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not worth reading - Old Article, posted to archive: Somatoform disorders in Pulse

Messages
13,774
Nothing particularly interesting here, but I'm just posting some stuff up to make it available to google.

I was recently reading about an old Pulse article and responses to it here:

http://meagenda.wordpress.com/2008/12/26/dr-chris-bass-pulse-somatoform-disorders-article-and-unum/

I really love Pulses response to the controversy, which is so exquisitely pompous:


Chronic fatigue syndrome and somatoform disorders, contrary views, 18 Dec 08

Dr Christopher Basss recent article on somatoform disorders, and in particular his inclusion of chronic fatigue syndrome and fibromyalgia within this grouping, has provoked a strong response from sufferers of the condition.

There is a highly vocal ME/CFS lobby which strongly opposes the categorisation of the condition as a psychiatric/mental disorder, arguing strongly that it is primarily caused by physical components.

Rather than add their extensive comments as feedback to Dr Basss article, which rather than stimulating debate we felt would somewhat drown it out, we reproduce them here for you to consider. Whats your view? Has there been too little focus on the physical aspects of CFS and Fibromyalgia?

Or are those with these conditions being overly sensitive to a diagnosis that its a psychiatric disorder, with the historic stigma this brings that its all in the mind and that the sufferer is weak.

May we also stress that, as pulsetoday is a site for GPs and other health professionals, it is people from these groups whose views we seek.

http://www.pulsetoday.co.uk/main-co...st/10926034/need-to-know-somatoform-disorders


However, when I tried to find the original article, it seemed that it had disappeared, and been replaced here: http://www.pulsetoday.co.uk/main-co...st/10926034/need-to-know-somatoform-disorders

The comments underneath are still to the now removed article by Christopher Bass. I got sent a copy of the original, so I'm posting it below, just in case anyone else ever decides to google it, and cannot find it elsewhere.



Related articles

Sixth of patients have somatoform disorder
Need to know: Somatoform disorders


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Need to know
Need to Know - somatoform disorders

10 Dec 08

Psychiatrist Dr Christopher Bass answers GP Dr Mandy Frys questions on the role of drug therapy and CBT

1. CBT seems to be the current treatment of choice for most psychological disorders. What is the evidence for its use in somatoform disorders? Does it depend on the individual being able to recognise the psychological component of their condition? What about computerised CBT, such as Beating the Blues?

Take-home points
A CBT approach has been shown to be effective for patients who have medically unexplained symptoms
But CBT software like Beating the Blues is not suitable for use in these patients
Tricyclic antidepressants are useful in a number of somatoform disorders but should be used in low doses
Symptom scales such as PHQ-15 can be used in primary care to identify somatising patients
Knowing when to stop ordering tests is a key skill for GPs as open-ended investigations can make things worse
Continuity of care is vital in successfully managing these patients
There is considerable overlap between disorders IBS patients often also suffer from fatigue and backache, for example
Most patients will have suffered adverse experiences during childhood
But there will be no evidence of a psychosocial cause in a small number of patients
A CBT approach is helpful in patients with somatoform disorders because it addresses the predisposing, precipitating and perpetuating factors. CBT has been shown in many trials to be helpful in patients with medically unexplained symptoms such as chronic fatigue syndrome and chronic IBS.

Generally speaking, the more psychologically minded the patient, the more likely they are to respond to this form of treatment. Psychological mindedness refers to the patients ability to look inwards to psychological factors rather than only outwards to environmental factors, and to understand the relationship between thoughts, feelings and actions.

Beating the Blues is helpful for depression and panic attacks, but I know of no evidence for its use in patients with somatoform disorders.

2 What role does medication, such as an SSRI, play in the treatment of somatisation if there is no overt depressive illness?

Medication plays an important role. But SSRIs are of little value in the absence of an overt depressive illness, although in a recent study of patients with severe IBS both psychotherapy and paroxetine were shown to improve health-related quality of life at no additional cost.

Tricyclic drugs such as amitriptyline and imipramine have analgesic effects which are independent of their antidepressant effects. They have been shown to be useful in diverse somatoform disorders characterised by non-cardiac chest pains, IBS, fibromyalgia (renamed chronic widespread pain) and somatoform pain disorder where psychosocial problems are the key maintaining factors in patients with chronic pain but no relevant underlying organic cause.

Many gastroenterologists, for example, use small doses of amitriptyline (25 to 50mg a day) to treat IBS.

It is important to start low and increase the dose gradually for example 10mg increments of amitriptyline a week because these patients are often exquisitely sensitive to any untoward physical side-effects. This somatosensory amplification is often a key component of a somatoform disorder.

