1. May 25, 2005 Somatoform Disorder or Medically Unexplained Symptoms Bruce Slater, MD, MPH Associate Professor (CHS) University of Wisconsin School of Medicine

2. May 25, 2005 Learning Objectives Discuss Several Theories of Somatoform Disorder List Techniques for Recognizing Somatoform Disorder Review Treatment Approaches for Patients With Medically Unexplained Symptoms

3. May 25, 2005 Financial Disclosure No Financial Support

4. May 25, 2005 Case Presentation 12 Visits Over 9 Months for Abdominal Pain Apparently Unnecessary Treatment for Presumed Disease Extensive Diagnostic Evaluation Several Consultants

5. May 25, 2005 Clinical Features of Case Slowly Evolving Nature of Symptoms Contradictory Symptomatology Minimal Secondary Gain Underlying Anxiety Uncovered

6. May 25, 2005 Historical Origins Dark Ages Organ Based Explanations of Disease Uterus Frequently Blamed for MUS Hysterical Symptoms 1667 Thomas Willis - ? Brain Involvement 1889 Charcot ?Nervous Center Lesion Babinski/Freud Psychological Explanations

7. May 25, 2005 (Loose) Diagnostic Criteria Several Non-specific Symptoms in Different Organ Systems Chronic Course Frequently Co-morbid for Psychiatric Disease Ten Times More Common in Women Fully Developed by Age 30

8. May 25, 2005 Diagnostic Criteria Diagnostic and Statistical Manual (DSM IV) –Multiple Recurring Pains and Symptoms Gastrointestinal Sexual Pseudoneurological –Occurring Over a Period of Years –Not Intentionally Induced –Significance Result in Medical Attention Functional Impairment

9. May 25, 2005 Therapeutic Approach Empathy Rational Reassurance Evaluation of Equivocal Symptoms Symptom Based Care Emphasize Return to Normal Activities Approach Psychiatric Disease Separately Treat Psychiatric Disease Actively

10. May 25, 2005 Therapeutic Approach (Details) Step 1 Set Stage, Intro, Ensure Comfort Step 2 Agenda (Constraints, the List, Negotiate) Step 3 HPI Open Ended, Non-focused, Gather Data Step 4 Focus on Symptoms, Context, Emotion, Address Emotion Step 5 Transition – Summary, Check, Assess Readiness to Change Focus to Physician Centered From RC Smith, et al. JGIM 2003

11. May 25, 2005 Interesting Findings and Theories Patients With Irritable Bowel Are Sensitive to Distention in the Gut, but Not As Sensitive to Pain From Skin. Increased Anxiety Is Associated With Increased Pain (Battlefield Versus Mva) Adrenaline Released at Sympathetic Nerve Endings May Sensitize Nociceptors and Trigger Somatic Muscle Tension Reflexes

12. May 25, 2005 From Wilhelmsen, Gut 2000;47 (Suppl 4);iv5-iv7(December)

13. May 25, 2005 More Interesting Theories Amplification of Bodily Sensations –Panic Attacks –Somatisation Family Dynamics and the Identified Patient The Need to Be Sick Dissociation –(Sensory Experience in the Absence of Sensory Stimulation) From D Servan-Schreiber AFP 2000

14. May 25, 2005 Summary Evolving Concepts Frequent in Minor Incomplete “Form Frust” Rule Out Disease for Rational And/or Potentially Serious Symptoms Understand the Patient With the Disease Care Not Cure

15. May 25, 2005 Questions for Me? Do You Enjoy Seeing Patients With Mus? What Diagnostic Clues Can You Add? What Have You Tried Therapeutically? Questions for You

16. May 25, 2005 References Brain-gut Axis As an Example of the Bio-psycho-social Model. I Wilhelmsen, Gut 2000;47(Suppl IV):Iv5-iv7 (December) Treating Patients With Medically Unexplained Symptoms in Primary Care. RC Smith. J Gen Intern Med 18:478-488. June 2003 Somatizing Patients: Part I. Practical Diagnosis. D Servan-Schreiber, et al. Am Fam Physician 61/4; pp. 1073-1079 2/15/2000.