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Understanding Somatization inthe Practice of ClinicalNeuropsychologyGreg J Lamberty PhD ABPP CnNoran Neurological Clinic.
Minneapolis MN5th Annual Conference of theAmerican Academy of ClinicalNeuropsychologyJune 7 9 2007.
Denver Colorado Noran Clinic Neuropsychology Purpose and goals The purpose of this workshop is to providepractitioners with the conceptual understanding and.
the clinical tools needed to put a constructive approach into practice Neuropsychologists are encouraged to look uponthese difficult patients as an opportunity to employtheir unique skills in assessment case.
conceptualization and education intervention With the current focus on best practices and cost effective treatments improving the management ofnotoriously high utilizing patients could be a decidedboon to our field and to healthcare in general .
Purpose and goals continued Thus this workshop is not about the neuropsychologyof somatization or the somatizing patient per se butabout effectively identifying assessing educating and referring such patients for appropriate.
management and intervention Organization of workshop History Nosology Epidemiology.
Developmental Etiologicalconsi... Neuropsychological assessment Treatment approaches Management A basic definition of our subject.
Somatization somatoform symptoms somatizing patients1 the clinical report of multiple somaticcomplaints that are medically unexplained2 significant functional impairment or disruption.
in every day life Ancient Egyptianswandering uterus Hippocrates Galen 2nd century .
sexual deprivation in History cont Somatization in the 18th 19th centuries E Shorter 1992 From Paralysis to FatigueSomatization as a function of prevailing medical culture.
Spinal irritation back pain associated peripheral symptoms Dissociation somnambulism catalepsy multiple personality Motor hysteria paralysis Charcot s hysteria inherited functional CNS disease Freudian Janetian Breuerian or psychological.
conceptualizations of hysteria Modern day patient oriented conceptualizations History cont Thomas Sydenham 1624 1689 English Hippocrates .
Proponent of observational methodsHysteria not only an affliction ofHysteria is a product of the mind History cont Robert Whytt 1714 1766 .
Spinal reflexes responsible for nervous conditions Nerves were a common affliction from the late 18th to early 20th century Paul Briquet 1796 1881 Comprehensive listing of symptoms in 1859 monograph based on 400 mostly female patients from the Salp tri re hospital in Paris from 1849 .
Reaffirmed Sydenham s view of hysteria as a nervous condition not solelyseen in women and characterized by many predisposing factors In DSM III somatization disorder was co named Briquet s syndrome inrecognition of the French psychiatrist s seminal contributions History cont .
Treatment of nervous disordersContemporary medical establishment focused on methods to bringhumors into balance like blisteringMeanwhile in France there was a burgeoning spa industry offering.
special curative waters wraps poultices and massages The curative powers of these treatments has never passed peer review muster but the spas live on Go figure History cont Jean Martin Charcot 1825 1893 .
Father of modern neurology His interest in treating hysterical patients with magnetism andhypnotism saw his views evolve Janet Freud took hysteria to a more psychological plane but Charcotheld fast in his belief of the neurologic basis of hysteria .
History cont Pierre Janet 1859 1947 Janet s work with Charcot led to his development of ideas about theconnection between subconscious states and earlier traumatic events Janet s thinking about suggestibility dissociation and the subconscious is.
widely acknowledged to have predated ideas popularized by Freud inthe late 19th and early 20th centuries Sigmund Freud 1856 1939 Freud s conceptualization of conversion became a dominant viewpoint inunderstanding the nature of hysteria .
Even today conversion disorder retains a place although arguably as adiagnostic entity in DSM IV History cont The struggle against dualismDSM III perhaps unwittingly reinforced the dualistic thinking.
of the past that separated mind and body That is by definition symptoms seen in the somatoformdisorders are medically unexplained and by default psychological or in one s mind head This is a very unpopular notion with patients as suggested by.
Shorter 1992 and the tide has seemingly turned History cont The struggle against dualism continued Advances in imaging technology and cognitive neuroscience havemade it possible to convincingly demonstrate relationships between.
neurophysiology and behavior mental illness Damasio 1994 Ledoux 1996 Schore 1994 Unfortunately despite modern day neuroscientists elegant attemptsto convince us of the inseparability of mind and body for many stigmaand shame cling to mental illness and psychological difficulties .
Fortunately emotion has become the new final frontier for prominentneuroscientists It seems like that this will lead to a betterunderstanding of the complex interplay between emotions somaticsymptoms and neuropsychiatric symptoms History cont .
In other words It s Not All in Your Head Asmundson Taylor 2005 How worrying about your health could be making you sick and what youcan do about it Marketing of clinical services is becoming cognizant of the.
public s sensibilities and maybe even reality Nosology There is a clear lack of consensus regarding nosology insomatoform syndromes Much of what we are interestedin is clinically defined .
somatizationsomatoform disordersfunctional somatic syndromesmedically unexplained symptoms Different systems define the problem in different ways .
but none of them meet reasonable criteria for anadequate diagnosis Nosology cont for example Hypertension.
DiagnosisChronically elevated blood pressureSystolic and diastolic pressures over 140 and 90 mm Hg TreatmentDietary changes.
And of course drugs Nosology cont DSM III APA 1980 a more descriptive atheoretical system ascompared to previous psychodynamically oriented systems DSM I II .
