BACKGROUND: Human herpesvirus-6 (HHV-6), Epstein-Barr virus and parvovirus B19 have been suggested as etiological agents of chronic fatigue syndrome but none of these viruses is consistently detected in all patients. However, active viral infections may be localized in specific tissues, and, therefore, are not easily detectable. The aim of this study was to investigate the presence of HHV-6, HHV-7, EBV and parvovirus B19 in the gastro -intestinal tract of CFS patients.
PATIENTS AND METHODS: Using real-time PCR, viral DNA loads were quantified in gastro-intestinal biopsies of 48 CFS patients and 35 controls.
RESULTS: High loads of HHV-7 DNA were detected in most CFS and control bi opsies. EBV and HHV-6 were detected in 15-30% of all biopsies. Parvovirus B19 DNA was detected in 40% of the patients versus less than 15% of the controls.
CONCLUSION: Parvovirus B19 may be involved in the pathogenesis of CFS, at least for a subset of patients. The gastro-intestinal tract appears as an important reservoir of infection for several potentially pathogenic viruses.
01 August 2008 Psychiatric Times. Vol. 25 No. 9 Special Report
PSYCHIATRY AND MEDICAL ILLNESS Unexplained Physical Symptoms What's a Psychiatrist to Do?
Humberto Marin, MD and Javier I. Escobar, MD
Dr Marin is assistant professor in the department of psychiatry and Dr Es= cobar is associate dean of global health and professor of psychiatry and family medicine at the University of Medicine and Dentistry of New Jersey-Robert= Wood Johnson Medical School in New Brunswick. Dr Marin reports that he has rec= eived research support from Eli Lilly and Pfizer. Dr Escobar reports that he ha= s no conflicts of interest concerning the subject matter of this article.
The psychogenic view generally considered somatic presentations as ancill= ary manifestations of psychological discomfort. The more direct and pragmatic approach to somatization that would eventually lead to the atheoretical f= rame of modern nomenclatures began with French psychopathologist Pierre Briquet,3= who, in 1859, brought an observational or experiential perspective to the stud= y of hysteria during the golden age of French psychopathology. His description= of a syndrome inclusive of multiple motor and sensorial symptoms (pseudoneurol= ogical symptoms) made possible the separation of somatization from conversion.
In the 1950s, a group of investigators at Washington University-Renard Ho= spital in St Louis resurrected Briquet's concept of hysteria in several clinical studies. They formulated criteria for the diagnosis of hysteria that requ= ired the presence of a specified number of symptoms from a comprehensive list = that included physical and psychological manifestations, personality traits, a= nd behavioral expressions, in addition to the neurological symptoms from the traditional French definition.4,5
With a few modifications, these were the criteria for somatization disord= er proposed by Feighner and colleagues6 in 1972 in their seminal paper, "Dia= gnostic Criteria for Use in Psychiatric Research." After Robert Spitzer and his colleagues7 coined the term "somatoform disorder" (inclusive of the Greek= soma and the Latin form), it officially entered American and world psychiatric terminology with the publication of the International Classification of D= iseases criteria in the late 1970s and the DSM-III in the 1980s.
Somatoform Disorders in DSM
Following the publication of DSM-III in the 1980s, somatization disorder = (SD) became the key somatoform diagnosis. In DSM-III and its subsequent revisi= ons, SD turned into a simple somatic symptom list that contracted or expanded rat= her capriciously. Partly because the atheoretical perspective of DSM discarde= d any presumptions of causality, other manifestations of the syndrome were not included in the criteria.
The list of somatoform disorders kept expanding with the addition of vagu= e categories, such as "undifferentiated somatoform disorder" or "somatoform disorder NOS [not otherwise specified]," which, unfortunately, are the mo= st common diagnoses within the somatoform genre. These terms failed to trans= cend specialty boundaries. Perhaps as a corollary of turf issues, general medi= cine and medical specialties started carving these syndromes with their own to= ols. The resulting list of "medicalized," specialty-driven labels that continu= es to expand includes fibromyalgia, chronic fatigue syndome, multiple chemical sensitivity, and many others (Table 1).
