Identifying and Treating Somatic Symptom

Disorder in the Primary Care Setting

Presented by: Ruth Tadesse, MS, RN
Date: 4/02/2015

Disclosures and Learning Objectives

Learning Objectives:
Identify 3 common types of somatization seen in
primary care setting
Know DSM 5 criteria used to diagnose Somatic
Symptom Disorder
Identify at least 2 assessment tools used to
diagnose somatic symptom disorder
List at least 4 treatment methods used to manage
somatic symptom disorder.
Disclosures: Ruth Tadesse has nothing to disclose.

Historical Background and Changes from

DSM III to DSM 5 (Dimsdale, J. E., et al. 2013)
Somatoform Disorder

Somatic Symptom Disorder

-First introduced 30yrs ago in DSM-III as Somatoform Disorder .

Somatoform didnt translate to another language well
-DSM-IV concept of medically unexplained symptoms were introduced .
Is it unexplained or unexamined medical condition?
-DSM-5 replaced Somatoform Disorder with Somatic Symptom Disorder
and Related Disorders
The symptoms may or may not be medically unexplained. If the
patient primarily had anxiety but not somatic complaints, the
diagnosis would be Illness Anxiety Disorder.
http://www.dsm5.org/documents/somatic%20symptom%20disorder%20fact%20sheet.pdf
Somatic Symptom Disorder Fact Sheet.pdf

Differences from DSM IV to DSM 5

(Dimsdale, J. E., et al. 2013)
D

DSM 5 - Somatic Symptom

Disorder and related disorders
DSM IV Somatoform Disorder

-Somatization Disorder

-Somatic Symptom Disorder

-Undifferentiated
Somatoform Disorder
-Conversion Disorder

-Illness Anxiety Disorder

-Pain Disorder
-Hypochondriasis

-Conversion Disorder
-Psychological factors affecting
a medical condition
-Factitious Disorder

-Other specific and nonspecific

-Somatoform Disorder NOS somatic symptom disorders
-Body Dysmorphic Disorder

Somatic Symptom Disorders and Other

Related Disorders

http://emedicine.medscape.com/article/294908-overview

Somatic Symptom Disorder vs Illness Anxiety

Disorder (Croicu, C., et al. 2014)

Approach to the patient with multiple somatic symptoms.pdf

DSM 5 Criteria for Somatic Symptom Disorder

A. One or more somatic symptoms that are distressing or result in significant

disruption of daily life.

B. Excessive thoughts, feelings, 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 - more than 6 months.
American Psychiatric Association ((APA) (2013). Diagnostic and Statistical Manual of Mental
Disorders. (5th ed.) Washington, DC: American Psychiatric Association Press. p. 30927.

Case Study Ms. B

Ms. B is a 37-year-old woman who presents to the

ED with abdominal pain. She reports that she has suffered
from chronic pain since her adolescence. She has a history
of multiple abdominal surgeries, the most recent was for
pain felt due to adhesions. These operations have failed to
reduce her complaints of pain. Her physical examination,
vital signs, and labs, including CBC, urinalysis, and
chemistry profile, are within normal limits. She is referred
back to her primary care physician for further examination.

Case Study Ms. B

If you are her PCP, what more would you like to know?

What additional tests/screenings would you like to do?

What will you include under your differential diagnosis?

What do you think her full mental status examination

would look like?

What will you prescribe to treat Ms. Bs chronic pain?

