged disease over time, and appropriate reassurances from physicians. Their preoccupation with illness interferes with their interaction with family, friends, and coworkers. They are often addicted to internet searches about their feared illness, inferring the worst from information (or misinformation) they find there. Unlike somatic symptom disorder, however, these individuals do not have significant physical symptoms. Sometimes people with this disorder develop a fear of going to medical appointments, while other times, they seek excessive reassurance about their health from medical providers. Conversion Disorder (Functional Neurologic Symptom Disorder) Conversion Disorder (Functional Neurologic Symptom Disorder) Persons with conversion disorder (also called functional neurologic symptom disorder) present with what appears to be a neurologic condition. The symptoms may be motor or sensory but are incompatible with known neurologic conditions. Often the illness is preceded by conflicts or other stressors and may seem to be associated with apparent psychological factors. Individuals with conversion disorder do not intentionally produce these symptoms or deficits. Conversion motor symptoms mimic syndromes such as paralysis, ataxia, dysphagia, or seizure disorder (nonepileptic seizures [NESs]), and the sensory symptoms mimic neurologic deficits such as blindness, deafness, or anesthesia. There can also be disturbances of consciousness (e.g., amnesia, fainting spells).  Psychological Factors Affecting Other Medical Conditions Patients with this disorder have physical disorders caused by or adversely affected by emotional or psychological factors. A medical condition must always be present to make the diagnosis. Common clinical examples include denial and refusal of treatment for an acute condition (such as myocardial infarct or abdominal emergencies) by individuals with certain personality styles (e.g., domineering or controlling), the exacerbation of asthma or irritable bowel attacks by anxiety, and the manipulation of insulin by an individual with diabetes, or diuretics in the case of hypertensive patients, in efforts to lose weight.  Factitious Disorder Patients with factitious disorder feign, misrepresent, simulate, cause, induce, or aggravate illness to receive medical attention, regardless of whether or not they are ill. Thus, they may inflict painful, deforming, or even lifethreatening injuries on themselves, their children, or other dependents. The primary motivation is not the avoidance of duties, financial gain, or anything concrete. The motivation is simply to receive medical care and to partake in the medical system. Factitious disorders can lead to significant morbidity or even mortality. Therefore, even the patients falsify their presenting complaints, health professionals must take the medical and psychiatric needs of these patients seriously, as their self-induced symptoms can result in significant harm or even death. Historically this disorder was called “Munchausen syndrome,” a reference to the Baron Munchausen, legendary for his outrageously exaggerated stories of his military career.  Management of somatoform pain disorders and chronic pain management  Introduction Somatization is among the most puzzling phenomena that healthcare workers encounter. In somatization physical symptoms occur in the absence of any identifiable causal mechanism. There appears to be a universal tendency to experience and communicate psychological distress in the form of physical symptoms and to seek medical attention for these symptoms. Often, these physical symptoms remain poorly explained and are associated with increased medical visits, unnecessary medical tests, and the performance of procedures that may result in iatrogenic complications.  Overview Presence of one or more persistent somatic symptoms that are associated with excessive thoughts, feelings, and behaviors related to the symptoms. Physical symptoms with uncertain etiologies are some of the most common presentations in primary care ( As many as 25%) Patients presenting with medically unexplained physical symptoms provide significant challenges to health care providers. These patients tend to overuse health care services, derive little benefit from treatment, and experience protracted impairment, often lasting many years. Often, patients with somatoform symptoms are dissatisfied with the medical services they receive and repeatedly change physicians.  Overview Physicians of these treatment-resistant patients often feel frustrated by patients’ frequent complaints and dissatisfaction with treatment. CBT has been the most widely studied alternative treatment for these disorders. Medically unexplained physical symptoms (MUPS). DSM-5 includes the following disorders: Somatic symptom disorder Illness anxiety disorder Conversion disorder(functional neurological symptom disorder) Psychological factors affecting another medical condition Factitious disorder Somatic syndromes that are below-threshold are classified under two residual categories, “other specified” and “unspecified somatic symptom and related disorders.  