Table 1
Functional somatic syndromes34
Irritable bowel syndrome
Chronic fatigue syndrome
Fibromyalgia
Multiple chemical sensitivity
Nonspecific chest pain
Premenstrual disorder
Non-ulcer dyspepsia
Repetitive strain injury
Tension headache
Temporomandibular joint disorder
Atypical facial pain
Hyperventilation syndrome
Globus syndrome
Sick building syndrome
Chronic pelvic pain
Chronic whiplash syndrome
Chronic Lyme disease
Silicone breast implant effects
Candidiasis hypersensivity
Food allergy
Gulf War syndrome
Mitral valve prolapse
Hypoglycemia
Chronic low back pain
Dizziness
Interstitial cystitis
Tinnitus
Pseudoseizures
Insomnia
Systemic yeast infection
Total allergy syndrome
These labels fall under the general category of functional somatic syndro= mes and seem more acceptable to patients because they may be perceived as less stigmatizing than psychiatric ones. However, using DSM criteria, virtuall= y all these functional syndromes would fall into the somatoform disorders categ= ory given their phenomenology, unknown physical causes, absence of reliable m= arkers, and the frequent coexistence of somatic and psychiatric symptoms. Epidemiology
Medically unexplained physical symptoms are extremely common in adults. T= hey are more frequently seen in females, in persons from lower socioeconomic backgrounds, and in certain ethnic groups. These symptoms are also fairly= common in childhood and adolescence; a recent study showed that 10% of children surveyed had unexplained headaches, 9% had unexplained abdominal pain, an= d 4% had unexplained pain in the extremities.8
The Epidemiological Catchment Area Survey of Mental Disorders in the Unit= ed States reported that fewer than 0.1% of respondents met strict DSM-III cr= iteria for SD, and about 5% met criteria for abridged SD, a less restrictive con= struct of somatization.9 In Germany, about 20% of a community sample met criteri= a for undifferentiated SD, but very few (about 1%) met criteria for the more sp= ecific somatoform disorders.10
The prevalence of unexplained physical symptoms is much higher in primary= care and medical specialty settings. A World Health Organization (WHO) study a= t 14 primary care sites in Asia, Europe, and the Americas showed that the rate= s for abridged SD differed widely across countries. They were lowest in Nigeria (7.6%), Italy (8.9%), and the United States (9.8%) and highest in Germany (25.5%), Brazil (32%), and Chile (36.8%).11
In a North American study, patients with SD reported spending an average = of 8.8 days sick in bed per month, compared with half a day for those without th= e disorder. More than 80% of patients with SD stopped working because of "p= oor health" and their per capita yearly health costs were 9 times higher than average.12 A study of patients with SD who attended a university outpatie= nt service in London showed that 61% were receiving disability benefits, 64%= had been treated for spurious physical disorders, 60% had had surgeries with = no pathology found, and 16% were using either wheelchairs or crutches withou= t any evidence of organic disorder.13
Unexplained physical symptoms tend to have a chronic, protracted course. = For example, in the South London Somatization Study, most patients had a chro= nic unremitting course. About 80% of these persons still qualified for a soma= toform diagnosis 4 years later.14 A follow-up in the WHO study showed that, 1 ye= ar later, somatization persisted in about half of the patients.11
The causes of SD are multifactorial. Although no consistent biological (b= rain) markers have been documented, genetic factors may play a role. Findings f= rom studies of adopted females with SD suggest excessive alcoholism or violen= t behavior in the biological fathers.15 More recent studies have shown that= there is familial clustering of functional syndromes such as fibromyalgia.16 A = large number of studies have shown a frequent association between unexplained p= hysical symptoms and early traumatic experiences; medical illness with long hospitalizations; serious medical illness of a parent; natural disasters;= or psychological factors such as sensitization processes, specific cognitive styles, or benefits derived from the sick role (secondary gain).17-23
The most common psychiatric conditions that coexist with unexplained phys= ical symptoms are major depression, anxiety, substance use, personality disord= ers, and posttraumatic stress disorders.24 Averaging data from several studies= , about two-thirds of patients with unexplained symptoms also met criteria for at= least one of these psychiatric disorders and a large portion of the remaining one-third, who did not fully meet the criteria, had significant symptoms,= mainly depression or anxiety.25
Diagnosing and Managing SD
Not surprisingly, patients with unexplained physical symptoms are first s= een by primary care or nonpsychiatric specialists, who usually make the initial diagnosis. Unfortunately, only about 1 of 4 primary care physicians ackno= wledge feeling confident about their ability to treat these patients. The percen= tage of primary care practitioners who report confidence in managing other mental disorders, such as depression or anxiety disorders, is much higher.26
Assisting primary care providers through instructional sessions and manua= ls or simply by using a consultation letter has proved to be useful.27,28 Refer= ral of these patients to mental health services is generally unsuccessful unless= proper bridges between primary and mental health care are built. This requires p= atient preparation, careful teamwork, and the presence at the primary care site = of trained mental health personnel.
