1. Everything Hurts: Dealing with Somatic Symptoms and Related Disorders
Cerrone Cohen, MD

2. “Burning all over my body”
“I can’t swallow”
“I blackout every day”
“I’m weak”
“I hurt everywhere”
“My tongue tingles”
“Burning all over my body”
“I’m always dizzy”
“My arms go numb”

3. Objectives
Discuss a framework for patient and provider well being while treating patients with somatic symptoms
Describes an interdisciplinary approach to care or patients with multiple unexplained symptoms
Identify 3 separate disorders that have chronic somatic symptoms as a core feature
If I could retitlte this it would be rediscovering the lost art of the lecture

4. Classically Somatic Disorders
Medically Unexplained Symptoms with a psychiatric origin =
Classically Somatic Disorders
Historically viewed as physical symptoms with a psychiatric origin

5. How They Feel

6. How You Feel

7. Everybody Loses

8. Up to 40% of patients seen in primary care have symptoms without a clear organic etiology
J Clin Psychiatry. 1998;59 Suppl 20:15-21.
Medically unexplained symptoms in primary care.
Lippincott’s primary care psychiatry
Medically unexplained symptoms in primary care. J Clin Psychiatry. 1998;59 Suppl 20:15-21.
Lippincott’s primary care psychiatry Medically Unexplained symptoms

9. J Clin Psychiatry. 1998;59 Suppl 20:15-21.
Medically unexplained symptoms in primary care.
Lippincott’s primary care psychiatry
Patients with somatization account for 2x the medical expenses as those without
Medically unexplained symptoms in primary care. J Clin Psychiatry. 1998;59 Suppl 20:15-21.
Lippincott’s primary care psychiatry Medically Unexplained symptoms

10. Having unexplained physical complaints does not mean that a patient has a psychiatric disorder
DSV-IV had an over emphasis on medically unexplained symptoms when making a diagnosis.
-In reality it can be quite difficult to deem something as “medically unexplained.”
-You can have a known physical disorder and still have somatic symptom disorder or something similar
-Old system was too rigid, classifying symptoms as either entirely mental or entirely physical.
-Patient also found it demeaning as if there symptoms were not “real”

11. Medically Unexplained Symptoms=
Somatic Disorders /
Historically viewed as physical symptoms with a psychiatric origin

12. Somatic Symptoms and Related Disorders
Illness Anxiety Disorder Somatic Symptom Disorder Factious Disorder Conversion Disorder (functional neurologic symptom disorder)
Illness anxiety disorder: preoccupation with acquiring or having a particular disease.
Focus is on the level of distress and impairment caused by chronic somatic sx rather than whether or not they can be explained.
-Patient may have symptoms, but they are usually mild if present
-focus here is on the distress about the possibility of being sick.
-Difficult to reassure
-used to be called hypochondriasis
Somatic Symptom Disorder: One or more somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to the symptoms
-doesn’t matter whether there is a clear “medical” explanation of symptoms or not
-many patients have somatic symptoms disorder and a medical diagnosis
-symptoms are often vague (pain, fatigue)
-Distress: high anxiety about symptoms, disproportionate thoughts, feelings, or behaviors related to the seriousness of symptoms, excessive time and energy devoted to these symptoms
-Presence of significant somatic symptoms is what differentiates this from illness anxiety disorder
-symptoms present for at least 6 months
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes
Malingering and /or factitious disorder are also possibilities.

13. Somatic Symptoms and Related Disorders
Illness Anxiety Disorder Somatic Symptom Disorder Factious Disorder Conversion Disorder (functional neurologic symptom disorder)
Illness anxiety disorder: preoccupation with acquiring or having a particular disease.
Focus is on the level of distress and impairment caused by chronic somatic sx rather than whether or not they can be explained.
-Patient may have symptoms, but they are usually mild if present
-focus here is on the distress about the possibility of being sick.
-Difficult to reassure
-used to be called hypochondriasis
Somatic Symptom Disorder: One or more somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to the symptoms
-doesn’t matter whether there is a clear “medical” explanation of symptoms or not
-many patients have somatic symptoms disorder and a medical diagnosis
-symptoms are often vague (pain, fatigue)
-Distress: high anxiety about symptoms, disproportionate thoughts, feelings, or behaviors related to the seriousness of symptoms, excessive time and energy devoted to these symptoms
-Presence of significant somatic symptoms is what differentiates this from illness anxiety disorder
-symptoms present for at least 6 months
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes
Malingering and /or factitious disorder are also possibilities.