3 Patients with somatoform disorders seem to follow a protracted course, with relapses common at times of psychological stress. Are there any factors that can predict outcome?

The failure to cope with distressing crises seems to be the hallmark of somatised disorders. Its been suggested that this protracted and relapsing course may be linked in some way to early experiences of deprivation and somatic illness as well as cognitive behavioural feelings of helplessness and hopelessness.

These patients appear to have difficulty with problem-solving in life crises, and instead of working out solutions tend to develop physical symptoms.

Its important to be aware that many of these chronic frequently unexplained syndromes occur in the general population and share common associated factors. These include:

female gender

high levels of aspects of health anxiety such as health worry preoccupation and reassurance-seeking behaviour

presence of other somatic symptoms

recent adverse life events.

A simple screening instrument like the Patient Health Questionnaire 15-item somatic symptom scale (PHQ-15) can identify such patients. Its been suggested that 8% of primary care patients have at least three medically unexplained bothersome symptoms. Descriptions of how to use the PHQ-15 in primry care a provided in the papers downloadable on the right.

Its important to identify these patients because these symptoms will persist for at least five years in 20% of cases. These patients are more likely to be rated as difficult by their doctors, be high users of healthcare and to have worse functional outcomes.

Its also been shown that life events can have an impact on the onset of many of these disorders, and it would be useful for the GP to enquire about life events and setbacks in the past six to nine months before the onset of disorders such as IBS, chronic fatigue and functional dysphonia.

Chronic fatigue syndrome is associated with stressful events and difficulties prior to onset. An association between loss and danger events and the onset of functional symptoms has been reported in many studies. Those events and difficulties characterised as being dilemmas seem to be particularly important, as is being trapped in a situation that the person is unable to change or modify.

Factors that predict poor outcome usually include:

older age of onset

chronic duration of symptoms

multiple unexplained symptoms

presence of a personality disorder

receipt of benefits

litigation.

4 To some extent somatisation is a diagnosis of exclusion as it implies the absence of an organic explanation for the patients symptoms. How do you deal with the tension between wanting to exclude serious underlying disease and not wanting to medicalise the patient?

Open-ended investigations can have serious adverse effects and knowing when to stop is an important skill.

This tension can often be resolved by saying to a patient after relevant and appropriate investigations have failed to reveal any significant findings The symptoms youre experiencing are real but they are not being caused by any disease or damage, and I suggest the way forward to help you with your symptoms is as follows. This may then involve drug treatment, an exercise programme, problem solving, physiotherapy or CBT.

Another possible approach is to say to a persistent patient that you will carry out just one more test and then complete the investigations. When this turns out to be normal as it invariably is the patients health concerns can be addressed, either by medication or by a clinical psychologist with experience in treating health anxiety using CBT.

5 Developing a trusting relationship with the patient traditionally a key part of general practice often seems to be the key in helping these patients. Do you think this is threatened by initiatives such as Darzi clinics and multiple registrations?

Most somatoform disorders are chronic, lasting more than six months, and are often enduring and complex. They are excellent examples of conditions that require continuity of care, which in my opinion is now under threat.

The GP has a very important gatekeeper role with these patients and relationship continuity is vitally important. Seeing a different GP at each visit is likely to be counterproductive for both the somatising patient and the doctor.

GPs can influence the course of the illness by not referring to tertiary care specialists to order further tests, which may have adverse iatrogenic consequences. Many patients with chronic pain who are referred to pain clinics display iatrogenic factors that are the consequence of doctor-related factors.

6 What about conversion disorders such as paralysis of a limb or movement disorders?

One myth that needs to be dispelled is that conversion disorders have disappeared from clinical practice. This is not the case, and these patients still turn up in neurology outpatients or even inpatient settings.

Indeed, studies suggest a burden of disability associated with chronic hysteria that is far higher than a typical practising psychiatrist might suspect or than is reflected in standard textbooks of psychiatry or clinical neurology. The lowest prevalence figures suggest a rate of about 50 per 100,000 for cases of conversion disorder known to health services at any one time about as common as other disabling conditions such as MS and schizophrenia.

7 Are there any simple strategies we can use in primary care to help these patients?

It would be helpful for GPs to use basic rating scales like the PHQ-15, to spot polysymptomatic patients at risk of chronic somatisation. These patients will require skilled management by the GP.

The shortened form of the illness perception questionnaire BIPQ is also useful because it allows the patient to describe illness concerns, beliefs and expectations. These questionnaires can provide useful information for the GP to develop a dialogue about the symptoms or illness. (The short BIPQ can be downloaded right).

Developing skills in problem-solving therapy would be helpful for most GPs, both for somatoform presentations and other common mental health problems.