Because of the high level of discomfort associated with unexplained sympt= oms, to be told that "there is no physical problem" is disconcerting to many pati= ents. For the provider, however, finding no physical abnormality generally brin= gs a sense of relief. In building a good therapeutic relationship, it is impor= tant for the therapist not to downplay the patient's discomfort at being told = "there is no problem" or "your symptoms are all psychological." As in any other = field of medicine, empathy and acknowledging the patient's distress are essenti= al ingredients for a sound therapeutic relationship. Table 2 provides a step= wise list of suggestions for communicating a diagnosis of SD to the patient.
Table 2
Communicating a diagnosis of somatoform disorder
1. Convey clearly, succinctly, and in a positive, supportive way that the physical examinations and laboratory tests show no physical abnormality 2. Tell the patient that he or she has a relatively common disorder with = no clear basis but which may cause severe discomfort and dysfunction 3. Explain that despite the lack of physical findings, the physical sympt= oms are not intentionally produced and cannot be eliminated by an act of will 4. Let the patient know that there are treatments that can provide relief= but require the close collaboration of the patient and all health care provid= ers 5. Do not use psychological or psychodynamic terminology or jargon (eg, d= enial, resistance) because most of these patients are not psychologically minded
If properly communicated, the diagnosis of SD may offer relief and encour= agement to the patient. For example, in a recent study, patients with unexplained symptoms felt that receiving such a diagnosis after a time of worry and uncertainty was an important factor in successfully managing the disorder= .29
Regular patient visits should be scheduled (eg, monthly or bimonthly) independent of fluctuations in symptoms. Treatment goals must be concrete= , stepwise, and realistic. Do not aim for an all-or-nothing result, but con= sider a gradual and incremental response. The goal is to progressively decrease emergency visits and calls.
A routine examination is recommended at every visit to reassure the patie= nt and to ensure that there are no physical abnormalities (remember that paranoi= d people may have real enemies). However, no new tests or consultations sho= uld be ordered unless there is a clear indication. Rather than reassuring patien= ts, unwarranted consultations or tests may feed their belief that they have a serious physical illness.
During the visit, the patient can be allowed to play the "sick role." All= ow him or her to verbalize complaints and concerns without entering into needles= s arguments on issues related to the reported symptoms. The objective is no= t to negate the symptoms but to improve functionality and well-being. Briefly = discuss current stress factors and other important circumstances, and make sure t= he patient understands that the unexplained symptoms are elements of a biopsychosocial illness. Table 3 presents a list of goals to work toward.
Table 3
Suggested goals in treatment of somatoform disorder
. Encourage the patient to decrease or (ideally) stop making emergency department visits . Address specific psychiatric comorbidities, such as depression, anxiety= , alcohol or substance use disorders, and other lifestyle measures (eg, die= t, excessive use of stimulants, smoking) . Improve sleep with sleep hygiene measures and, if necessary, add a brie= f course of nonaddictive hypnotic medication . Address fatigue with an aerobic exercise program (eg, walking, jogging, biking, swimming) at least 4 days a week but ideally, every day; exercise= should be sustained rather than intensive (a half hour walk is better than sprin= ting or lifting weights for 10 minutes) and should start at a comfortable level f= or the patient . Discourage secondary gains such as missing work or class or avoiding ho= me chores
Treatment Options
Evidence is rapidly growing for the usefulness of modified cognitive-beha= vioral therapies for somatoform syndromes.30,31 A comprehensive model successful= ly applied in several studies included relaxation training, behavioral manag= ement, cognitive restructuring, emotion identification, emotion regulation, and interpersonal skills training.32 Other types of psychotherapy have not be= en tested in well-controlled studies. However, it is our impression that int= ensive or exploratory therapies that focus on internal conflict and mental chang= e may be counterproductive.
