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About somatic symptom disorders
General practitioners commonly encounter individuals who display excessive concern with a health complaint or present with physical symptoms that have no readily evident organic cause. These presentations can lead to a diagnosis of a somatic symptom disorder (previously known as somatoform disorders).
The category of somatic symptom disorder includes a range of clinical presentations such as health anxiety (previously hypochondriasis), medically unexplained symptoms, and persistent pain. Common to all these conditions is the central place of somatic symptoms in the presenting problem, along with cognitive distortions and/or excessive thoughts, feelings and behaviours related to these physical complaints. For example, a veteran may present with multiple physical symptoms that medical investigations fail to explain. He or she may report disproportionate concerns about the seriousness of those symptoms, along with a tendency to devote excessive time and energy to behaviours associated with them. It is important to note that these symptoms are not intentional or fabricated, and that they cause significant distress and impairment for the veteran.
The boundary between physical and mental health can be difficult to determine. As a general rule however, a veteran’s physical complaints should be considered as part of a mental health diagnosis if cognitive, emotional and behavioural problems are also prominent.
A related, but slightly different, area is the construct of psychosomatic disorders. This construct is applied when physical health problems are caused or made worse by psychological factors, such as when stress or anxiety makes asthma or a gastrointestinal condition worse. It is, therefore, important to investigate the influence of psychosocial factors on the onset, exacerbation, and maintenance of physical symptoms. Relevant psychological factors include mental health disorders, or symptoms, personality traits, maladaptive health behaviours and stress-related physiological responses.
Clinical experience and general prevalence studies suggest that, for the veteran population, chronic pain problems, health anxiety and psychological factors affecting existing medical conditions are the most likely presentations to health practitioners. The evidence also indicates high rates of comorbid anxiety and depression.
Screening and assessment
There are no well-established and widely accepted measures to screen for somatic symptoms and related disorders. However, the following questions adapted from the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998) may help identify veterans with a problem in this area:
- Have you had many physical complaints not clearly related to a specific disease?
- In the past six months, have you worried a lot about having a serious physical illness?
- Currently, is pain your main problem?
If the client responds ‘yes’ to one or more questions, and there is no adequate physical explanation, and/or there is significant distress in relation to the symptoms, then assess further. The Patient Health Questionnaire-15 (PHQ-15; Kroenke, Sptizer, & Williams 2002) is a freely available tool for assessing the presence and severity of somatic symptoms.
Important assessment considerations
- In all assessments, practitioners need to be alert to the common comorbidity of mental health problems in veterans presenting with somatic complaints.
- Ensure that any medical issue related to their complaint is attended to (e.g., ensuring that organic causes are investigated or that pain is adequately medicated). Avoid referral for ongoing specialist investigations unless there is clear evidence of a physical problem.
- Consider transcultural variations in presentation. In some cultures, physical symptoms are an accepted way of expressing emotional distress and may not be problematic. This does not mean that the veteran does not need treatment for other psychological issues such as anxiety or depression. For example, it is not unusual for aboriginal clients to present with somatic symptoms as part of their depression (Dudgeon, Garvey, & Pickett, 2000).
There has been little advance in the understanding of somatic symptom disorders or their treatment over the past 20 years. To date, there is insufficient evidence from the research literature to make firm recommendations for the treatment of somatic symptom disorders. Many veterans with somatic symptoms disorders will be primarily treated by their general practitioners. Recommended management principles are listed below:
- Acknowledge the reality of the problem. In this way, the veteran will feel ‘heard’ and it will be acknowledged that his/her symptoms are not ‘put on’ or imagined.
- Their general practitioner should schedule regular review appointments rather than make appointments in response to the individual’s psychosomatic crises (Singh, 1998).
- General practitioners should ensure they conduct a routine medical assessment that includes a thorough physical examination. Avoid diagnostic testing, prescription of new medication or referral to a medical specialist for each new symptom unless clearly indicated. Needless to say, the results should be discussed with the veteran.
- When somatic symptoms have become entrenched, shift treatment emphasis from symptom eradication to maintenance care and rehabilitation.
- The veteran should be strongly encouraged and supported in maintaining, or resuming, normal routines and activities.
There is no current consensus on the best psychological treatments for somatic symptom disorders as there have been insufficient studies to warrant a meta-analysis. However, a review of the published studies has found that cognitive behavioural therapy (CBT) appears to be the most promising psychological approach for managing health anxiety, somatic symptoms, and pain (Sharma & Manjula, 2013; Kroenke, 2007; Sumathipala, 2007). Although several variations of CBT have been employed, two elements are common to all:
- Cognitive therapy – This allows for the identification and modification of unhelpful beliefs about symptoms and disease.
