Re: AAEM News: Influential Psychiatrist Expands Unexplained Illnesses to Include Fo

[Guest guest]

Dear Gil,

Here is the original article by Dr. Escobar,

written for a psychiatric newspaper funded

primarily by drug company ads, not in a scholarly

journal. Nevertheless, the Psychiatric Times is

very influential among psychiatrists. Escobar is

saying that environmentally-evoked illnesses are

medically unexplained, and therefore must be

psychiatric. The truth is just the

opposite: when people associate symptoms as

provoked by environmental incitants, the likely

explanation can be seen. Who would not agree

with this? The chemical, insurance, real estate,

and food industries and the military, who wish to

obscure the role of chemicals, molds, and foods

in the development of illnesses. If they

succeed, people with environmentally-induced

diseases will all be labelled as psychiatric, and

will be denied medical treatment. I agree with

you that Escobar's conclusions are disgusting.

Appreciatively,

Lawrence Plumlee, M.D.

Special Report

PSYCHIATRY AND MEDICAL ILLNESS

Unexplained Physical Symptoms

What’s a Psychiatrist to Do?

<http://www.psychiatrictimes.com/dsm-v/article/10168/1171223?pageNumber=1>http:/\

/www.psychiatrictimes.com/dsm-v/article/10168/1171223?pageNumber=1#

Humberto Marin, MD and I. Escobar, MD

Psychiatric Times. Vol. 25 No. 9

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– Wood

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.

CHECK POINTS

* Medically unexplained physical symptoms are

more common in women, in persons from lower

socioeconomic backgrounds, and in certain ethnic

groups, as well as in children and adolescents.

* Unexplained physical symptoms tend to have

a chronic, protracted course, and the causes are multifactorial.

* In treating somatization disorder (SD),

psychiatric comorbidities such as significant

depression and anxiety symptoms should be specifically addressed.

* Because patients with SD may be at higher

risk for addiction or dependence, caution is

advised for the use of medications with addictive

potential, especially opiate analgesics and

tranquilizers, such as benzodiazepines.

The key manifestations of DSM-IV somatoform

disorder are unexplained physical symptoms or

complaints that tend to coexist with other

psychiatric syndromes or are linked to

psychological issues. These symptoms typically

lead to repeated medical or emergency department

visits; are associated with serious discomfort,

dysfunction, and disability; and lead to

significant health expenditures. Despite their

frequency and relevance to both primary care and

psychiatric practices, the definition,

classification, and management of these disorders

remain difficult and controversial. Moreover,

there are little systematic research data

available for these disorders across medical

disciplines. Diagnostic changes made on the basis

of capricious committee recommendations often

become a “moving target,” thus decreasing the

ability to compare studies over time.

A Brief History

Dramatic and peculiar somatic manifestations that

perplex clinicians have been with us since

ancient times. A brief review of their historical

evolution shows that they metamorphose as medical

paradigms change. For example, labels such as

hysteria, hypochondria, spleen, English disease,

soldier’s heart, neurocirculatory asthenia,

neurasthenia, surmenage, humoral disorders,

psychosomatic disorders, and many others have

been fashionable or relevant during certain

periods, but most eventually faded into oblivion

or were replaced by more technical terminology.

Despite steady efforts to eradicate them, the

survival of some of these terms (hysteria,

neurasthenia) is probably proof of their validity.

In psychiatry, the term “somatization” has been

used for decades to label these somatic

presentations. The classical concept of

somatization was coined by Wilhelm Stekel,1 a

Viennese psychoanalyst who immigrated to America.

He described it as a “deep-seated neurosis” or as

the “process by which neurotic conflicts appear

as a physical disorder.” In North American

psychiatry, this concept was expanded by Zbigniew

J. Lipowski,2 who described somatization as the

“tendency to experience, conceptualize, and/or

communicate psychological states or meanings as

corporeal sensations, functional changes, or somatic metaphors.”