As mentioned, mental disorders such as significant depression and anxiety= are common in those with SD and should be specifically addressed. However, th= ere is no clear evidence from randomized clinical trials demonstrating the effic= acy of psychotropic drugs for the treatment of unexplained physical symptoms. Th= e benefit observed in some studies has been attributed to the effect of medications on anxiety or depressive symptoms and not to a direct effect = on somatic symptoms.
On the basis of our clinical experience, patients with SD accompanied by significant depression and anxiety symptoms can be initially treated with= an SSRI or a serotonin norepinephrine reuptake inhibitor. Mirtazapine seems = to be a reasonable first option for patients with unexplained symptoms who have significant insomnia or anorexia because of the drug's positive effects o= n sleep and appetite. In patients with significant fatigue/sleepiness or poor concentration, or those in whom the avoidance of sexual adverse effects i= s paramount, bupropion may be a good first-line agent.
Because patients with SD may be at a heightened risk for addiction or dependence, caution must be exercised when prescribing medications with addictive potential, such as opiate analgesics and tranquilizers such as benzodiazepines. In patients with SD, pain complaints are very common and include headaches, and joint, abdominal, and pelvic pain. NSAIDs should b= e used whenever possible for pain relief.
FDA-Approved Medications
The anticonvulsant pregabalin and the antidepressant duloxetine have been recently approved for the treatment of fibromyalgia. Pregabalin has analg= esic properties, especially for neuropathic pain, and has also shown some anti= anxiety effects in randomized clinical trials. Duloxetine, a dual action antidepr= essant, also seems to exert some analgesic properties similar to those reported f= or other dual action drugs as well as tricyclic antidepressants.
Lufriprostone has been approved for clinical use in irritable bowel sympt= oms alternating with chronic idiopathic constipation syndromes. This drug app= ears to exert a laxative action by increasing the secretion of chloride and fluid= in the intestinal epithelium.
Fluoxetine, paroxetine, and sertraline have been approved for the treatme= nt of premenstrual dysphoric disorder/premenstrual syndrome, which have a numbe= r of somatic manifestations and also include anxiety and depression symptoms. = A recent meta-analysis found that all SSRIs seem to be about equally helpfu= l for premenstrual symptoms, their continuous use is better than intermittent u= se, and their clinical effect on symptoms seems to be relatively small.33
The Future Definition of SD
As we prepare for the new edition of DSM-V, we suggest the following:
. Consider a dimensional approach for unexplained physical symptoms with differences in severity. . Avoid further expansion of somatoform categories and the mechanistic co= unt of symptoms and systems. There is a need for evidence-based, inclusive, and = simpler definitions. . Do not devalue the psychological, cultural, and social aspects in patie= nts with somatoform disorders; instead, emphasize their character as complex expressions of distress and sickness. . Do not subordinate somatic presentations to other mental disorders or t= o purely mental mechanisms. Acknowledge the unique and independent nature o= f somatoform disorders.
This is clearly designed as exercise for those of Prof Weasly's patients who somatise IBS & M.E. as the same aberrant illness belief!
ReplyDeleteWhat a considerate, caring, thoughtful doctor he is to have designed this treatment after years of intensive scientific research.
It saves on lithium prescriptions when they are all cured too! Praise be to Prof Weasel & his cronies!
Detection of herpes viruses and parvovirus b19 in gastric and intestinal mucosa of chronic fatigue syndrome patients.
ReplyDeleteJournal: In Vivo. 2009 Mar-Apr;23(2):209-13.
Authors: Fr=E9mont M, Metzger K, Rady H, Hulstaert J, DE Meirleir K.