Somatic Symptom Disorder - Pathophysiology

Pathophysiology is unknown

Associated with a heightened awareness of normal

bodily sensations which maybe paired with a cognitive
bias to interpret any physical symptom as indicative of
medical illness

Some tend to have autonomic arousal

Brain imaging shows reduced volume of amygdala

Comorbidity depressive disorders, anxiety disorders,

substance use, and personality disorders

Somatic complaints epidemiology and psychiatric co-morbidity.pdf

http://emedicine.medscape.com/article/294908-overview#a0104

Somatic Symptom Disorder - Epidemiology

Somatic Symptom Disorder Prevalence

-

Community sample 0.1%

Medical chart review show prevalence rate in women

as high as 2%

Liberal criteria rates as high as 11.6%

Hypochondriasis in primary care 4-6%

50% of patients presents in primary care with physical

symptoms has no diagnosable disease

Female-to-Male ratio is 10:1

Symptoms usually begin in childhood, adolescence or

early adulthood

Somatic complaints epidemiology and psychiatric co-morbidity.pdf

http://emedicine.medscape.com/article/294908-overview#a0199

Common types of somatization seen in

primary care (Croicu, C., et al. 2014)
1. Acute somatization
- Temporary production of physical symptoms associated with
transient stressors

2. Relapsing somatization
- Repeated episodes of physical symptoms associated with
repetitive stressors & anxiety or depressive episodes

3. Chronic somatization
- Nearly continuous somatic focus, perception of ill health,
development of disability
Approach to the patient with multiple somatic symptoms.pdf

Assessing for Somatic Symptom Disorder Using

the 3-Ps (Croicu C, et al. 2014)
-

Predisposing

Chronic childhood illnesses, childhood adversities,

comorbid medical illness, lifetime psychiatric diagnosis,
poor coping ability
-

Precipitating

Medical illness, psychiatric disorder, social & occupation

stress, and changes in social support
- Perpetuating
Chronic stressors, maladaptive coping skills, negative
health habits, and disability payments
Approach to the patient with multiple somatic symptoms.pdf

Assessing Mental Health in Patients with SSD

using S4 Model (Jackson, et al., 2003)
1. Stress recently (last week) (yes/no)
2. Symptom count (checklist of 15 somatic symptoms;
scored as positive if more than 5 symptoms)
3. Self-rated overall health poor or fair on a 5-point-scale
(excellent, very good, good, fair, poor); scored as
positive for fair or poor responses.)
4. Self-rated severity of symptoms from 0 (none at all) to
10 (unbearable) scale, scored as positive for responses
greater than 5
Clinical predictors of mental disorders among medical outpatients.pdf
Validation of the S4 Model.pdf

Identifying Somatic Symptom Disorder

(Croicu C, et al. 2014)

Do a thorough history and detailed physical assessment

Rule out medical illness

Consider medication side effects

Identify ability to meet basic needs

Identify secondary gains

Identify ability to communicate emotional needs

Determine substance use

Build therapeutic alliance with the patient

Use screening tools appropriate for somatic symptom

disorder: SSS-8 and PHQ-15

Approach to the patient with multiple somatic symptoms.pdf

The BATHE Technique

B: Background - What is going on in your life? And What

brings you in here today?
A: Affect How do you feel about that?
T: Trouble What bothers you the most about this
situation?
H:Handling - How are you handling that?
E: Empathy That must be very difficult for you.
The BATHE Method.pdf
Approach to the patient with multiple somatic symptoms.pdf

PHQ-15 - Screening for Somatic Symptom

Presence and Severity

http://www.phqscreeners.com/instructions/instructions.pdf
http://www.phqscreeners.com/pdfs/04_PHQ-15/English.pdf

Somatic Symptom Scale 8 [SSS-8]

(Table is hyperlinked)

Essential Treatment Approaches for Patients

with Somatic Symptom Disorder (Croicu, C., et al. 2014)
Schedule time-limited regular appointments (e.g. 4-6
weeks) to address complaints
Explain that although there may not be a reason for their
symptoms, you will work together to improve their
functioning as much as possible
Educate patients how psychosocial stressors and
symptoms interact
Avoid comments like Your symptoms are all
psychological. or There is nothing wrong with you
medically.
Approach to the patient with multiple somatic symptoms.pdf