Deborah and her multiple somatic symptoms Deborah is a 24-year-old student. She reports multiple, fluctuating physical symptoms that have persisted over the last 2 years. She predominantly experiences breathlessness. It feels like a “resistance” in her throat or as if her “larynx is too tight,” and is accompanied by a sensation of pressure in her left chest. Moreover she reports that the breathing and chest complaints are accompanied by nausea and vomiting. Her symptoms partly appear spontaneously and partly after physical exercise and persist between 30 min and several hours. She experienced them for the first time 2 years ago, after she had excessively drunken alcohol. Two months later, symptoms appeared again. During several appointments with orthopedist, cardiologist, or neurologist, she received contradictory information about options to treat her symptoms. None of the specialists could identify a medical explanation and none of the prescribed interventions (taking a beta- blocker or physical therapy) was successful.  Deborah and her multiple somatic symptoms During her appointment with the clinical psychologist, she additionally complains about symptoms such as frequent yawning without being tired, muscle weakness, frequent burping, and a feeling of pressure in the right half of her head. She describes herself as a very active and achievement-oriented student. However, these physical symptoms let her feel weak and less resilient. She avoids more and more physical activity, even everyday life activities such as walking stairs or going by bike to the university. She also reduces her social activities. She says at the end of this appointment that she felt very comfortable and taken seriously. However, she would be still skeptical about how a psychologist could help her. Moreover, she does not know why her GP referred her to a psychologist. She has somatic symptoms but no mental problems!  Targets of CBT for somatoform disorders and pain Attention bias toward somatic stimuli: vicious cycle of attention bias and symptom-intensifying effects of attention focusing Individuals with an increased risk of developing somatoform disorders bear a high vigilance toward bodily changes and tend to experience quickly negative cognitions and emotions in regard to the physical symptoms. They focus their attention more intensively on bodily complaints, which are amplified in turn. Deborah focuses her attention strongly on her body. Even after slight physical exercise, she observes her body thoroughly and often experiences breathlessness. The more she pays attention to this somatic symptom the worse it becomes. Then she withdraws to a quiet place and continues observing her symptoms.  Dysfunctional cognitions Symptom-related catastrophizing thoughts and misjudgments of the risk of having a severe somatic disorder. Illness worries Cognitions related to the body image play a significant etiological role. Deborah, obtains catastrophizing cognitions about her breathlessness and her perceptions of a “resistance in her throat.” She often thinks about suffering from a severe cardiovascular disease or larynx cancer. She is able to reassure herself that there is no medical evidence, and she can accept alternative explanations of her symptoms (bad physical shape, persistently high workload at university). However, when her symptoms get worse, she cannot control her worries. She has never been very sporty. She now regrets that she has never exercised more frequently. Her body image has never been very positive. Now it even deteriorates. She feels weak and vulnerable. She loses trust in the functions of her body and experiences somatic symptoms as dominating. Negative affectivity Illness behaviors (Weiss et al., 2016) such as extensive health care utilization and reassurance behaviors (need for physicians’ confirmation that somatic symptoms are not caused by severe medical illness), avoidance behaviors (avoiding physical exercise), and body scanning (checking the stool for blood associated with the worry to have intestinal cancer). Health care utilization (“doctor shopping”) can result in negative consequences for the doctor patient relationship (Murray et al., 2016). A systematic review about challenges in the somatizing patient GP relationship showed, that practitioners frequently experience caring for patients with MUPS as burden, distressing, frustrating, and difficult (Murray et al., 2016). Somatoform patients in turn fear social stigma of being “mentally disordered” and do not feel taken seriously (Murray et al., 2016).  CBT FOR SOMATOFORM DISORDERS AND PAIN: BASIC THERAPEUTIC TOOLS  Establishing Working Alliance and Therapy Compliance During these medical appointments, potential psychosocial causes of somatic complaints are usually not or not sufficiently discussed with patients (Ring et al. 2004). In consequence, many patients with MUPS have difficulties in understanding why psychological interventions could be helpful for them. Unrealistic hopes (“You and this therapy are my last hope.”) Cognitions that bring a lot of pressure on the therapist and degrades other patients’ previous clinicians (“You are the only one who can help me... all previous doctors I saw couldn’t help me anyway.”) Resigning thoughts (“It’s hopeless, nothing helps.”), or rejecting cognitions (“I don’t know how a psychologist can help me. I feel sick, but not crazy.”).  