8 How many people with a somatoform disorder have a significant underlying psychological cause, such as sexual abuse? Is this something we should be enquiring about or is it better to take their symptoms at face value?

Psychosocial factors should have a key causal or maintaining influence on the presentation of the somatoform disorder. So its important always to ask about developmental factors, for example significant childhood illness or parental illness, loss of a parent before the age of 11 or other adverse experiences.

The childhood experience of abdominal pain has been shown to be a powerful predictor of adult hospitalisations for medically unexplained symptoms.

The GP should also enquire about key life events in the months before symptom onset and symptoms of anxiety and depression.

The HAD scale may be helpful to screen for symptoms of anxiety and depression, and enquiry about illness beliefs can be quickly rated using the short BIPQ.

But there is a small group of patients who have medically unexplained symptoms in whom a psychosocial cause or a psychosocial formulation is impossible to establish. In this group it is best to say to them:

your symptoms are real

the tests are all normal

there is no relevant organic disease to account for your symptoms

the symptoms are not caused by any disease or damage

the symptoms are not your fault

let us explore ways of helping you to cope with and manage these symptoms.

Sexual and physical abuse have been reported in some patients with chronic somatoform disorders such as unexplained chronic pelvic pain. But its important to be aware that a history of physical or sexual abuse or neglect in childhood is associated with high rates of retrospectively reported medical utilisation as an adult.

Some gastroenterologists have suggested that asking about sexual abuse should be integrated into history taking. If a GP is uncertain, one approach might be to ask: Is there anything about your background or upbringing that might help me to understand your symptoms better?

9. Are there any cultural variants in somatisation disorder? Are there any particular racial groups in whom it is particularly prevalent, or, conversely, absent?

There is some evidence for specific somatic complaints to be common in certain cultures. For example complaints of vaginal discharge in South Asian women are thought to be manifestations of psychosocial distress. These women explicitly link their personal experiences of social adversity and stress such as marital problems and heavy workloads with their complaints of abnormal vaginal discharge. But data from large-scale population studies involving 14 countries do not support the common belief that females somatise more than males or that somatisation is a basic orientation prevailing in developing countries. Despite this women do seem to present more often to both primary and secondary health services.

10. Sometimes these patients are too complex and/or time consuming for us to deal with in primary care yet they do not fit well in the current models of acute psychiatric services. Where would you suggest we turn if we need further specialist help?

This is a key question. The tragedy of modern psychiatry is that it is now mainly diagnosis based. This means that if a patient does not have a serious mental illness or reach certain severity criteria the community mental healthcare team is not able to assess them. This approach completely disregards patients with somatoform disorders, many of whom may be disabled, on incapacity benefit, or even in wheelchairs.

As a consequence, these patients may have limited access to community mental health teams, although there is no reason why a competent clinical psychologist should not have the skills to manage a patient with, for example, CFS or chronic pain. A GPs main problem is getting access to one.

One possible way to overcome this shortfall would be to broaden the therapeutic network by training physiotherapists and occupational therapists to acquire basic CBT skills.

They could treat patients at an earlier stage and prevent these disorders evolving into more chronic and somatoform presentations.

GPs could also employ psychologists in-house as some fundholding practices often used to. This may offer more rapid access to treatment resources for patients in primary care.

11. Are there any simple strategies we can use to help these patients? What about simple relaxation strategies? Do you know of any helpful resources that you can signpost us to?

I think it would be helpful for GPs to use basic rating scales like the PHQ-15 to spot polysymptomatic patients who are likely to be at risk of chronic somatisation and to be potential frequent attenders. These patients will require skilled management by the GP.

The shortened form of the illness perception questionnaire BIPQ is also useful because it allows the patient to describe their illness concerns, beliefs and expectations of treatment. These questionnaires can provide useful information for the GP to develop a dialogue about the symptoms or illness.

Developing skills in problem-solving therapy would be helpful for most GPs, both for somatoform presentations and other common mental health problems such as anxiety and depression seen in primary care. A recent excellent book on this topic by Mynors Wallace is recommended. Nortin Hadlers book The Last Well Person: How to Stay Well Despite the Healthcare System will also provide a mind-altering experience that most GPs should enjoy.

There are also some useful handouts for patients with functional neurological syndromes (see Stone et al, further reading), and the NICE guidelines for the management of CFS were published in 2007 and are available at www.nice.org.uk .

12 What are the official diagnostic criteria for somatoform disorder? I often hear the term medically unexplained symptoms used is this the same thing
?

Psychiatrists tend to use terms such as somatoform disorders while GPs and non-psychiatric physicians use terms like IBS, fibromyalgia, and chronic fatigue syndrome.