14. Illness Anxiety Disorder
Core Feature: Preoccupation with acquiring or having a serious illness
-focus here is on the distress about the possibility of being sick.
-Difficult to reassure-usually have excessive health related behaviors (lab draws, repeated self exams or physician exams). -preoccupation lasts at least 6 months though the symptoms may change over time
-used to be called hypochondriasis
Illness anxiety disorder: preoccupation with acquiring or having a particular disease.
Focus is on the level of distress and impairment caused by chronic somatic sx rather than whether or not they can be explained.

15. Illness Anxiety Disorder
Somatic symptoms are not present, or are mild
High level of anxiety about health
Excessive health related behaviors or exhibits maladaptive avoidance
Present for greater than 6 months
-focus here is on the distress about the possibility of being sick.
-Difficult to reassure-usually have excessive health related behaviors (lab draws, repeated self exams or physician exams). -preoccupation lasts at least 6 months though the symptoms may chagne over time
-used to be called hypochondriasis

17. Somatic Symptoms and Related Disorders
Illness Anxiety Disorder Somatic Symptom Disorder Factious Disorder Conversion Disorder (functional neurologic symptom disorder)
Illness anxiety disorder: preoccupation with acquiring or having a particular disease.
Focus is on the level of distress and impairment caused by chronic somatic sx rather than whether or not they can be explained.
-Patient may have symptoms, but they are usually mild if present
-focus here is on the distress about the possibility of being sick.
-Difficult to reassure
-used to be called hypochondriasis
Somatic Symptom Disorder: One or more somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to the symptoms
-doesn’t matter whether there is a clear “medical” explanation of symptoms or not
-many patients have somatic symptoms disorder and a medical diagnosis
-symptoms are often vague (pain, fatigue)
-Distress: high anxiety about symptoms, disproportionate thoughts, feelings, or behaviors related to the seriousness of symptoms, excessive time and energy devoted to these symptoms
-Presence of significant somatic symptoms is what differentiates this from illness anxiety disorder
-symptoms present for at least 6 months
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes
Malingering and /or factitious disorder are also possibilities.

18. Somatic Symptom Disorder
Core Feature: Distressing somatic symptoms and abnormal thoughts, feeling, and behaviors in response
Somatic Symptom Disorder: One or more somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to the symptoms
-doesn’t matter whether there is a clear “medical” explanation of symptoms or not
-many patients have somatic symptoms disorder and a medical diagnosis
-symptoms are often vague (pain, fatigue)
-Distress: high anxiety about symptoms, disproportionate thoughts, feelings, or behaviors related to the seriousness of symptoms, excessive time and energy devoted to these symptoms
-Presence of significant somatic symptoms is what differentiates this from illness anxiety disorder
-symptoms present for at least 6 months
Malingering and /or factitious disorder are also possibilities.

19. Individual distress is authentic whether or not it is medically explained

20. Somatic Symptom Disorder
One or more somatic symptoms that are distressing or result in significant disruption of daily life.
Excessive thoughts, feelings, or behavior related to sx or associated health concerns manifesting as at least 1 of the following:
-High level of heath-related anxiety
-Disproportionate concern about the medical seriousness of one's symptoms
-Excessive time and energy devoted to these symptoms or health concerns 
3. The state of being symptomatic lasts more than 6 months.
 symptoms sometimes represent normal bodily sensations or discomfort that does not generally signify serious disease.
-many patients have somatic symptoms disorder and a medical diagnosis
-symptoms are often vague (pain, fatigue)
-Distress: high anxiety about symptoms, disproportionate thoughts, feelings, or behaviors related to the seriousness of symptoms, excessive time and energy devoted to these symptoms
-Presence of significant somatic symptoms is what differentiates this from illness anxiety disorder
-symptoms present for at least 6 months

21. Somatic Symptoms and Related Disorders
Illness Anxiety Disorder Somatic Symptom Disorder Factious Disorder Conversion Disorder (functional neurologic symptom disorder)
Illness anxiety disorder: preoccupation with acquiring or having a particular disease.
Focus is on the level of distress and impairment caused by chronic somatic sx rather than whether or not they can be explained.
-Patient may have symptoms, but they are usually mild if present
-focus here is on the distress about the possibility of being sick.
-Difficult to reassure
-used to be called hypochondriasis
Somatic Symptom Disorder: One or more somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to the symptoms
-doesn’t matter whether there is a clear “medical” explanation of symptoms or not
-many patients have somatic symptoms disorder and a medical diagnosis
-symptoms are often vague (pain, fatigue)
-Distress: high anxiety about symptoms, disproportionate thoughts, feelings, or behaviors related to the seriousness of symptoms, excessive time and energy devoted to these symptoms
-Presence of significant somatic symptoms is what differentiates this from illness anxiety disorder
-symptoms present for at least 6 months
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes
Malingering and /or factitious disorder are also possibilities.