Establishing Working Alliance and Therapy Compliance Important to establish realistic, specifically worded, and operationalized goals that do not only focus on somatic symptoms but also on other areas of problems in the patients’ life (“I want to start cycling again” in contrast to “First my somatic symptoms have to remit completely before I can start doing sports again.”). Developing realistic expectations and validating and extending patients’ illness beliefs are important steps for establishing a trustful working alliance between patient and therapist. Validating the symptom-related distress and shifting patients’ focus from physical symptoms to the disability in everyday life and limitations of quality of life. Psychoeducation: Extending Somatic Illness Beliefs by Psychosocial Factors Patients’ illness beliefs are explored thoroughly and validated which does not mean to convince patients of biopsychosocial explanations. Patients should be slowly encouraged to extend their illness beliefs by demonstrating that besides somatic also psychosocial factors play an etiological role. Psychoeducation about the reciprocal relationships between body and mind (between negative emotions, peripheral arousal, and somatic changes) and using a symptom diary in order to observe associations between external stressors (conflicts with the partner) and the perception of physical changes are helpful strategies. Dependent on how receptive patients are toward psychosocial besides medical symptom attributions, a cognitive behavioral model of somatoform disorders is discussed at this point  Stress Management and Biofeedback Usually starts with psychoeducation about the relationships between stressors, the activation of the sympathetic nervous system, and physical symptoms. Relaxation response and activating the parasympathetic NS. Progressive muscle relaxation is usually recommended to patients to be used as relaxation technique. Biofeedback is a perfect method to complement relaxation training. It feedbacks psychophysiological variables (muscle tone or heart rate). It helps demonstrating the influence of mental processes on bodily reactions and helps patients developing biopsychosocial symptom attributions. Moreover, BFB helps patients experiencing control of bodily reactions  Refocusing Attention Concept of somatosensory amplification focusing attention on bodily processes can have amplifying effects on somatic sensations. Brief exercises help patients to experience and understand these relationships-- therapists conduct an “alienated” body scan in which patients are guided to shift their attention between different body regions. Typically patients describe perceptions of bodily changes they have not been aware of before the exercise started. This body scan helps demonstrating that bodily processes become conscious as soon as attention is shifted to them. Effects of distraction on somatic sensations are an important therapeutic tool- patients are exposed to a brief, painful, but nonthreatening stimulus (keeping hands in ice-cold water or keeping arms stretched) under pain-focusing versus distracting instructions. Distraction strategies (activity oriented strategies such as positive or attention-consuming activities, physical exercise or exercises where patients shift attention on specific senses such as listening consciously to different sounds in the environment).  Cognitive Restructuring Besides catastrophizing thoughts and biased illness attributions (“The pain in my chest is a sign of a severe cardiovascular disease.”), there are a lot of other dysfunctional cognitions. Loss of control (“The nausea appears spontaneously and I have no control.”), Self blaming thoughts (“I should have gone to the physician when symptoms appeared for the first time. Maybe a medical cause would have been found.”) Thoughts related to illness behaviors (“Due to the spontaneously starting diarrhea I can use only trains which have a restroom.”) Biased thoughts regarding the own body or body image (“I feel weak; my body does not work anymore as it should do.”).  Cognitive Restructuring Somatoform patients obtain typical cognitive styles such self- fulfilling prophecies (“I know that my nausea will start again as soon as I will go the party tonight.”). In a first step, these dysfunctional cognitions have to be identified. Then the therapist starts questioning and modifying these thoughts by using methods of cognitive restructuring and Socratic questioning or dialogue. Cognitive strategies are complemented with behavioral experiments where somatic symptoms are prompted intentionally. Such behavioral experiments are especially helpful when patients bear specific symptom attributions and fears of consequences of specific symptoms (pain in the chest could be a sign of a heart attack).  