Somatic symptom disorder in primary care: A collaborative approach

,

doi:doi: 10.12788/jfp.0384

Behavioral Health

Somatic symptom disorder in primary care: A collaborative approach

J Fam Pract. 2022 April;71(3):E8-E12 | doi: 10.12788/jfp.0384

PDF Download

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition (DSM-5). American Psychiatric Publishing; 2013.

2. Johnson KK, Bennett C, Rochani H. Significant improvement of somatic symptom disorder with brief psychoeducational intervention by PMHNP in primary care. J Am Psychiatr Nurses Assoc. 2020;28:171-180. doi: 10.1177/1078390320960524

3. Weigel A, Maehder K, Witt M, et al. Psychotherapists’ perspective on the treatment of patients with somatic symptom disorders. J Psychosom Res. 2020;138:110228. doi: 10.1016/j.jpsychores.2020.110228

4. American Psychiatric Association. Handbook of Differential Diagnosis. American Psychiatric Publishing; 2014;234-235.

5. Mayo Clinic. Somatic symptom disorder. Accessed February 21, 2022. www.mayoclinic.org/diseases-conditions/somatic-symptom-disorder/symptoms-causes/syc-20377776?p=1

6. Toussaint A, Riedl B, Kehrer S, et al. Validity of the Somatic Symptom Disorder-B Criteria Scale (SSD-12) in primary care. Fam Pract. 2018;35:342-347. doi: 10.1093/fampra/cmx116

7. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64:258-66. doi: 10.1097/00006842-200203000-00008

8. Kroenke K, Spitzer RL, Williams JB, et al. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32:345-359. doi: 10.1016/j.genhosppsych.2010.03.006

9. Toussaint A, Löwe B, Brähler E, et al. The Somatic Symptom Disorder - B Criteria Scale (SSD-12): factorial structure, validity and population-based norms. J Psychosom Res. 2017;97:9-17. doi: 10.1016/j.jpsychores.2017.03.017

10. First MB, Williams JBW, Karg RS, Spitzer RL, eds. Structured Clinical Interview for DSM-5 Disorders, Research Version. American Psychiatric Association, 2015.

11. First MB, Williams JBW, Karg RS, Spitzer RL, eds. Structured Clinical Interview for DSM-5 Disorders, Clinician Version. American Psychiatric Publishing; 2016.

12. McDaniel SH, Hepworth J, Campbell TL, et al, eds. Family Oriented Primary Care. Springer Publishing Co; 2005:1-15.

13. Hunter Integrated Pain Service (2016). Brainman videos. Hunter New England Local Health District. New South Wales, Australia. Accessed February 21, 2022. www.tga.gov.au/chronic-pain-management-video-resource-brainman

14. Murray AM, Toussaint A, Althaus A, et al. The challenge of diagnosing non-specific, functional, and somatoform disorders: a systematic review of barriers to diagnosis in primary care. J Psychosom Res. 2016;80:1-10. doi: 10.1016/j.jpsychores.2015.11.002

15. Leaviss J, Davis S, Ren S, et al. Behavioral modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess. 2020;24:1-490. doi: 10.3310/hta24460

16. Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. 2007;69:881-888. doi: 10.1097/PSY.0b013e31815b00c4

17. Steinbrecher N, Koerber S, Frieser D, et al. The prevalence of medically unexplained symptoms in primary care. Psychosomatics. 2011;52:263-271. doi: 10.1016/j.psym.2011.01.007

18. Kessler R, Stafford D. Primary care is the de facto mental health system. In Kessler R, Stafford D, eds. Collaborative Medicine Case Studies: Evidence in Practice. Springer Publishing Co, 2008; 9-21.

19. Barsky AJ, Ahern DK, Bauer MR, et al. A randomized trial of treatments for high-utilizing somatizing patients. J Gen Intern Med. 2013;28:1396-1404. doi: 10.1007/s11606-013-2392-6

20. Newby JM, Smith J, Uppal S, et al. Internet-based cognitive behavioral therapy versus psychoeducation control for illness anxiety disorder and somatic symptom disorder: A randomized controlled trial. J Consult Clin Psychol. 2018;86:89-98. doi: 10.1037/ccp0000248

21. van Dessel N, den Boeft M, van der Wouden JC, et al. Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane Database Syst Rev. 2014(11):CD011142. doi: 10.1002/14651858.CD011142.pub2

22. Verdurmen MJ, Videler AC, Kamperman AM, et al. Cognitive behavioral therapy for somatic symptom disorders in later life: a prospective comparative explorative pilot study in two clinical populations. Neuropsychiatr Dis Treat. 2017;13:2331-2339. doi: 10.2147/NDT.S141208

23. Liu J, Gill NS, Teodorczuk A, et al. The efficacy of cognitive behavioural therapy in somatoform disorders and medically unexplained physical symptoms: a meta-analysis of randomized controlled trials. J Affect Disord. 2019;245:98-112. doi: 10.1016/j.jad.2018.10.114

24. Abbass A, Leichsenring F, Steinert C. Re: Jing et al., the efficacy of cognitive behavioural therapy in somatoform disorders and medically unexplained physical symptoms: a meta-analysis of randomized controlled trials. J Affect Disord. 2019;255:S0165-0327(18)33197-5. doi: 10.1016/j.jad.2019.02.055

Structured Clinical Interview for DSM Disorders (SCID)^10,11 is perhaps the most rigorous differential diagnostic tool. However, SCID administration requires training and skill; time for administration and cost of the materials may be prohibitive in primary care.

CBT is empirically supported as a treatment approach to medically unexplained symptoms and somatic symptom disorder.

Finally, SSD symptoms are highly associated with depression and anxiety. Ongoing elevated screening scores for anxiety and depression refractory to interventions may indicate the possibility of overlooked SSD. Furthermore, use of SSD screening tools with anxiety and depression screening tools can provide a more comprehensive picture of impairment, as well as symptom progress.

Treatment: Avoid a split approach

Diagnosing and treating SSD can be challenging for physicians who focus on biomedically based approaches in patient care. Additional tests, studies, and prescriptions are likely to fuel (rather than pacify) patients’ concerns, as such steps divert attention from the underlying psychological needs and mechanisms which maintain SSD. Avoid using a split biopsychosocial approach—ie, beginning the inquiry and treatment planning from a biomedical perspective, and then falling back on psychosocial formulation when treatment efforts have been ineffective. Such an approach leads to understandable patient dissatisfaction and can be interpreted by them as the caregiver suggesting that physical symptoms are “all in [their] head.”¹²

These 4 tips can help

1. Use a biopsychosocial formulation when initiating treatment. Be familiar with biopsychosocial factors in SSD and develop a narrative for discussing this formulation with patients. For example: “Mr. R, we are going to use the following [medical tests/studies/medications] to understand the cause of your symptoms and better manage them. We also need to think about the role of stress and distress in your symptoms because these can also be at play with dizziness.” This may be particularly beneficial for a functional disorder, such as chronic pain. Incorporating patient education resources is an important step toward shared understanding (see Hunter Integrated Pain Service for chronic pain educational videos; www.tga.gov.au/chronic-pain-management-video-resource-brainman¹³).

2. Combine education about pathophysiology with patient-centered interviewing. Significant SSD symptom improvements were noted following a single 30-minute educational session, while motivational interviewing techniques were used to probe patients’ concerns.²

Continue to: Maintain professionalism and good clinical practice