Anita R. Webb, PhD JPS Health Network Fort Worth, TX

 “Extremely Common”  Examples  Headache  Abdominal pain  Fatigue  No clear organic cause identified  No definitive organic diagnosis  “Psychosomatic”

 Chronic Fatigue Syndrome  Fibromyalgia  Irritable Bowel Syndrome  Multiple chemical sensitivities  Still highly controversial  Most are not recognized

 Especially common symptoms in primary care  Headache  Abdominal pain  Fatigue  Up to 50% of new outpatient visits  At least 1/3 of somatic symptoms  20-25% are chronic/recurrent - K. Kroenke. Int. J. Meth. Res. (2003)

 Important role in the evolution of mental classifications  Historically: “ Hysteria ”  Current paradigm  Mind-Body Continuum  Interacting continuously

 Multifactorial complex factors  Bio-Psycho-Socio-Spiritual  Medical community needs:  Integration and understanding about  How these components interact

-C auses problems in functioning - Also: Pain, disability - Avoidance of people and activities - Negative body image changes - Psychiatric disorders: Anxiety, depression - “Psychosomatic”

 Changes in body image  Avoidance of people and activities  Anxiety  Depression  “Entanglement” in medical system

 Unnecessary medical utilization  Tests  Medical treatments  Even surgeries  Costly interventions  Without any benefit  “Possibly even dangerous”  Distraction from recommending psychological tx.

 Risk Factors:  Childhood experience of health/illness  Parents’ inappropriate response to family illness  Perhaps reaction to “Adverse Parenting”  A learned condition?  Parents, family, teachers reinforce by secondary gain  Attention  Special privileges  School avoidance, etc.

 “Somatic Symptom Disorder”  Physical symptoms which are:  Severe  Chronic  Troublesome  May or may not have a medical explanation  (May 2013)

 N = 3107 (age 36, with MUS): Prospective study  “Powerful relationship” with parents’ poor health  When subjects were age 15  Also correlated with patients’ childhood abdominal pain  (in the absence of defined childhood disease)  Additional conclusions:  Majority of MUS are mild  Most are not recognized  Personality D/O is a common comorbid diagnosis  MRCNSHD: N=191(Craig et al in United Kingdom)

 As a result of early trauma  e.g. Childhood abuse, illness, accident  Child becomes “highly sensitive to sensory stimuli”  Plus low tolerance for pain  Dysregulation of the stress system  Patient feels symptoms more intensely  Down-regulation in opioid receptor activity  May exaggerate sensitivity to pain

 Psychodynamic Theory  “Unexpressed bereavement or trauma”  Could cause bodily symptoms  Versus Learning Theory  Heightened anxiety predisposes the patient  To feel normal bodily sensations more intensely  Results in an exaggerated response  Reinforced by parents, family, teachers

 Decreased functioning  Changes in body image  Avoidance of people, activities  Reactive depression, anxiety  Entangled in medical system  Unnecessary, possibly dangerous interventions

 A less common category of MUS  Moderate to severe symptoms  Correlated with  Anxiety and  Depression  Requires investigation  Severity  Duration  Comorbidities

 National Institutes of Health (2008)  “Undiagnosed Diseases Program”  Multifactorial, complex conditions  Biological-Psychological-Social factors  Research  Treatment: “Low success rate”

 Decrease stress  Cope with symptoms  Improve quality of life  Acknowledge physical symptoms  Acknowledge emotional symptoms  Promote positive life changes  Low success rate

 Decrease high utilization  Medical testing  Treatments  Psychotherapy may address:  Anxiety  Depression  Pain  Living with uncertainty

 One theory to explain the origin of MUS  Difficulty living with UNCERTAINTY  “Existential” issues?  Morality  Chaos  Ambivalence

 Antidepressant medication  Even if not depressed  “Neural pathways for  “Negative psychological  “And physical symptoms  “Are closely related.”  Support Groups

 Provide Support: Bond with patient  Fear of facing medical problems alone  “I can help you.”  Treatment goals  Decrease symptoms, especially pain  Validate patient’s experience  Increase functioning  Focus on quality of life

 “Difficult Area”  “Strong feelings”  “Pejorative”  Advice for physicians: C-3  Consider Complex Causes

 Natural course is:  Decreased intensity  Over time  (i.e. even without medical intervention)

 Strive to integrate  And understand  Conditions that may have  Both physical and  Psychological  Components

 Tori DeAngelis  “When symptoms are a mystery”  Monitor on Psychology  July/August 2013