- Behavioural techniques – These are helpful to alter illness and sick role behaviours, resume engagement in normal activities, and promote more effective coping.
Psychoeducation and self-management strategies
While undergoing more targeted psychological intervention it is also important to encourage the veteran to do the following:
- Monitor symptoms to help identify psychosocial factors (e.g., times, situations and emotional states) which exacerbate their symptoms, emphasising the links between psychological factors and the experience of somatic symptoms. Then assist the veteran to manage these perpetuating factors through strategies that may include anxiety management, problem solving, facilitating engagement with social support, etc.
- Maintain (or re-establish) their daily routine and current roles (e.g., work, family). This is particularly important for veterans who have a lot of unstructured time.
- Reduce substance use. It is common for veterans to self-medicate with alcohol and other drugs when struggling with pain and other somatic symptoms. While alcohol and drugs may alleviate distress and somatic symptoms in the short term, they inhibit recovery. If analgesic medication is used, it should be taken on a regular schedule as far as possible, rather than on an ‘as needed’ or ‘prn’ basis.
Pain management programs
Pain management programs (PMPs) are the treatment of choice for veterans suffering from chronic pain syndromes, including somatoform pain disorders. Effective PMPs adopt an explicit biopsychosocial model embedded within a cognitive behavioural paradigm, and include the following elements:
- multidisciplinary teams
- a holistic view of the veteran
- education on pain coping strategies
- promotion of self-efficacy beliefs and self-management
- support for improved function and lifestyle
- targeting of related depression and anxiety
- encouragement for improved general physical health and fitness.
PMPs typically occur in a group setting and vary from two to six weeks’ duration.
Treatment setting and duration
In research studies, CBT treatment for somatic symptom disorders varies between 6 and 16 sessions. It is likely that 16–20 sessions would be required for veterans being seen in routine clinical practice. Treatments may occur on an individual or group basis. Hospitalisation should be avoided. Treatment setting and duration specific to pain management programs is outlined above.
Given the lack of firm evidence for the efficacy of pharmacological interventions, CBT should be considered the first-line treatment for somatic symptom disorders. However, medication may be beneficial for veterans who are unwilling or unable to engage in CBT, or when appropriate psychological treatment is unavailable. In cases where medication is considered necessary, new generation antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are the preferred first-line treatment. Veterans with predominant pain symptoms may also respond to anticonvulsants, such as gabapentin (e.g., Neurontin) or pregablin (e.g., Lyrica).
Referral and coordinated care
- VVCS – Veterans and Veterans Families Counselling Service (VVCS): This service provides veterans and their families with counselling and group programs Australia-wide. VVCS can be contacted 24 hours on 1800 011 046. (www.vvcs.gov.au)
- Psychiatrist: for specialist management of more severe, chronic or complex problems. Some psychiatrists specialise in psychological treatments; they can review or prescribe medication, provide diagnoses, and manage co-occurring physical health problems. Allied health providers should liaise with GPs to arrange a referral. GPs can access a list of private psychiatrists at http://www.ranzcp.org/Resources/find-a-psychiatrist.aspx.
- A treatment plan should be developed collaboratively with the veteran and their family, and coordinated across service providers.
- Consider psychosocial and/or vocational rehabilitation services from the beginning of treatment. DVA can offer extensive rehabilitation services for entitled veterans (www.dva.gov.au/rehabilitation).
- Veterans Line (1800 011 046) can be reached 24 hours a day across Australia for crisis support and counselling. This service is provided by VVCS.
- The At Ease portal (www.at-ease.dva.gov.au) contains mental health and wellbeing resources, including websites, mobile apps and information booklets for both veterans and clinicians.
- Healthdirect Australia (http://www.healthdirect.gov.au/) is a useful website for information on chronic pain and other somatic complaints.
This Advice Book has the following resources in the appendices that may be useful for veterans who are experiencing somatic symptom disorders:
- further explanation of CBT elements (Appendix B)
- veteran psychoeducation handout and general psychoeducation script outline (Appendix D & Appendix L)
- self-monitoring sheets including daily activity schedule (Appendix E)
- pleasant events list (Appendix F)
- information on where veterans can get more help, e.g., Veterans Line, DVA funded psychological and rehabilitation services (Appendix J).