Functional Somatic Syndromes 3. generalized autonomic dysfunction - - PowerPoint PPT Presentation
Functional Somatic Syndromes Somatization - a challenge for the Health Care System Clinical aspects of Functional Somatic Syndromes Dr. med. Bernhard Palmowski, Berlin Functional Somatic Syndromes Guiding symptom is somatic Organ function
Somatization - a challenge for the Health Care System
Clinical aspects of Functional Somatic Syndromes
Guiding symptom is somatic
Patient suffers physically!
Nomenclature Medically unexplained Symptoms Organ Neurosis Psychogenic Syndrome Somatisation Disorder Complex Somatic Symptom Disorder Bodily Distress Syndrome Functional Somatic Syndrome
Henningsen, Zipfel und Herzog; THE LANCET 2007 Management of Functional Somatic Syndromes Current classification acc. ICD10 as “Somatoform Disorder“ or “Somatization Disorder” unsatisfactory, because
n out of touch with reality and medical framework n therapeutically counterproductive
Mandatory requirements for useful terminology
„Functional“ Somatic Syndrome, 2 meanings according to Uexkuell:
Functional Somatic Syndromes
autonomic dysfunction
High Variability High Complexity High Chronificity
autonomic dysfunction
Epidemiology
26% of the urban population suffer from a psychogenic disease
3 out of 10 patients attending a GP’s surgery suffer from functional somatic complaints
Out of every 10 patients with a functional somatic disorder:
physical complaints
5
physical complaints and anxiety
2
physical complaints and depression
3
Pat atie ient nts s wit ith h FSS / So / Soma matis tisation ation
in comparison with other medical patients show considerably higher values in:
n number of physicians n appointments with physicians n in-patient treatment n emergency-room treatment n number of technical measures n inability to work n unemployability n unemployment
Pat atie ient nts s wit ith h FS FSS S / Som / Somat atisation isation
n incur appr. 100% higher costs than other medical
patients
n incur an estimated 20% of the overall medical costs
in the USA
n cost an estimated $ 256 million per year -
n do not have an increased use of
psychiatric or psychotherapeutic care
Pathogenesis
Subjective perception cognitive evaluation symp./parasymp. reaction endocrinal reaction
expressive reaction gestures, facial expression, language, psychomot.
complex centr.nerv. activation
Pathogenesis
Comple Vollständiges Erleben
defense - defense - defense - defense - defense - defense - defense defense - defense - defense - defense - defense - defense - defense defense - defense - defense - defense - defense - defense - defense
Theoretical Clarification:
Defense Conscious Unconcsious Isolation Cognition Affect Repression Affect Cognition
Doctors suffer when they cannot alleviate their patients’ suffering Psychosomatic Patients often are: angry, anxious, complaining, complicated, craving, dangerous, demanding, disappointed, embittered, entitled, extorting, fearful, fixated, frustrated, hurt, moaning, nagging, pressurizing, offended, obsessed, risky, scheming, stubborn … “no real patients”
Doctors suffer when they cannot alleviate their patients’ suffering Doctors with these Patients often are: angry, anxious, confused, depressed, disappointed, embittered, extorting, fearful, fixated, furious, frustrated, hurt, insulted, nervous, obsessed, offended, overstrained, pressurizing, overwhelmed, tense, useless, worthless, left alone … “no good doctors”
Compile and evaluate all findings
make telephone contact with GP and ext. specialists complete insufficient or fragmented findings actively involve the patient, e. g. in tasks repeat discussions with the pat. about the findings, if needed
Guidelines for Diagnosis and Therapy
All these are indispensable preconditions for Confrontation
What is “confrontation” in Psychoanalysis? Description of the shared experience of the patient’s defensive behaviour within the transference The three most important words in psychoanalysis are: Guidelines for Diagnosis and Therapy
Formulations:
“There is nothing wrong with you.” “There is nothing there.” “There never was anything there.” “You are in good health”. “Organically, you are in good health,” etc.
“You are depressed.” “You are mentally disturbed.” “In your case, there is a mental cause,” etc. Guidelines for Diagnosis and Therapy
Guidelines for Diagnosis and Therapy
Procedure: Step 1 – Recognize the organic disorder explanatory intervention, for example: “Your complaints are due to a disturbance in the function of the organ. The tissue has not been damaged.”
Guidelines for Diagnosis and Therapy
Procedure: Step 2 – Produce the link with the affect helpful intervention, for example: “The function of an organ is often closely linked to internal feelings and moods. Do you often feel inwardly restless, tense and under pressure?”
Guidelines for Diagnosis and Therapy
Procedure: Step 3 – Enter the psycho-social constellation helpful intervention, for example: “The sources of restlessness, tension and pressure are not always obvious. There must be something in your life. Would you like to tell me a bit more about yourself?“
Guidelines for Diagnosis and Therapy
Procedure: Step 4 – Give feedback to referring colleague Write an early+short+simple care recommendation letter including
patients underdiagnosed patients
psychogenically somatically fixated patients iatragenically somatically fixated patients
primary / secondary gain of patient primary / secondary gain of doctor
defence against psycho-social conflict by somatisation defence against somatic illlness by psychologising