None of these terms are satisfactory, but it has been shown that patients feel reasonably comfortable when doctors use the term functional to describe these disorders, as in functional bowel disorder and functional dysphonia.

There is considerable evidence of overlap between the various functional syndromes at the level of symptoms, diagnostic criteria, and clinical diagnoses made. For example, patients with IBS report very high levels of fatigue and backache.

Generally speaking, most patients with medically unexplained symptoms lasting for more than six months will have a somatoform disorder.

The official diagnostic criteria for somatoform disorders which include hypochondriasis, recently renamed health anxiety to reduce stigma somatoform pain disorder, conversion disorder and somatisation disorder include symptoms that:

are medically unexplained

are caused or maintained by psychosocial factors

last for more than six months.

Dr Christopher Bass is consultant liaison psychiatrist at the John Radcliffe Hospital Oxford

Competing interests: None declared

What I will do now

Dr Fry considers the answers to her questions

This is a very helpful set of answers in approaching these potentially problematic patients. It was particularly startling that the prevalence of conversion disorder is comparable to that of MS or schizophrenia.

Ill continue to use low-dose tricyclic antidepressants as appropriate, bearing in mind that these patients are often exquisitely sensitive even to small doses. Ill also think about how best to access formal CBT for patients who display appropriate psychological mindedness and discuss this with our local mental health services. Ill increase my own level of skill by using some of the rating scales such as PHQ-15 and BIPQ that Dr Bass suggests and accessing some of the recommended resources.

Some of the terminology he recommends such as relevant investigations and functional seem particularly helpful. As does the idea of at least considering the possibility of sexual abuse in patients I am considering referring to secondary care.

Dr Mandy Fry is a GP in Cirencester, Gloucestershire, and senior primary care lecturer at Oxford Brookes University

What I will do now
-

Dr Fry considers the answers to her questions
This is a very helpful set of answers in approaching these potentially problematic patients. It was particularly startling that the prevalence of conversion disorder is comparable to that of MS or schizophrenia.
Ill continue to use low-dose tricyclic antidepressants as appropriate, bearing in mind that these patients are often exquisitely sensitive even to small doses. Ill also think about how best to access formal CBT for patients who display appropriate psychological mindedness and discuss this with our local mental health services. Ill increase my own level of skill by using some of the rating scales such as PHQ-15 and BBQ that Dr Bass suggests and accessing some of the recommended resources.
Some of the terminology he recommends such as relevant investigations and functional seem particularly helpful. As does the idea of at least considering the possibility of sexual abuse in patients I am considering referring to secondary care.

Dr Mandy Fry is a GP in Cirencester, Gloucestershire, and senior primary care lecturer at Oxford Brookes University

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alex3619

Senior Member
Messages
13,810
Location
Logan, Queensland, Australia
It is very clear to me now just how much information there is that is against the notions of evidence based medicine, biopsychosocial theories, and psychosomatic theories. The first is political, not science based, they cherry pick the science and are subject to Zombie science. The second is unfounded - I could be wrong about this, but the guy who created the biopsychosocial theory (I think, this needs confirmation) objects to how it is being used; and finally psychosomatic medicine is under very strong attack ... from other psychiatrists and doctors. They claim we have an imaginary disease. Their peers claim they are playing with imaginary medicine. Bye, Alex
 

kaffiend

Senior Member
Messages
167
Location
California
It is very clear to me now just how much information there is that is against the notions of evidence based medicine, biopsychosocial theories, and psychosomatic theories. The first is political, not science based, they cherry pick the science and are subject to Zombie science. The second is unfounded - I could be wrong about this, but the guy who created the biopsychosocial theory (I think, this needs confirmation) objects to how it is being used; and finally psychosomatic medicine is under very strong attack ... from other psychiatrists and doctors. They claim we have an imaginary disease. Their peers claim they are playing with imaginary medicine. Bye, Alex

I almost find it fascinating that an entire field of research/medicine is constructed in this manner (and that its adherents can pursue it while keeping a straight face). Nearly every statement begs the question, employs innuendo or implies a causal factor without actually stating one.

Are there any placebo controlled studies on "psychosomatic amplification"? This would be straightforward and easy to do. Also, flip the assumed model: now the mind is influenced by (or emerges from) the functions of the bodily systems. Real evidence from gut-brain interactions is starting to demonstrate this.
 
Messages
15,786
Any theories as to why the original article was removed and replaced with an older one? My guess would be because it advocates medical malpractice by telling doctors that they must avoid specialist referrals and testing, but I thought that was still the general practice in the UK.