Reducing Illness Behaviors Typical kinds of illness behaviors are avoidance behaviors, body scanning, extensive healthcare utilization, or other kinds of reassurance behaviors (excessive search for health-/ illness- related information online, so-called “cyberchondriasis”; Muse et al., 2012). Avoidance behaviors can be caused by various dysfunctional cognitions--patients avoid activities when they are afraid of being embarrassed (when a patient often feels dizzy he or she maybe avoids public places where he or she could be judged by others to be drunken) or when they expect a specific activity amplifying symptoms or causing reinjury. Cost Benefit of avoidance  Reducing Illness Behaviors Body scanning behaviors can be very subtle and have to be thoroughly understood before they can be changed. Deborah was asked to swallow intensively and repeatedly over 10 min every day. This strategy helps patients understanding the relationship how body scanning amplifies physical perceptions. Finally, the therapist provides strategies for reducing or relinquishing body scanning behaviors. She decided to have a fixed period of 5 min every day at 8 p.m. where she planned to check her larynx. Over the day every time she experienced a drive to touch her throat, she tried to distract herself and to postpone her “larynx check” to 8 p.m. At 8 p.m. usually her need to check her throat was low. This strategy helped her getting defused from her drive to scan her body. Reducing extensive health care utilizing behaviors Exploring individual motives and needs standing behind this illness behavior (need to feel taken seriously or need for care). Therapist explore consequences of “doctor shopping.” Deborah, realized that she connected lots of hope but also disappointment and frustration with every doctoral appointment. She realized that her illness behaviors make her more and more dependent on physicians’ reassurance. Moreover, she realized that her doctor-shopping behavior could pressurize clinicians who in turn will not take her seriously anymore. The therapist encourages the patient to choose one instead of several physicians with whom time- but not symptom-related appointments should be made. This helps breaking up the vicious cycle of the strong anxiety reducing effect of reassurance.  Specific Issues in CBT for Pain Catastrophizing thoughts and fear of movement. Patients fear that movements and physical exercise could intensify pain and could lead to reinjury. Disability in everyday life, deconditioning, and depressive mood can be a consequence. Exposure: The rationale and mechanisms of exposure are explained to patients. Then a hierarchy of feared movements is created. The next step is that patients are gradually exposed to fear-inducing movements (lifting heavy bags out of the trunk) until the a priori defined level of anxiety is reached and the patient habituated anxiety successfully  Specific Issues in CBT for Illness Anxiety Disorder Patients usually avoid different places (hospitals, medical practices, grave yards, apartments of sick friends), situations, activities (physical exercise, media reports, talking with friends about illnesses, reading list of side effects of medications, medical check- ups) or other things (“harmful” food)--In vivo exposure Imaginal exposure: patients are asked to imagine their most fear- inducing worries (the imagination of the situation in which a doctor confirms the diagnosis of a severe disorder) and to write a script about this imagination. Patients are guided to end their worries in a worst case-scenario. Then the therapist reads out the script aloud while the patient imagines the content of the worst case scenario. This procedure is repeated until the patient imagines the content of the worst case scenario. Developments of CBT for Somatoform Disorders and Pain “third wave” CBT, the role of emotions regulation. Applying concepts of mindfulness- and acceptance-based interventions. Fjorback et al. (2013) developed a mindfulness group therapy for patients with MUPS. The intervention is a combination of traditional CBT and mindfulness-based strategies. Patients learn to be mindful toward their body, emotions, and mental and mind states and shall move toward acceptance of their symptoms and self- compassion. Eilenberg, et al., (2015) developed an ACT for patients with health anxiety. Patients learn to commit to alternative behaviors than controlling and avoidance behaviors with applying typical ACT-concepts such as creative hopelessness, defusion strategies, values, and committed actions combined with mindfulness exercises.  Empirical evidence for CBT for somatoform disorders and pain A recent Cochrane review (Van Dessel et al., 2014) included four randomized controlled trials (RCT) encountering CBT with a waiting list control or a usual medical care control group. A significant, moderate effect regarding severity of somatic symptoms at posttreatment, g = 0.58; 95%-CI: 0.38, 0.77, and 1-year follow-up was identified. Regarding secondary outcomes such as quality of life and depressive symptoms only small to even very small, nonsignificant effects were identified.  Empirical evidence for CBT for somatoform disorders and pain Demonstrate a significant benefit favoring exposure therapy in contrast to waiting list control group in regard to functioning in everyday life (Linton et al., 2008), perceived severity of pain, depression, and cognitive or emotional variables such as kinesiophobia, fear avoidance cognitions, or catastrophizing thoughts (Woods & Asmundson, 2008). In a third study (Leeuw et al., 2008), exposure-based therapy was even more effective than an active control group with graded physical activity at posttreatment and 6 months after the end of therapy. However, results have to be interpreted cautiously since dropout rates are high, e.g., 58% in the study by Woods and Asmundson (2008).  