22. Factitious Disorder (Munchausen)
Core Feature: Deceptively falsifying of medical or psychological symptoms in yourself or someone else

23. Factitious Disorder (munchausen)
Falsification of physical or psychological sx, or induction of injury or disease associated with deception
Individual presents self to others as ill, injured, or impaired
Deception is present in absence of obvious external rewards
“Imposed on Self” or “Imposed on Another”
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes

24. She told everyone Gypsy had diseases like leukemia and epilepsy, forced her to use a wheelchair and a feeding tube and made her take prescription drugs she didn’t need. Dee Dee even shaved Gypsy’s head to make her appear sick. 

25. Somatic Symptoms and Related Disorders
Illness Anxiety Disorder Somatic Symptom Disorder Factious Disorder Conversion Disorder (functional neurologic symptom disorder)
Illness anxiety disorder: preoccupation with acquiring or having a particular disease.
Focus is on the level of distress and impairment caused by chronic somatic sx rather than whether or not they can be explained.
-Patient may have symptoms, but they are usually mild if present
-focus here is on the distress about the possibility of being sick.
-Difficult to reassure
-used to be called hypochondriasis
Somatic Symptom Disorder: One or more somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to the symptoms
-doesn’t matter whether there is a clear “medical” explanation of symptoms or not
-many patients have somatic symptoms disorder and a medical diagnosis
-symptoms are often vague (pain, fatigue)
-Distress: high anxiety about symptoms, disproportionate thoughts, feelings, or behaviors related to the seriousness of symptoms, excessive time and energy devoted to these symptoms
-Presence of significant somatic symptoms is what differentiates this from illness anxiety disorder
-symptoms present for at least 6 months
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes
Malingering and /or factitious disorder are also possibilities.

26. (functional neurological symptoms disorder)
Conversion Disorder
 (functional neurological symptoms disorder)
Core Feature: Altered motor or sensory function that is inconsistent with a medical diagnosis
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes

27. (functional neurologic symptoms disorder)
Conversion Disorder
(functional neurologic symptoms disorder)
One or more symptoms of altered voluntary motor or sensory function
Not consistent with a medical diagnosis
Causes some sort of impairment in function, significant, distress, or requires medical evaluation
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes

28. (functional neurologic symptoms disorder)
Conversion Disorder
(functional neurologic symptoms disorder)
Non-epileptic seizures
Partial paralysis/weakness
Tremor or gait problems
Loss of sight
Difficulty swallowing
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes

30. Somatic Symptoms and Related Disorders
Illness Anxiety Disorder Somatic Symptom Disorder Factious Disorder Conversion Disorder (functional neurologic symptom disorder)
Illness anxiety disorder: preoccupation with acquiring or having a particular disease.
Focus is on the level of distress and impairment caused by chronic somatic sx rather than whether or not they can be explained.
-Patient may have symptoms, but they are usually mild if present
-focus here is on the distress about the possibility of being sick.
-Difficult to reassure
-used to be called hypochondriasis
Somatic Symptom Disorder: One or more somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to the symptoms
-doesn’t matter whether there is a clear “medical” explanation of symptoms or not
-many patients have somatic symptoms disorder and a medical diagnosis
-symptoms are often vague (pain, fatigue)
-Distress: high anxiety about symptoms, disproportionate thoughts, feelings, or behaviors related to the seriousness of symptoms, excessive time and energy devoted to these symptoms
-Presence of significant somatic symptoms is what differentiates this from illness anxiety disorder
-symptoms present for at least 6 months
Conversion Disorder
-one or more symptoms of altered voluntary motor or sensory function
-not consistent with a medical diagnosis
-causes some sort of impairment in function OR distress
-motor symptoms (weakness, paralysis, tremor, gait problems etc. ) or sensory (seizures, loss of skin sensation, alterations in speech, vision, globus sensation, etc.)
-Conversion Disorder focuses more on the unexplained loss of function and less on the distress that it causes
Malingering and /or factitious disorder are also possibilities.

