Psychosomatic illness

Psychosomatic means mind (psyche) and body (soma) and can have both mental and physical aspects.

 Psychosomatic related conditions can be separated into three classes.

Class1: those with both a mental and medical illness. Both illnesses complicate the symptoms and management of each other.

Class 2: those with a mental issue as a direct result of a medical illness or its treatment, i.e. depression brought on by having cancer and subsequent treatment.
Class 3, the most prevalent type of psychosomatic related condition is somatoform disorders. These are a group of mental or psychiatric disorders manifested as physical problems or feelings of illness with no apparent, identifiable medical issue. To put another way, the physical symptoms experienced are related to psychological factors as opposed to anything identifiably medical.

 Somatoform disorder are more common in females. Onset is usually before age 30. Common somatoform symptoms include digestive problems, headaches, pain, fatigue, menstrual problems, and sexual difficulties.

The exact cause isn’t known. Family history / genetic predisposition may be a contributing factor. Somatoform disorders may be triggered by strong emotions, situations or events, such as anxiety, grief, trauma, abuse, stress, depression, anger or guilt. Despite what anyone thinks, they are not intentionally producing physical symptoms or making up physical problems. These are real, but caused by psychological factors.

In the main, there are four main types: -

Body dysmorphic disorder is an individual’s obsession or fixation with a minor or imaginary physical flaw, or with the shape or size of their body parts, leading to severe anxiety impacting negatively on ability to function normally.

Conversion disorder: a condition where a person experiences neurological symptoms that affect their movement and senses not attributable to any physical cause. They may feel they’ve lost the use of a body part, however, no medical or physical reason can explain it. Conversion disorder can produce symptoms as debilitating as seizures, blindness or paralysis.

Hypochondriasis: a preoccupation with the fear of having a serious disease. Sufferers misinterpret normal body functions or minor symptoms as being those of a more serious illness or even, life threatening. For example, a person with hypochondriasis may become convinced that they have colon cancer whilst experiencing a bout of temporary flatulence after eating cabbage.

Somatisation disorder:a disorder where a person experiences physical complaints, with no apparent physical cause (e.g.)  headaches, diarrhoea, or premature ejaculation. A person may have a history of medical complaints with no organic foundation.

In the main, somatoform disorders are not considered life-threatening. With the right support and treatment pathway, sufferers can lead normal lives even whilst living with ongoing symptoms. That said, there is currently no cure and treatment can be difficult. The key to a successful outcome is based on the establishment of a consistent and relationship between the patient and their healthcare professional, in most cases in Ireland, their GP. In many cases, the GP will refer the patient to a mental health specialist such as a psychiatrist to help better manage their symptoms.

Symptoms

 

Somatoform disorders are the major forms of psychosomatic illness. Physical symptoms of these disorders are real and may appear to be those of medical conditions. However, they are psychological in nature rather than physical. Medical testing and evaluation may sometimes be required to establish that the symptoms are in fact, by elimination, psychosomatic.

Common symptoms of body dysmorphic disorder

Those with body dysmorphic disorder become fixated with physical appearance. The person sees minor flaws as a major issue or indeed, may see flaws where none exist. Common areas of focus include loss of hair; the physical size and shape of body features, such as the facial (eyes, nose, lips etc.); breast size / shape; weight gain; wrinkles.

Associated behaviours may include:

·         Anxiety, fear of what other people “see”.

·         Depression, perhaps related to low self esteem

·         Withdrawal from situations where there are other people, i.e. public, social

·         Mirrors: - either avoiding or the need to constantly check appearance

·         Seeking reassurance /validation from others about their appearance

Common symptoms of conversion disorder

Symptoms of conversion disorder usually look like neurological problems and can include:

·         Vision impairment (Sudden loss of vision, double vision)

·         Swallowing (can lead to tube feeding in severe cases)

·         Impaired balance or coordination, difficulty walking

·         Inability to speak (aphonia)

·         Loss of sensation

·         Paralysis or weakness, in a limb, or entire body

·         Seizures

·         Urinary retention or conversely incontinence

Common symptoms of hypochondriasis

Hypochondriasis is thinking that everyday normal body functions or minor symptoms represent a serious medical condition. In the mind of a sufferer, for example, a common headache may be a brain tumour or muscle soreness in the limbs may be a sign of impending paralysis. Typical behaviours include:

·         Anxiety and depression

·         Feeling that their GP has made an error in not diagnosing the cause of symptoms, or in some cases, not taking them seriously.

·         Repeated GP visits until (in their mind) a correct diagnosis is made

·         Seeking constant reassurance / validation from friends and family about their symptoms and that they’re “ok”.

Common symptoms of somatisation disorder
Somatisation disorder is characterised by physical symptoms manifesting without an attributable physical cause. May include:

·         Digestive related symptoms, such as nausea, vomiting, abdominal pain, constipation, and diarrhoea

·         Neurological symptoms, headaches and constant fatigue

·         Pain, anywhere

·         Sexual symptoms, such as pain during intercourse, loss of libido, erectile dysfunction, and extreme menstrual problems in women

 

Potential complications of psychosomatic illness?

