Unexplained Physical Symptoms

What’s a Psychiatrist to Do?

By Humberto Marin, MD and Javier I. Escobar, MD

| August 1, 2008

Dr Marin is assistant professor in the department of psychiatry and Dr Escobar is associate dean of global health and professor of psychiatry and family medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School in New Brunswick. Dr Marin reports that he has received research support from Eli Lilly and Pfizer. Dr Escobar reports that he has no conflicts of interest concerning the subject matter of this article.

Treatment Options

Evidence is rapidly growing for the usefulness of modified cognitive-behavioral therapies for somatoform syndromes.^30,31 A comprehensive model successfully applied in several studies included relaxation training, behavioral management, cognitive restructuring, emotion identification, emotion regulation, and interpersonal skills training.³² Other types of psychotherapy have not been tested in well-controlled studies. However, it is our impression that intensive or exploratory therapies that focus on internal conflict and mental change may be counterproductive.

As mentioned, mental disorders such as significant depression and anxiety are common in those with SD and should be specifically addressed. However, there is no clear evidence from randomized clinical trials demonstrating the efficacy of psychotropic drugs for the treatment of unexplained physical symptoms. The benefit observed in some studies has been attributed to the effect of medications on anxiety or depressive symptoms and not to a direct effect on somatic symptoms.

On the basis of our clinical experience, patients with SD accompanied by significant depression and anxiety symptoms can be initially treated with an SSRI or a serotonin norepinephrine(Drug information on norepinephrine) reuptake inhibitor. Mirtazapine(Drug information on mirtazapine) seems to be a reasonable first option for patients with unexplained symptoms who have significant insomnia or anorexia because of the drug’s positive effects on sleep and appetite. In patients with significant fatigue/sleepiness or poor concentration, or those in whom the avoidance of sexual adverse effects is paramount, bupropion may be a good first-line agent.

Because patients with SD may be at a heightened risk for addiction or dependence, caution must be exercised when prescribing medications with addictive potential, such as opiate analgesics and tranquilizers such as benzodiazepines. In patients with SD, pain complaints are very common and include headaches, and joint, abdominal, and pelvic pain. NSAIDs should be used whenever possible for pain relief.

FDA-Approved Medications

The anticonvulsant pregabalin(Drug information on pregabalin) and the antidepressant duloxetine(Drug information on duloxetine) have been recently approved for the treatment of fibromyalgia. Pregabalin has analgesic properties, especially for neuropathic pain, and has also shown some antianxiety effects in randomized clinical trials. Duloxetine, a dual action antidepressant, also seems to exert some analgesic properties similar to those reported for other dual action drugs as well as tricyclic antidepressants.

Lufriprostone has been approved for clinical use in irritable bowel symptoms alternating with chronic idiopathic constipation syndromes. This drug appears to exert a laxative action by increasing the secretion of chloride and fluid in the intestinal epithelium.

Fluoxetine(Drug information on fluoxetine), paroxetine(Drug information on paroxetine), and sertraline(Drug information on sertraline) have been approved for the treatment of premenstrual dysphoric disorder/premenstrual syndrome, which have a number of somatic manifestations and also include anxiety and depression symptoms. A recent meta-analysis found that all SSRIs seem to be about equally helpful for premenstrual symptoms, their continuous use is better than intermittent use, and their clinical effect on symptoms seems to be relatively small.³³

The Future Definition of SD

As we prepare for the new edition of DSM-V, we suggest the following:

• Consider a dimensional approach for unexplained physical symptoms with differences in severity.
• Avoid further expansion of somatoform categories and the mechanistic count of symptoms and systems. There is a need for evidence-based,inclusive, and simpler definitions.
• Do not devalue the psychological, cultural, and social aspects in patients with somatoform disorders; instead, emphasize their character as complex expressions of distress and sickness.
• Do not subordinate somatic presentations to other mental disorders or to purely mental mechanisms. Acknowledge the unique and independent nature of somatoform disorders.

Drugs Mentioned in This Article
Bupropion (Wellbutrin, Zyban)
Duloxetine (Cymbalta)
Fluoxetine (Prozac, Sarafem)
Gabapentin(Drug information on gabapentin) (Neurontin)
Lubriprostone (Amitiza)
Mirtazapine (Remeron)
Paroxetine (Paxil)
Pregabalin (Lyrica)
Sertraline (Zoloft)