Essential Treatment Approaches for Patients with

Somatic Symptom Disorder (Croicu, C., et al. 2014)
Avoid the temptation to order unnecessary, repetitive, or
invasive investigations
Educate the patient on how to cope with their symptoms
instead of focusing on a cure
Evaluate somatic symptom burden
Collaborate with the patient in setting treatment goals
Screen for common psychiatric conditions associated
with somatic complaints such as depression and anxiety
Treat identified comorbid psychiatric disorders
Approach to the patient with multiple somatic symptoms.pdf

Essential Treatment Approaches for Patients with

Somatic Symptom Disorder (Croicu, C., et al. 2014)

Case management to minimize economic impact

Medications to treat anxiety and depression (SSRIs)

Short term use of anxiety meds (dependence is a risk)

Non-pharmacological treatments
*CBT Shows promising evidence
Psychodynamic therapy
Integrative therapy
Approach to the patient with multiple somatic symptoms.pdf

http://www.sciencedirect.com.liboff.ohsu.edu/science/article/pii/S0025712514000959

Summary

Scheduling a regular visit with the patient reduces or

eliminates unnecessary ED visits.

Identifying risks such as childhood trauma can suggest

screening for somatic symptom disorders using
appropriate assessment tools (PHQ-15 & SSS-8).

Identifying, screening for and treating common psychiatric

comorbidities such as depression (PHQ-9) and anxiety
(GAD-7) can decrease somatic symptom burden.

Non-pharmacological interventions such as CBT has

shown evidence in decreasing somatic symptom disorder.

Therapeutic alliance with the patient with somatic

complaints improves outcomes.

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental

disorders. 5th edition. American Psychiatric Association Press.
Croicu, C., Chwastiak, L., & Katon, W. (2014). Approach to the patient with multiple somatic
symptoms. Medical Clinics of North America. 98(5): 1079-1095.
Dimsdale, J. E., Creed F., Escobar, J., Levenson, J. (2013). Somatic symptom disorder: An
important change in DSM. Journal of Pscyhosomatic Research. 75(3): 223-228.
DSM V Somatic Symptom Disorder Fact Sheet available online
http://www.dsm5.org/documents/somatic%20symptom%20disorder%20fact%20sheet.pdf
Glerk,B., Kohlmann,S., Kroenke, K., Lowe, B. (2014). The Somatic Symptom Scale-8 (SSS8). A Brief Measure of somatic symptom burden. JAMA Internal Medicine. 174(3): 399407.
Gierk, B., Kohlmann, S., Toussaint, A. Lowe, B. (2014). Assessing somatic symptom burden.
A psychometric comparison of the Patient Health Questionnaire 15 (PHQ-15) and the
Somatic Symptom Scale- 8(SSS-8)

References Cont.

Jackson, J.L., OMalley, P., & Kroenke, K. (1998). Clinical Predictors of Mental Disorders Among
Medical Outpatients: Validation of the S4 Model. The Journal of Consultation and Liaison
Psychiatry. 39(5): 431436.
Kroenke K., (2003). Patients presenting with somatic complaints epidemiology, psychiatric
comorbidity and management. International journal of methods in psychiatric research .12(1):
34-43
Kroenke, K., Jackson, J.L., & Chamberlin, J. (1997). Depressive and anxiety disorders in patients
presenting with physical complaints. The American Journal of Medicine. 103(5): 339347.
Martin, A., Rauh, E., Fichter, M., & Rief, W. (2007). A One-session treatment for patients suffering
from medically unexplained symptoms in primary care: A randomized clinical trial.
Psychosomatics. 48(4): 294-303.
Ravesteign, H., Wittkampf, K., Lucassen, P., ,Weel, C. (2009). Detecting somatoform disorders in
primary care with the PHQ-15. Annals of Family Medicine. 7: 232-238.
Van Dessel, N., den Boeft, van der Wouden, J.C. van Marwijk, H. (2014). Non-pharmacological
interventions for somatoform disorders and medically unexplained physical symptoms (MUPS)
in
adults. Cochrane Database Systematic Review.11(1): Vol.11, p.CD011142-CD011142

The End!

Gero.
Series
Begins on
04/09/15