===

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The psychogenic view generally considered somatic

presentations as ancillary manifestations of

psychological discomfort. The more direct and

pragmatic approach to somatization that would

eventually lead to the atheoretical frame of

modern nomenclatures began with French

psychopathologist Pierre Briquet,3 who, in 1859,

brought an observational or experiential

perspective to the study of hysteria during the

golden age of French psychopathology. His

description of a syndrome inclusive of multiple

motor and sensorial symptoms (pseudoneurological

symptoms) made possible the separation of somatization from conversion.

In the 1950s, a group of investigators at

Washington University–Renard Hospital in St Louis

resurrected Briquet’s concept of hysteria in

several clinical studies. They formulated

criteria for the diagnosis of hysteria that

required the presence of a specified number of

symptoms from a comprehensive list that included

physical and psychological manifestations,

personality traits, and behavioral expressions,

in addition to the neurological symptoms from the

traditional French definition.4,5

With a few modifications, these were the criteria

for somatization disorder proposed by hner

and colleagues6 in 1972 in their seminal paper,

“Diagnostic Criteria for Use in Psychiatric

Research.” After Spitzer and his

colleagues7 coined the term “somatoform disorder”

(inclusive of the Greek soma and the Latin form),

it officially entered American and world

psychiatric terminology with the publication of

the International Classification of Diseases

criteria in the late 1970s and the DSM-III in the 1980s.

Somatoform Disorders in DSM

Following the publication of DSM-III in the

1980s, somatization disorder (SD) became the key

somatoform diagnosis. In DSM-III and its

subsequent revisions, SD turned into a simple

somatic symptom list that contracted or expanded

rather capriciously. Partly because the

atheoretical perspective of DSM discarded any

presumptions of causality, other manifestations

of the syndrome were not included in the

criteria. The list of somatoform disorders kept

expanding with the addition of vague categories,

such as “undifferentiated somatoform disorder” or

“somatoform disorder NOS [not otherwise

specified],” which, unfortunately, are the most

common diagnoses within the somatoform genre.

These terms failed to transcend specialty

boundaries. Perhaps as a corollary of turf

issues, general medicine and medical specialties

started carving these syndromes with their own

tools. The resulting list of “medicalized,”

specialty-driven labels that continues to expand

includes fibromyalgia, chronic fatigue syndome,

multiple chemical sensitivity, and many others

(<http://www.psychiatrictimes.com/dsm-v/article/10168/1171223?pageNumber=2#table\

1>Table

1).

Table 1 Functional somatic syndromes34

Irritable bowel syndrome

Chronic fatigue syndrome

Fibromyalgia

Multiple chemical sensitivity

Nonspecific chest pain

Premenstrual disorder

Non-ulcer dyspepsia

Repetitive strain injury

Tension headache

Temporomandibular joint

disorder

Atypical facial pain

Hyperventilation syndrome

Globus syndrome

Sick building syndrome

Chronic pelvic pain

Chronic whiplash syndrome

Chronic Lyme disease

Silicone breast implant effects

Candidiasis hypersensivity

Food allergy

Gulf War syndrome

Mitral valve prolapse

Hypoglycemia

Chronic low back pain

Dizziness

Interstitial cystitis

Tinnitus

Pseudoseizures

Insomnia

Systemic yeast infection

Total allergy syndrome

These labels fall under the general category of

functional somatic syndromes and seem more

acceptable to patients because they may be

perceived as less stigmatizing than psychiatric

ones. However, using DSM criteria, virtually all

these functional syndromes would fall into the

somatoform disorders category given their

phenomenology, unknown physical causes, absence

of reliable markers, and the frequent coexistence

of somatic and psychiatric symptoms.

===

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Epidemiology

Medically unexplained physical symptoms are

extremely common in adults. They are more

frequently seen in females, in persons from lower

socioeconomic backgrounds, and in certain ethnic

groups. These symptoms are also fairly common in

childhood and adolescence; a recent study showed

that 10% of children surveyed had unexplained

headaches, 9% had unexplained abdominal pain, and

4% had unexplained pain in the extremities.8

The Epidemiological Catchment Area Survey of

Mental Disorders in the United States reported

that fewer than 0.1% of respondents met strict

DSM-III criteria for SD, and about 5% met

criteria for abridged SD, a less restrictive

construct of somatization.9 In Germany, about 20%

of a community sample met criteria for

undifferentiated SD, but very few (about 1%) met

criteria for the more specific somatoform disorders.10

The prevalence of unexplained physical symptoms

is much higher in primary care and medical

specialty settings. A World Health Organization

(WHO) study at 14 primary care sites in Asia,

Europe, and the Americas showed that the rates

for abridged SD differed widely across countries.

