Case 7: Desta Ayo - Somatic Symptom Disorder

Psychosomatic Mind-Body

Bidirectional interaction between psychological processes + physical/somatic symptoms

• Psychological distress = Physical symptoms

Spectrum of Somatic Symptoms

Primary psychiatric disorders

Functional somatic syndromes

Primary Psychiatric Disorders

Ex: Mood + anxiety disorders

Mechanism:

1. Serotonin + norepinephrine dysfunction

• Cause psychiatric disorders

2. Decrease pain inhibition + amplify sensory processing

• Cause somatic symptoms

Functional Somatic Syndromes

Recurring physical symptoms in specific body system not explained by pathology

Medical diagnoses

• Ex: IBS, fibromyalgia

Mechanism: Central sensitization

1. CNS changes = Amplify sensory signals + decrease inhibitory signals

• Structural

• Functional

• Neurochemical

2. Chronic immune + SNS activation = Chronic inflammation

• Cause somatic symptoms

Fibromyalgia: Description

Chronic noninflammatory MSK pain

Fibromyalgia: Pathophysiology

1. Increased excitatory and decreased inhibitory NTs + HPA axis dysfunction + glial cell activation

2. CNS nociceptive signal processing dysfunction = Pain

Fibromyalgia: Clinical Presentation

Chronic diffuse MSK pain

Fatigue

Fibro fog: Cognitive dysfunction causing difficulty concentrating + lack of clear thought

Fibromyalgia: Treatment/Management

Nonpharmacological:

• Pt education

  • Exercise

  • Reassurance

  • Relaxation techniques

  • Sleep hygiene

• Physiotherapy

• CBT

Pharmacological:

• For severe pain

  • Anticonvulsants: Pregabalin

  • SNRIs: Nilnacipran, duloxetine

• For poor sleep

  • TCAs: Amtriptyline

Somatic Symptom Disorder (SSD): Description

Prominent somatic symptoms not explained by a medical condition causing significant distress or impair daily function

• Exacerbated by stress, depression, interpersonal conficts

• Psychiatric diagnoses

SSD: Epidemiology

More common in women

Risk factors…

• Genetics

• Chronic illness

  • Medical

  • Psychiatric

• Childhood adversity

• Alcohol + SUD

SSD: Etiology

Stress

Cognitive factors

Developmental personality

Interpersonal factors

Behavioural factors

SSD Etiology: Cognitive Factors

Somatosensory Amplification: Increased attention to bodily sensations = Amplify normal sensations → Intense/noxious

Symptom Attribution: Attribute symptoms to organic/somatic causes

SSD Etiology: Developmental Personality

Childhood trauma

Attachment insecurity/anxiety

SSD Etiology: Interpersonal Factors

Poor pt-provider interactions = Excessive referrals + testing = Iatrogenic cause

Psychiatric symptoms stigmatization = Somatization (psychiatric symptoms manifest as physical symptoms)

SSD Etiology: Behavioural Factors

Repeated “sick” behaviours

• Checking symptoms

• Seeking reassurance

• Avoiding physical activity

SSD: Pathophysiology

Stress →

• Psychological mechanisms

• Neurochemical mechanisms

SSD Pathophysiology: Psychological Mechanisms

Alexithymia: Difficulty identifying + describing emotions

• Symptom attribution

Health Anxiety

• Somatosensory amplification

SSD Pathophysiology: Neurochemical Mechanisms

HPA axis dysfunction

Neuroinflammation

SSD Pathophysiology: HPA Axis Dysfunction

1. Initially: Stress = Increase HPA activation = Increase cortisol production

2. Chronic: Increased cortisol acting on glucocorticoid receptors = Glucocorticoid (cortisol) resistance

SSD Pathophysiology: Neuroinflammation

1. Stress = HPA + SNS activation = Pro-inflammatory state

2. Disrupt BBB + microbiome dysbiosis + redistribute immune cells = Positive feedback = Increase inflammation

SSD: Diagnostic Criteria

DSM-5

≥ 1 somatic symptoms causing significant distress + impairment

• Ex: Heartburn, fatigue, headache, pain

Excessive thoughts, feelings, behaviours related to symptoms

• ≥ 1 of:

  • Constant thoughts of symptom severity

  • Constant anxiety about symptoms/health

  • Excessive time/energy spent attending to symptoms/health

≥ 6 months

SSD: Treatment/Management

Nonpharmacological

Pharmacological

SSD Management: Nonpharmacological

Educate pt

Minimize unnecessary investigations + prescriptions

Schedule regular visits with same PCP

• Review symptom severity

• Physical exam

Psychotherapy

• CBT: First-line

• Reassurance

  • Empathize + understand pt experience

    • Acknowledge symptoms

    • Not “all in your head”

  • Ruled out serious medical conditions

SSD Management: Pharmacological

Analgesics

• Avoid opiates

Antidepressants

• Ex: SSRIs, SNRIs, TCAs

• Indications:

  • Comorbidities (anxiety, depression)

  • CBT ineffective

  • Severe SSD

SSD: Complications

Iatrogenic injury from unnecessary testing, treatment, hospitalization

Increased SUD risk

Opioid Use Disorder (OUD)

Compulsive opioid use despite harmful consequences

Opioid Misuse

Prescription opioid consumption in manner/dose different than physician directions

Opioid Use

Opioid consumption as prescribed for medical purposes

OUD: Treatment/Management

Nonpharmacological

• CBT

Pharmacological

OUD Management: Pharmacological

Opioid agonist

Opioid antagonist

OUD: Opioid Agonist

Ex: Methadone, buprenorphine + naloxone

Indication:

• Induction (treat opioid withdrawal symptoms)

• Maintenance

OUD: Opioid Antagonist

Ex: Naltrexone

• Oral or IM

Indications: Maintenance (after abstinence)