Somatoform disordersIn addition to somatization disorder several relatively rare and specificsyndromes were included based mainly on the presence of unexplainedphysical symptoms conversion hypochondriasis BDD pain disorder Somatization disorder.
Hysteria as a neurotic disorder in DSM II APA 1968 was replaced inDSM III APA 1980 by somatization disorder which focused on theclinical description of multiple somatic complaints to the exclusion of apresumed neurotic etiology Nosology cont .
The descriptive pathological approach to mental disorders positionedpsychiatry favorably among traditional medical specialties Schizophrenia mood and anxiety disorders have benefited because of a moreclear sense of their biological underpinnings This has allowed biomedical and pharmaceutical research to proceed with.
generally positive findings Somatoform disorders have suffered a different fate Because a real physical cause is by definition lacking there has not beenmuch interest in identifying therapeutics for these disorders except as theyoverlap with mood or anxiety disorders .
Nosology cont In fact the lack of clear biological underpinnings for thesomatoform disorders has led some to encourage theabolition of the category e g Mayou et al 2005 in favor ofa more basically descriptive or pragmatic approach Engel .
Nosology cont All contemporary systems borrow heavily from Briquet s 1859 monograph summarized by Mai Mersky 1980 430 patients seen over a 10 year period Etiologic factors were youth female gender affective and.
impressionable temperament family history of the disorder low social class migration sexual licentiousness situationaldifficulties and poor physical health Briquet considered the effective part of the brain the finalcommon pathway that mediated these causative agents .
In treatment Briquet emphasized the importance of animprovement in social circumstances and the need to minimizeenvironmental problems Nosology cont Somatization disorder per DSM IV APA 1994 .
A A history of many physical complaints beginning before age 30 yearsthat occur over a period of several years and result in treatmentbeing sought or significant impairment in social occupational orother important areas of functioning B Each of the following criteria must have been met with individual.
symptoms occurring at any time during the course of thedisturbance 1 four pain symptoms a history of pain related to at least fourdifferent sites or functions e g head abdomen back joints extremities chest rectum during menstruation during sexual.
intercourse or during urination Nosology cont 2 two gastrointestinal symptoms a history of at least twogastrointestinal symptoms other than pain e g nausea bloating vomiting other than during pregnancy diarrhea or intolerance of.
several different foods 3 one sexual symptom a history of at least one sexual or reproductivesymptom other than pain e g sexual indifference erectile orejaculatory dysfunction irregular menses excessive menstrualbleeding or vomiting throughout pregnancy .
4 one pseudoneurological symptom a history of at least one symptomor deficit suggesting a neurological condition not limited to pain conversion symptoms such as impaired coordination or balance paralysis or localized weakness difficulty swallowing or lump inthroat aphonia urinary retention hallucinations loss of touch or pain.
sensation double vision blindness deafness seizures dissociativesymptoms such as amnesia or loss of consciousness other than Nosology cont C Either 1 or 2 1 after appropriate investigation each of the symptoms in.
Criterion B cannot be fully explained by a known general medicalcondition or the direct effects of a substance e g a drug ofabuse a medication 2 when there is a related general medical condition thephysical complaints or resulting social or occupational.
impairment are in excess of what would be expected from thehistory physical examination or laboratory findingsD The symptoms are not intentionally produced or feigned asin Factitious Disorder or Malingering Nosology cont .
The major diagnostic systems have experimentedwith the somatization issues in various ways DSM IV requires 8 symptoms from 4 symptom groups ICD 10 requires 6 symptoms from 2 symptom groups DSM and ICD systems have residual or undifferentiated .
categories that require fewer overall symptoms to be But is there any validity to these approaches Nosology cont Basically No Several studies have failed to indicate better.
diagnostic precision as a function of differing sets ornumber of symptoms Gureje Simon 1999 Liu Clark Eaton 1997 Simon Gureje 1999 A factor analytic study Liu Clark Eaton 1997 highlighted the chronic nature of unexplained.
symptoms regardless of the diagnostic scheme Nosology cont In general studies have highlighted Variability in individual symptom report over time Lieb et al 2002 Variability in the consistency accuracy of the report of lifetime.
symptoms Gureje Simon 1999 Simon Gureje 1999 Thus specific criteria do not influence the basicdescription of somatizing patient groups i e chronic andunexplained But they may influence epidemiological estimates of different.
somatoform syndromes This observation highlights the fact that current diagnostic criteriaare heuristically valuable but quite limited from a practicalclinical standpoint Nosology cont .
Alternative descriptive systems Medically unexplained symptomsUltimately atheoreticalPopular with neuropsychologists Binder Campbell 2004 Abridged somatization Escobar et al 1987 .
Based on this group s experience with the EpidemiologicalCatchment Area ECA studies of the early 1980sA less restrictive operational definition of the somatizer 4 unexplained symptoms for men 6 such symptoms for women Nosology cont .
Multisomatoform disorder Kroenke et al 1997 DSM somatization disorder too restrictive but undifferentiatedsomatoform disorder too inclusiveThree or more medically unexplained symptoms regardless of.
Epidemiology (cont.) Pediatric studies Fritz, Fritsch, & Hagino (1997) reviewed literature from the previous 10 years with regard to conceptual and clinical reports of somatization in children a lack of developmentally appropriate schemas and a call for more thorough outcome studies Campo et al., (1999) examined a group of pediatric "somatizers ...

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