They were lowest in Nigeria (7.6%), Italy (8.9%),

and the United States (9.8%) and highest in

Germany (25.5%), Brazil (32%), and Chile (36.8%).11

In a North American study, patients with SD

reported spending an average of 8.8 days sick in

bed per month, compared with half a day for those

without the disorder. More than 80% of patients

with SD stopped working because of “poor health”

and their per capita yearly health costs were 9

times higher than average.12 A study of patients

with SD who attended a university outpatient

service in London showed that 61% were receiving

disability benefits, 64% had been treated for

spurious physical disorders, 60% had had

surgeries with no pathology found, and 16% were

using either wheelchairs or crutches without any

evidence of organic disorder.13

Unexplained physical symptoms tend to have a

chronic, protracted course. For example, in the

South London Somatization Study, most patients

had a chronic unremitting course. About 80% of

these persons still qualified for a somatoform

diagnosis 4 years later.14 A follow-up in the WHO

study showed that, 1 year later, somatization

persisted in about half of the patients.11

The causes of SD are multifactorial. Although no

consistent biological (brain) markers have been

documented, genetic factors may play a role.

Findings from studies of adopted females with SD

suggest excessive alcoholism or violent behavior

in the biological fathers.15 More recent studies

have shown that there is familial clustering of

functional syndromes such as fibromyalgia.16 A

large number of studies have shown a frequent

association between unexplained physical symptoms

and early traumatic experiences; medical illness

with long hospitalizations; serious medical

illness of a parent; natural disasters; or

psychological factors such as sensitization

processes, specific cognitive styles, or benefits

derived from the sick role (secondary gain).17-23

The most common psychiatric conditions that

coexist with unexplained physical symptoms are

major depression, anxiety, substance use,

personality disorders, and posttraumatic stress

disorders.24 Averaging data from several studies,

about two-thirds of patients with unexplained

symptoms also met criteria for at least one of

these psychiatric disorders and a large portion

of the remaining one-third, who did not fully

meet the criteria, had significant symptoms, mainly depression or anxiety.25

===

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Diagnosing and Managing SD

Not surprisingly, patients with unexplained

physical symptoms are first seen by primary care

or nonpsychiatric specialists, who usually make

the initial diagnosis. Unfortunately, only about

1 of 4 primary care physicians acknowledge

feeling confident about their ability to treat

these patients. The percentage of primary care

practitioners who report confidence in managing

other mental disorders, such as depression or

anxiety disorders, is much higher.26

Assisting primary care providers through

instructional sessions and manuals or simply by

using a consultation letter has proved to be

useful.27,28 Referral of these patients to mental

health services is generally unsuccessful unless

proper bridges between primary and mental health

care are built. This requires patient

preparation, careful teamwork, and the presence

at the primary care site of trained mental health personnel.

Because of the high level of discomfort

associated with unexplained symptoms, to be told

that “there is no physical problem” is

disconcerting to many patients. For the provider,

however, finding no physical abnormality

generally brings a sense of relief. In building a

good therapeutic relationship, it is important

for the therapist not to downplay the patient’s

discomfort at being told “there is no problem” or

“your symptoms are all psychological.” As in any

other field of medicine, empathy and

acknowledging the patient’s distress are

essential ingredients for a sound therapeutic

relationship.

<http://www.psychiatrictimes.com/dsm-v/article/10168/1171223?pageNumber=4#table2\

>Table

2 provides a stepwise list of suggestions for

communicating a diagnosis of SD to the patient.