Affiliation: Protea Biopharma, Z.1-Researchpark 100, 1731 Zellik, Belgium
NLM Citation: PMID: 19414405
BACKGROUND: Human herpesvirus-6 (HHV-6), Epstein-Barr virus and parvovirus B19 have been suggested as etiological agents of chronic fatigue syndrome but none of these viruses is consistently detected in all patients. However, active viral infections may be localized in specific tissues, and,
therefore, are not easily detectable. The aim of this study was to investigate the presence of HHV-6, HHV-7, EBV and parvovirus B19 in the gastro
-intestinal tract of CFS patients.
PATIENTS AND METHODS: Using real-time PCR, viral DNA loads were quantified in gastro-intestinal biopsies of 48 CFS patients and 35 controls.
RESULTS: High loads of HHV-7 DNA were detected in most CFS and control bi
opsies. EBV and HHV-6 were detected in 15-30% of all biopsies. Parvovirus
B19 DNA was detected in 40% of the patients versus less than 15% of the
controls.
CONCLUSION: Parvovirus B19 may be involved in the pathogenesis of CFS, at
least for a subset of patients. The gastro-intestinal tract appears as an important reservoir of infection for several potentially pathogenic viruses.
http://www.psychiatrictimes.com/dsm-v/article/10168/1171223?pageNumber=3D=
ReplyDelete2
01 August 2008
Psychiatric Times. Vol. 25 No. 9
Special Report
PSYCHIATRY AND MEDICAL ILLNESS
Unexplained Physical Symptoms
What's a Psychiatrist to Do?
Humberto Marin, MD and Javier I. Escobar, MD
Dr Marin is assistant professor in the department of psychiatry and Dr Es=
cobar
is associate dean of global health and professor of psychiatry and family
medicine at the University of Medicine and Dentistry of New Jersey-Robert=
Wood
Johnson Medical School in New Brunswick. Dr Marin reports that he has rec=
eived
research support from Eli Lilly and Pfizer. Dr Escobar reports that he ha=
s no
conflicts of interest concerning the subject matter of this article.
The psychogenic view generally considered somatic presentations as ancill=
ary
manifestations of psychological discomfort. The more direct and pragmatic
approach to somatization that would eventually lead to the atheoretical f=
rame of
modern nomenclatures began with French psychopathologist Pierre Briquet,3=
who,
in 1859, brought an observational or experiential perspective to the stud=
y of
hysteria during the golden age of French psychopathology. His description=
of a
syndrome inclusive of multiple motor and sensorial symptoms (pseudoneurol=
ogical
symptoms) made possible the separation of somatization from conversion.
In the 1950s, a group of investigators at Washington University-Renard Ho=
spital
in St Louis resurrected Briquet's concept of hysteria in several clinical
studies. They formulated criteria for the diagnosis of hysteria that requ=
ired
the presence of a specified number of symptoms from a comprehensive list =
that
included physical and psychological manifestations, personality traits, a=
nd
behavioral expressions, in addition to the neurological symptoms from the
traditional French definition.4,5
With a few modifications, these were the criteria for somatization disord=
er
proposed by Feighner and colleagues6 in 1972 in their seminal paper, "Dia=
gnostic
Criteria for Use in Psychiatric Research." After Robert Spitzer and his
colleagues7 coined the term "somatoform disorder" (inclusive of the Greek=
soma
and the Latin form), it officially entered American and world psychiatric
terminology with the publication of the International Classification of D=
iseases
criteria in the late 1970s and the DSM-III in the 1980s.
Somatoform Disorders in DSM
Following the publication of DSM-III in the 1980s, somatization disorder =
(SD)
became the key somatoform diagnosis. In DSM-III and its subsequent revisi=
ons, SD
turned into a simple somatic symptom list that contracted or expanded rat=
her
capriciously. Partly because the atheoretical perspective of DSM discarde=
d any
presumptions of causality, other manifestations of the syndrome were not
included in the criteria.
The list of somatoform disorders kept expanding with the addition of vagu=
e
categories, such as "undifferentiated somatoform disorder" or "somatoform
disorder NOS [not otherwise specified]," which, unfortunately, are the mo=
st
common diagnoses within the somatoform genre. These terms failed to trans=
cend
specialty boundaries. Perhaps as a corollary of turf issues, general medi=
cine
and medical specialties started carving these syndromes with their own to=
ols.