Pages: 1 2 3 4 5

References
1. Stekel W. Die Sprache des Traumes. Wiesbaden, Germany: Bergmann; 1911.
2. Lipowski ZJ. Somatization: the concept and its clinical application. Am J Psychiatry. 1988;145:1358-1368.
3. Briquet P. Traité l’hystérie. Paris: Baillière; 1859.
4. Purtell JJ, Robins E, Cohen ME. Observations on clinical aspects of hysteria. JAMA. 1951;146:902-909.
5. Perley MJ, Guze SB. Hysteria: the stability and usefulness of clinical criteria. N Engl J Med. 1962;266: 421-426.
6. Feighner JP, Robins E, Guze SB, et al. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry. 1972;26:57-63.
7. Spitzer RL, Endicott J, Robins E. Research diagnostic criteria: rationale and reliability. Arch Gen Psychiatry. 1978;35:773-782.
8. Eminson DM. Medically unexplained symptoms in children and adolescents. Clin Psychol Rev. 2007;27: 855-871.
9. Escobar JI, Burnam MA, Karno M, et al. Somatization in the community. Arch Gen Psychiatry. 1987;44: 713-718.
10. Grabe HJ, Meyer C, Hapke U, et al. Specific somatoform disorder in the general population. Psychosomatics. 2003;44:304-311.
11. Gureje O, Simon GE, Ustun TB, Goldberg DP. Somatization in cross-cultural perspective: a World Health Organization study in primary care. Am J Psychiatry. 1997;154:989-995.
12. Smith GR, Monson RA, Ray DC. Patients with multiple unexplained symptoms: their characteristics, functional health, and health care utilization. Arch Intern Med. 1986;146:69-72.
13. Bass C, Murphy M. Somatisation disorder in a British teaching hospital. Br J Clin Pract. 1991;45: 237-244.
14. Craig TK, Boardman AP, Mills K, et al. The South London Somatisation Study, I: longitudinal course and the influence of early life experiences. Br J Psychiatry. 1993;163:579-588.
15. Bohman M, Cloninger R, von Knorring AL, Sigvardsson S. An adoption study of somatoform disorders, III: cross-fostering analysis and genetic relationship to alcoholism and criminality. Arch Gen Psychiatry. 1984;41:872-878.
16. Buskila D, Neumann L, Hazanov I, Carmi R. Familial aggregation in the fibromyalgia syndrome. Semin Arthritis Rheum. 1996;26:605-611.
17. Walker EA, Unutzer J, Rutter C, et al. Costs of health care use by women HMO members with a history of childhood abuse and neglect. Arch Gen Psychiatry. 1999;56:609-613.
18. Grunau RV, Whitfield MF, Petrie JH, Fryer EL. Early pain experience, child and family factors, as precursors of somatization: a prospective study of extremely premature and fullterm children. Pain. 1994;56:353-359.
19. Hotopf M, Mayou R, Wadsworth M, Wessely S. Childhood risk factors for adults with unexplained symptoms: results from a national birth cohort study. Am J Psychiatry. 1999;156:1796-1800.
20. Escobar JI, Canino G, Rubio-Stipec M, Bravo M. Somatic symptoms after a natural disaster: a prospective study. Am J Psychiatry. 1992;149:965-967.
21. Wilhelmsen I. Somatization, sensitization, and functional dyspepsia. Scand J Psychol. 2002;43:177-180.
22. Rief W, Hiller W, Margraf J. Cognitive aspects of hypochondriasis and the somatization syndrome. J Abnorm Psychol. 1998;107:587-595.
23. Craig TK, Drake H, Mills K, Boardman AP. The South London Somatisation Study, III: influence of stressful life events, and secondary gain. Br J Psychiatry. 1994;165:248-258.
24. Allen LA, Gara MA, Escobar JI, et al. Somatization: a debilitating syndrome in primary care. Psychosomatics. 2001;42:63-67.
25. Escobar JI, Gara M, Silver RC, et al. Somatisation disorder in primary care. Br J Psychiatry. 1998;173: 262-266.
26. Hartz AJ, Noyes R, Bentler SE, et al. Unexplained symptoms in primary care: perspectives of doctors and patients. Gen Hosp Psychiatry. 2000;22:144-152.
27. García-Campayo J, Claraco LM, Sanz-Carrillo C, et al. Assessment of a pilot course on the management of somatization disorder for family doctors. Gen Hosp Psychiatry. 2002;24:101-105.
28. Smith GR Jr, Rost K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry. 1995;52:238-243.
29. Servan-Schreiber D, Tabas G, Kolb R. Somatizing patients, part II: practical management. Am Fam Physician. 2000;61:1423-1428, 1431-1432.
30. Allen LA, Woolfolk RL, Escobar JI, et al. Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial. Arch Intern Med. 2006;166:1512-1518.
31. Escobar JI, Gara MA, Diaz-Martinez AM, et al. Effectiveness of a time-limited cognitive behavior therapy type intervention among primary care patients with medically unexplained symptoms. Ann Fam Med. 2007;5:328-335.
32. Woolfolk RL, Allen LA, Tiu JE. New directions in the treatment of somatization. Psychiatr Clin North Am. 2007;30:621-644.
33. Shah NR, Jones JB, Aperi J, et al. Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder: a meta-analysis. Obstet Gynecol. 2008;111:1175-1182.
34. Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet. 2007;369: 1691-1692.

Evidence-Based References
Escobar JI, Gara MA, Diaz-Martinez AM, et al. Effectiveness of a time-limited cognitive behavior therapy type intervention among primary care patients with medically unexplained symptoms. Ann Fam Med. 2007;5:328-335.
Smith GR Jr, Rost K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry. 1995;52:238-243.

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Unexplained Physical Symptoms

What’s a Psychiatrist to Do?

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