Table 2 Communicating a diagnosis of somatoform disorder

1. Convey clearly, succinctly, and in a positive,

supportive way that the physical examinations and

laboratory tests show no physical abnormality

2. Tell the patient that he or she has a

relatively common disorder with no clear basis

but which may cause severe discomfort and dysfunction

3. Explain that despite the lack of physical

findings, the physical symptoms are not

intentionally produced and cannot be eliminated by an act of will

4. Let the patient know that there are treatments

that can provide relief but require the close

collaboration of the patient and all health care providers

5. Do not use psychological or psychodynamic

terminology or jargon (eg, denial, resistance)

because most of these patients are not psychologically minded

If properly communicated, the diagnosis of SD may

offer relief and encouragement to the patient.

For example, in a recent study, patients with

unexplained symptoms felt that receiving such a

diagnosis after a time of worry and uncertainty

was an important factor in successfully managing the disorder.29

Regular patient visits should be scheduled (eg,

monthly or bimonthly) independent of fluctuations

in symptoms. Treatment goals must be concrete,

stepwise, and realistic. Do not aim for an

all-or-nothing result, but consider a gradual and

incremental response. The goal is to

progressively decrease emergency visits and calls.

A routine examination is recommended at every

visit to reassure the patient and to ensure that

there are no physical abnormalities (remember

that paranoid people may have real enemies).

However, no new tests or consultations should be

ordered unless there is a clear indication.

Rather than reassuring patients, unwarranted

consultations or tests may feed their belief that

they have a serious physical illness. During the

visit, the patient can be allowed to play the

“sick role.” Allow him or her to verbalize

complaints and concerns without entering into

needless arguments on issues related to the

reported symptoms. The objective is not to negate

the symptoms but to improve functionality and

well-being. Briefly discuss current stress

factors and other important circumstances, and

make sure the patient understands that the

unexplained symptoms are elements of a

biopsychosocial illness.

<http://www.psychiatrictimes.com/dsm-v/article/10168/1171223?pageNumber=4#table3\

>Table

3 presents a list of goals to work toward.

Table 3 Suggested goals in treatment of somatoform disorder

* Encourage the patient to decrease or

(ideally) stop making emergency department visits

* Address specific psychiatric comorbidities,

such as depression, anxiety, alcohol or substance

use disorders, and other lifestyle measures (eg,

diet, excessive use of stimulants, smoking)

* Improve sleep with sleep hygiene measures

and, if necessary, add a brief course of nonaddictive hypnotic medication

* Address fatigue with an aerobic exercise

program (eg, walking, jogging, biking, swimming)

at least 4 days a week but ideally, every day;

exercise should be sustained rather than

intensive (a half hour walk is better than

sprinting or lifting weights for 10 minutes) and

should start at a comfortable level for the patient

* Discourage secondary gains such as missing

work or class or avoiding home chores

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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 reuptake

inhibitor. 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 and the

antidepressant 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, paroxetine, and 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 (Neurontin)

Lubriprostone (Amitiza)

Mirtazapine (Remeron)

Paroxetine (Paxil)

Pregabalin (Lyrica)

Sertraline (Zoloft)

===

References

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2. Lipowski ZJ. Somatization: the concept and its

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3. Briquet P. Traité l’hystérie. Paris: Baillière; 1859.

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6. hner JP, Robins E, Guze SB, et al.

Diagnostic criteria for use in psychiatric

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7. Spitzer RL, Endicott J, Robins E. Research

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8. Eminson DM. Medically unexplained symptoms in

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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.

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history of childhood abuse and neglect. Arch Gen Psychiatry. 1999;56:609-613.

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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

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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.

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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. 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. 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.

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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.

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meta-analysis. Obstet Gynecol. 2008;111:1175-1182.

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Evidence-Based References

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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.

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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At 03:15 PM 5/10/2009, you wrote:

>Lawrence,

>

> Thanks for posting this to the sickbuilding

> web site. As I read this, I kept thinking there

> must be more to this, and perhaps the doctor's

> more complete writings would put more

> restrictions on these assumptions. But reading

> the linked article from Psychiatric Times

> failed to show any qualifications, and strongly

> suggests that this doctor thinks psychiatry is

> the answer to any problems not confirmable by lab tests. Disgusting.

>

> Anyway, I was wondering if you have the link

> to the original article you posted below.

>

>Thanks,

>Gil Vice