The resulting list of "medicalized," specialty-driven labels that continu=
es to
expand includes fibromyalgia, chronic fatigue syndome, multiple chemical
sensitivity, and many others (Table 1).
Table 1
Functional somatic syndromes34
Irritable bowel syndrome
Chronic fatigue syndrome
Fibromyalgia
Multiple chemical sensitivity
Nonspecific chest pain
Premenstrual disorder
Non-ulcer dyspepsia
Repetitive strain injury
Tension headache
Temporomandibular joint disorder
Atypical facial pain
Hyperventilation syndrome
Globus syndrome
Sick building syndrome
Chronic pelvic pain
Chronic whiplash syndrome
Chronic Lyme disease
Silicone breast implant effects
Candidiasis hypersensivity
Food allergy
Gulf War syndrome
Mitral valve prolapse
Hypoglycemia
Chronic low back pain
Dizziness
Interstitial cystitis
Tinnitus
Pseudoseizures
Insomnia
Systemic yeast infection
Total allergy syndrome
These labels fall under the general category of functional somatic syndro=
mes and
seem more acceptable to patients because they may be perceived as less
stigmatizing than psychiatric ones. However, using DSM criteria, virtuall=
y all
these functional syndromes would fall into the somatoform disorders categ=
ory
given their phenomenology, unknown physical causes, absence of reliable m=
arkers,
and the frequent coexistence of somatic and psychiatric symptoms.
Epidemiology
Medically unexplained physical symptoms are extremely common in adults. T=
hey are
more frequently seen in females, in persons from lower socioeconomic
backgrounds, and in certain ethnic groups. These symptoms are also fairly=
common
in childhood and adolescence; a recent study showed that 10% of children
surveyed had unexplained headaches, 9% had unexplained abdominal pain, an=
d 4%
had unexplained pain in the extremities.8
The Epidemiological Catchment Area Survey of Mental Disorders in the Unit=
ed
States reported that fewer than 0.1% of respondents met strict DSM-III cr=
iteria
for SD, and about 5% met criteria for abridged SD, a less restrictive con=
struct
of somatization.9 In Germany, about 20% of a community sample met criteri=
a for
undifferentiated SD, but very few (about 1%) met criteria for the more sp=
ecific
somatoform disorders.10
The prevalence of unexplained physical symptoms is much higher in primary=
care
and medical specialty settings. A World Health Organization (WHO) study a=
t 14
primary care sites in Asia, Europe, and the Americas showed that the rate=
s for
abridged SD differed widely across countries. They were lowest in Nigeria
(7.6%), Italy (8.9%), and the United States (9.8%) and highest in Germany
(25.5%), Brazil (32%), and Chile (36.8%).11
In a North American study, patients with SD reported spending an average =
of 8.8
days sick in bed per month, compared with half a day for those without th=
e
disorder. More than 80% of patients with SD stopped working because of "p=
oor
health" and their per capita yearly health costs were 9 times higher than
average.12 A study of patients with SD who attended a university outpatie=
nt
service in London showed that 61% were receiving disability benefits, 64%=
had
been treated for spurious physical disorders, 60% had had surgeries with =
no
pathology found, and 16% were using either wheelchairs or crutches withou=
t any
evidence of organic disorder.13
Unexplained physical symptoms tend to have a chronic, protracted course. =
For
example, in the South London Somatization Study, most patients had a chro=
nic
unremitting course. About 80% of these persons still qualified for a soma=
toform
diagnosis 4 years later.14 A follow-up in the WHO study showed that, 1 ye=
ar
later, somatization persisted in about half of the patients.11
The causes of SD are multifactorial. Although no consistent biological (b=
rain)
markers have been documented, genetic factors may play a role. Findings f=
rom
studies of adopted females with SD suggest excessive alcoholism or violen=
t
behavior in the biological fathers.15 More recent studies have shown that=
there
is familial clustering of functional syndromes such as fibromyalgia.16 A =
large
number of studies have shown a frequent association between unexplained p=
hysical
symptoms and early traumatic experiences; medical illness with long
hospitalizations; serious medical illness of a parent; natural disasters;=
or
psychological factors such as sensitization processes, specific cognitive
styles, or benefits derived from the sick role (secondary gain).17-23
The most common psychiatric conditions that coexist with unexplained phys=
ical
symptoms are major depression, anxiety, substance use, personality disord=
ers,
and posttraumatic stress disorders.24 Averaging data from several studies=
, about
two-thirds of patients with unexplained symptoms also met criteria for at=
least
one of these psychiatric disorders and a large portion of the remaining
one-third, who did not fully meet the criteria, had significant symptoms,=
mainly
depression or anxiety.25
Diagnosing and Managing SD
Not surprisingly, patients with unexplained physical symptoms are first s=
een by
primary care or nonpsychiatric specialists, who usually make the initial
diagnosis. Unfortunately, only about 1 of 4 primary care physicians ackno=
wledge
feeling confident about their ability to treat these patients. The percen=
tage of
primary care practitioners who report confidence in managing other mental
disorders, such as depression or anxiety disorders, is much higher.26
Assisting primary care providers through instructional sessions and manua=
ls or
simply by using a consultation letter has proved to be useful.27,28 Refer=
ral of
these patients to mental health services is generally unsuccessful unless=
proper
bridges between primary and mental health care are built. This requires p=
atient
preparation, careful teamwork, and the presence at the primary care site =
of
trained mental health personnel.