31. How do these develop?
Biological Factors: increased sensitivity to pain
Social: early traumatic experiences
Psychological: learning, attention obtained from illness, or lack of reinforcement of nonsomatic expressions of distress
(ex:), 

32. Treatment
CARE MD
A mnemonic for caring for patients with chronic somatic symptoms

33. Treatment
SCARE MD
A mnemonic for caring for patients with chronic somatic symptoms

34. Treatment
MD CARES
A mnemonic for caring for patients with chronic somatic symptoms

35. Mind-body Connection Do No Harm Collaboration Assessment Regular Visits Empathy Set Realistic Goals

36. Collaboration
Who else should be apart of this treatment team?

37. 2. Psychological Symptoms
Assessment
1. Physical Symptoms
2. Psychological Symptoms
3. Prior Work up
Often done over multiple visits
Determine if there is a medical explanation that may have been missed or a comorbid mental illness that can be treated. Either one will improve functioning
Consider consulting others on whether or not prior work up is complete or not
Review Records
Write a summary note
Focus on gather information rather than giving information

38. Regular Visits Regular visits can reduce costs by 50%
Psychiatric Consultation in Somatization Disorder
G. Richard Smith, Jr., M.D., Roberta A. Monson, M.D., and Debby C. Ray, B.S.
N Engl J Med 1986; 314:
List reasons why regular visits are good for both patients and provider
Regular visits from the patient standpoint: visits without a crisis, improve outcomes, decreases ED visits
From the provider standpoint: allow you to triage complaints rather than all in one, allows for health maintenance, allows for check in regarding collaboration, necessary to reinforce the mind body connection, decreases phone calls/ED visits/and mychart messages
These should be short visits and short notes
Smith et al. Psychiatric Consultation in Somatization Disorder. N Engl J Med 1986; 314:

39. Regular Visits
Necessary due to the volume and intensity of symptoms in the patient and the provider
Psychiatric Consultation in Somatization Disorder
G. Richard Smith, Jr., M.D., Roberta A. Monson, M.D., and Debby C. Ray, B.S.
N Engl J Med 1986; 314:
List reasons why regular visits are good for both patients and provider
Regular visits from the patient standpoint: visits without a crisis, improve outcomes, decreases ED visits
From the provider standpoint: allow you to triage complaints rather than all in one, allows for health maintenance, allows for check in regarding collaboration, necessary to reinforce the mind body connection, decreases phone calls/ED visits/and mychart messages
These should be short visits and short notes
Smith et al. Psychiatric Consultation in Somatization Disorder. N Engl J Med 1986; 314:

40. Focused check-in on symptoms Introduce Mind-body Connection
Regular Visits
Focused Exam
Focused check-in on symptoms
Introduce Mind-body Connection
Focused exam especially early on
with focus on triggers/coping strategies

41. Patients will not let you care for them, unless they feel that you care about them
Empathy
Sometimes we do a poor job of helping our patients feel as though we care even though we do
-example of coming into a room with no empathy

42. Avoid statements that assume that symptoms are not real
Mind-Body Connection
Symptom logs
Wonder out loud
Avoid statements that assume that symptoms are not real
Logs that include things like stress level or mood
Introduce ideas don’t pass judgment (express curiousity and wonder outloud). Plenty of opportunities because patient are looking for answers
Avoid statements that assume that symptoms are not real

43. Every one of us has a somatic component to our emotional lives

44. Do No Harm Sometimes less is more
Sometimes less is more. Avoid uncessary tests.
Don’t be afraid of healthy conflict
Also means self-care.

45. Set Realistic Goals Reduction in ER visits or Hospitalizations
Reduction in Opiate Dose
Improvement in Pain
Decreased expense to the Patient
Sometimes less is more. Avoid uncessary tests.
Also means self-care.

46. Case 1
A 25 yo married male comes into clinic complaining of warmth in his groin and bumps on his scrotum. He reports that symptoms began after an erotic massage he received at a massage parlor. Symptoms come and go. He is concerned that he may have contracted an STD from the massage though there was no intercourse. He has been seen 3 times in the past 8 weeks for the same complaint and repeated STD testing is normal. He was referred to urology who found a varicocele which was surgically repaired. He underwent repeat imaging which now shows a small varicocele on the opposite side. He presents today asking for another HIV test.

47. Questions?