Empirical evidence for CBT for somatoform disorders and pain In a RCT on ACT for IAD, a large significant between group effect size (d = 0.89) on health anxiety was identified posttreatment and at the 10-month follow-up (Eilenberg et al., 2015). Dropout rates were low (8%). A systematic review and meta-analysis (Veehof et al., 2011) obtained small effects for pain depression, physical wellbeing, quality of life, and a moderate effect for anxiety (g = 0.55).  Summary Cognitive behavioral interventions target on many factors that have been empirically evidenced to be involved in the etiology and maintenance of somatoform disorders. CBT is the only psychological therapy for patients with multiple MUPS that has sufficiently been examined regarding its efficacy. However, the effects of CBT are only moderate or small which raises the question why the efficacy is low in comparison to anxiety disorders and depression. A potential explanation could be a methodological problem. Future research will show if additional interventions of third wave CBT can result in better effects. A 30-year-old man presented at the emergency department with sudden onset of severe chest pain, which had come on during his morning break while talking to colleagues. The pain resolved rapidly on arrival of an ambulance. His father had died of myocardial infarction at age 55 years while at work. The patient had recently separated from his wife, and a child custody hearing was due the next day. He had slept poorly in recent days, and was preoccupied with the possible consequences of the hearing. He worked as a building labourer. He was taking no medication and was in good physical health. Physical examination, ECG and cardiac enzymes were normal. What is the most appropriate next management step? A. Arrange an urgent outpatient cardiology appointment B. Dismiss his concerns about his heart C. Inform him that this probably was not a heart attack D. Link the chest pain to his current stressor E. Prescribe benzodiazepines for his anxiety Question A 35-year-old woman presented to the rheumatology clinic with a 12-month history of severe fatigue after a flu-like illness. She had been unable to work in her job as a solicitor for 3 months. She had completely given up her hobby of competitive triathlon and was resting in bed for much of the day. Physical examination was normal. Investigations conducted in the infectious disease clinic, general medical clinic and now in the rheumatology clinic were all normal. She was anxious about her physical health, and was a frequent attender at her GP surgery. What is the most appropriate management step? A.Refer back to primary care B.Refer for cognitive behavioural therapy C.Refer to the cardiology clinic D.Refer to the endocrine clinic A 24-year-old woman was admitted to hospital for video telemetry as a work-up for potential surgical treatment for intractable epilepsy (temporal lobe resection). She had a 5-year history of seizures usually consisting of an aura followed by a 3-minute tonic clonic event, often with incontinence and tongue-biting. She had imaging suggestive of mesial temporal sclerosis. On her first day of admission, she had a 45-minute episode of whole body shaking with no EEG correlate, and with preserved consciousness. She mentioned that she had recently had two of these new types of seizure events after an admission with status epilepticus. What is the next most appropriate action? A. Cancel the hospital admission, and tell her that all her symptoms are functional B. Continue with further video telemetry as planned, and consider medication reduction if she has not had her typical event within 2e3 days C. Consider starting an antidepressant D. Take further history, clarifying these events differ from her typical seizure interpretation E. Document this event in her notes as a possible complex partial seizure  Illness Anxiety Disorder Patients with illness anxiety disorder, like those with somatic symptom disorder, believe they have a serious but undiagnosed disease despite evidence to the contrary. They may maintain a belief that they have a particular disease or, as time progresses, they may transfer their belief to another disease. Their convictions persist despite negative laboratory results, the benign course of the alleged disease over time, and appropriate reassurances from physicians. Their preoccupation with illness interferes with their interaction with family, friends, and coworkers. They are often addicted to internet searches about their feared illness, inferring the worst from information (or misinformation) they find there. Unlike somatic symptom disorder, however, these individuals do not have significant physical symptoms. Sometimes people with this disorder develop a fear of going to medical appointments, while other times, they seek excessive reassurance about their health from medical providers.  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 anyone somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). MODELS OF SOMATIZATION no adequate theory of somatization exists. “emotional distress expressed as physical symptoms” or a “somatic idiom of distress” or a tendency to “somatize rather than