Because of the high level of discomfort associated with unexplained sympt=
oms, to
be told that "there is no physical problem" is disconcerting to many pati=
ents.
For the provider, however, finding no physical abnormality generally brin=
gs a
sense of relief. In building a good therapeutic relationship, it is impor=
tant
for the therapist not to downplay the patient's discomfort at being told =
"there
is no problem" or "your symptoms are all psychological." As in any other =
field
of medicine, empathy and acknowledging the patient's distress are essenti=
al
ingredients for a sound therapeutic relationship. Table 2 provides a step=
wise
list of suggestions for communicating a diagnosis of SD to the patient.
Table 2
Communicating a diagnosis of somatoform disorder
1. Convey clearly, succinctly, and in a positive, supportive way that the
physical examinations and laboratory tests show no physical abnormality
2. Tell the patient that he or she has a relatively common disorder with =
no
clear basis but which may cause severe discomfort and dysfunction
3. Explain that despite the lack of physical findings, the physical sympt=
oms are
not intentionally produced and cannot be eliminated by an act of will
4. Let the patient know that there are treatments that can provide relief=
but
require the close collaboration of the patient and all health care provid=
ers
5. Do not use psychological or psychodynamic terminology or jargon (eg, d=
enial,
resistance) because most of these patients are not psychologically minded
If properly communicated, the diagnosis of SD may offer relief and encour=
agement
to the patient. For example, in a recent study, patients with unexplained
symptoms felt that receiving such a diagnosis after a time of worry and
uncertainty was an important factor in successfully managing the disorder=
.29
Regular patient visits should be scheduled (eg, monthly or bimonthly)
independent of fluctuations in symptoms. Treatment goals must be concrete=
,
stepwise, and realistic. Do not aim for an all-or-nothing result, but con=
sider a
gradual and incremental response. The goal is to progressively decrease
emergency visits and calls.
A routine examination is recommended at every visit to reassure the patie=
nt and
to ensure that there are no physical abnormalities (remember that paranoi=
d
people may have real enemies). However, no new tests or consultations sho=
uld be
ordered unless there is a clear indication. Rather than reassuring patien=
ts,
unwarranted consultations or tests may feed their belief that they have a
serious physical illness.
During the visit, the patient can be allowed to play the "sick role." All=
ow him
or her to verbalize complaints and concerns without entering into needles=
s
arguments on issues related to the reported symptoms. The objective is no=
t to
negate the symptoms but to improve functionality and well-being. Briefly =
discuss
current stress factors and other important circumstances, and make sure t=
he
patient understands that the unexplained symptoms are elements of a
biopsychosocial illness. Table 3 presents a list of goals to work toward.
Table 3
Suggested goals in treatment of somatoform disorder
. Encourage the patient to decrease or (ideally) stop making emergency
department visits
. Address specific psychiatric comorbidities, such as depression, anxiety=
,
alcohol or substance use disorders, and other lifestyle measures (eg, die=
t,
excessive use of stimulants, smoking)
. Improve sleep with sleep hygiene measures and, if necessary, add a brie=
f
course of nonaddictive hypnotic medication
. Address fatigue with an aerobic exercise program (eg, walking, jogging,
biking, swimming) at least 4 days a week but ideally, every day; exercise=
should
be sustained rather than intensive (a half hour walk is better than sprin=
ting or
lifting weights for 10 minutes) and should start at a comfortable level f=
or the
patient
. Discourage secondary gains such as missing work or class or avoiding ho=
me
chores
Treatment Options
Evidence is rapidly growing for the usefulness of modified cognitive-beha=
vioral
therapies for somatoform syndromes.30,31 A comprehensive model successful=
ly
applied in several studies included relaxation training, behavioral manag=
ement,
cognitive restructuring, emotion identification, emotion regulation, and
interpersonal skills training.32 Other types of psychotherapy have not be=
en
tested in well-controlled studies. However, it is our impression that int=
ensive
or exploratory therapies that focus on internal conflict and mental chang=
e may
be counterproductive.
As mentioned, mental disorders such as significant depression and anxiety=
are
common in those with SD and should be specifically addressed. However, th=
ere is
no clear evidence from randomized clinical trials demonstrating the effic=
acy of
psychotropic drugs for the treatment of unexplained physical symptoms. Th=
e
benefit observed in some studies has been attributed to the effect of
medications on anxiety or depressive symptoms and not to a direct effect =
on
somatic symptoms.
On the basis of our clinical experience, patients with SD accompanied by
significant depression and anxiety symptoms can be initially treated with=
an
SSRI or a serotonin norepinephrine reuptake inhibitor. Mirtazapine seems =
to be a
reasonable first option for patients with unexplained symptoms who have
significant insomnia or anorexia because of the drug's positive effects o=
n sleep
and appetite. In patients with significant fatigue/sleepiness or poor
concentration, or those in whom the avoidance of sexual adverse effects i=
s
paramount, bupropion may be a good first-line agent.
Because patients with SD may be at a heightened risk for addiction or
dependence, caution must be exercised when prescribing medications with
addictive potential, such as opiate analgesics and tranquilizers such as
benzodiazepines. In patients with SD, pain complaints are very common and
include headaches, and joint, abdominal, and pelvic pain. NSAIDs should b=
e used
whenever possible for pain relief.
FDA-Approved Medications
The anticonvulsant pregabalin and the antidepressant duloxetine have been
recently approved for the treatment of fibromyalgia. Pregabalin has analg=
esic
properties, especially for neuropathic pain, and has also shown some anti=
anxiety
effects in randomized clinical trials. Duloxetine, a dual action antidepr=
essant,
also seems to exert some analgesic properties similar to those reported f=
or
other dual action drugs as well as tricyclic antidepressants.
Lufriprostone has been approved for clinical use in irritable bowel sympt=
oms
alternating with chronic idiopathic constipation syndromes. This drug app=
ears to
exert a laxative action by increasing the secretion of chloride and fluid=
in the
intestinal epithelium.
Fluoxetine, paroxetine, and sertraline have been approved for the treatme=
nt of
premenstrual dysphoric disorder/premenstrual syndrome, which have a numbe=
r of
somatic manifestations and also include anxiety and depression symptoms. =
A
recent meta-analysis found that all SSRIs seem to be about equally helpfu=
l for
premenstrual symptoms, their continuous use is better than intermittent u=
se, and
their clinical effect on symptoms seems to be relatively small.33
The Future Definition of SD
As we prepare for the new edition of DSM-V, we suggest the following:
. Consider a dimensional approach for unexplained physical symptoms with
differences in severity.
. Avoid further expansion of somatoform categories and the mechanistic co=
unt of
symptoms and systems. There is a need for evidence-based, inclusive, and =
simpler
definitions.
. Do not devalue the psychological, cultural, and social aspects in patie=
nts
with somatoform disorders; instead, emphasize their character as complex
expressions of distress and sickness.
. Do not subordinate somatic presentations to other mental disorders or t=
o
purely mental mechanisms. Acknowledge the unique and independent nature o=
f
somatoform disorders.