A person with psychosomatic illness, specifically a somatoform disorder are at increased risk of:

·         Difficulty functioning effectively

·         Physical Disability

·         Diminished quality of life

·         Major depression

·         Suicidal thoughts or actions (especially prevalent in younger people)

It can be hard to spot and especially in people we see every day. Indicative symptoms to look for may present as follows, if identified, prompt medical help should be sought

·         Noticeable changes in eating habits. such as overeating, bingeing or conversely, loss of appetite, desire to eat “alone”.

·         Inability to concentrate

·         Recall or memory issues

·         Constant lethargy

·         Feelings of despair, low self-esteem.

·         Irritability and restlessness

·         Activities and hobbies once enjoyed no longer interesting or important.

·         Persistent melancholy, desolate feelings

·         Problems sleeping (either too much or too little), the change from normal is key

Causes

The exact cause is not known, there may be a genetic link. Somatoform disorders represent the major form of psychosomatic illness. Somatoform disorders may be a coping strategy related to a previous life experience or trauma such as abuse or loss. It may be a learned behaviour, or the result of a personality characteristic. Research also indicates possible comorbidities with other mental health disorders, such as mood disorders, anxiety disorders, personality disorders, eating disorders, and psychotic disorders. Irrespective of causes, the symptoms are real to the person experiencing them, not imagined or made up.

A reaction to a particular emotional or psychological experience, past or present, may act as a trigger to the disorder.

Risk factors

It can be difficult to identify specific risk factors. If a family member has had a somatoform disorder in the past, a person may also be at risk. Other risk factors include:

·         Past sexual, emotional or physical abuse

·         A major childhood illness

·         Poor or reduced ability to show or express emotions

How is psychosomatic illness treated?

Diagnosis and subsequent treatment of somatoform disorders, can not only be challenging and can create stress and frustration for patients. Believing or feeling that there's no known explanation for their symptoms and getting nowhere can then lead to further increased stress and a vicious cycle ensues as they then become even more worried about their health. Once actual physical causes of symptoms have been eliminated, the focus of further treatment is based on a continuing, trusting, supportive relationship between patient and GP or lead health professional, in the mutual knowledge that there is in fact something to treat.  Once a treatment pathway has been agreed, close monitoring of progress through regularly scheduled follow up appointments is important for treatment success.

Psychiatric treatment of somatoform disorders

The GP may refer a patient to a psychiatrist or qualified mental health professional for help in managing their disorder. Psychotherapy and particularly “talking therapies” such as CBT (cognitive-behavioural therapy), may prove effective in dealing with those underlying psychological factors that are causing the physical symptoms and having a positive effect on both. Stress management techniques may also be part of the therapy. Learning to identify, anticipate and manage stress in a healthy way can help those patients where stress brought on by certain triggers is a particular issue.

If a mental disorder, such as depression, anxiety etc. is identified, then treatment with suitable medications may also be recommended and initiated as part of the overall programme.

Symptomatic treatment of somatoform disorders

Talking therapies such as CBT, whilst proven effective in a wide range of mental health management strategies, are not necessarily beneficial for everyone, so for some, symptoms may continue. In such cases, treatment will then be centred on providing symptomatic relief and helping people live normal lives.

Medication

As stated above, comorbid psychiatric disorders should be treated with the appropriate intervention. Medications can help to provide relief from symptoms, such as headache, fatigue, pain, and digestive problems etc. However, any medication should be used sparingly and always for an identified cause and in many cases may not be needed.

For comprehensive and free health advice and information call in to Whelehans, log on to www.whelehans.ie or dial 04493 34591.

Some light at the end of the tunnel at Midlands Rheumatoid Arthritis Event

More than 70 people took the positive step of attending the “Rheumatoid Arthritis” (RA) talk, hosted by Whelehans Pharmacy, Mullingar in conjunction with the Westmeath Branch of the Arthritis Ireland on Wednesday 12^th Oct at the Greville Arms Mullingar. There was an impressive line-up of 4 speakers.

The main speaker was Dr Killian O’Rourke, Consultant Rheumatologist at Midlands Regional Hospital, Tullamore. Dr O’Rourke delivered an excellent presentation which focused on two main areas:-

o   Update on Midlands Rheumatology Services to Oct 2016

o   Advances in RA treatment

Dr O’Rourke gave an overview of the extensive range of facilities now available at the service in Tullamore. One other really positive development within the unit was the extensive training programme for Midlands GP’s, hosted by Dr O’Rourke. On completion, each GP will have had around 400 hours of Rheumatology related training, which is then immediately relevant at point of first contact for most people (ie) the GP Surgery. This greatly assists with early diagnosis and subsequent quick referral.

New National Electronic Referral Form

To support the many recognised benefits of very early diagnosis, Dr O’Rourke outlined a new referral system of suspected IJD (Inflammatory Joint Disease) for GP’s using the new extremely detailed National Early Inflammatory Arthritis Referral form, developed in association with the charity Irish Society of Rheumatology and the HSE, full patient details along with supporting information (x-rays, pictures, history etc) can be sent electronically to rheumatology departments like Tullamore with a commitment to see referrals within six weeks.

Waiting list for Tullamore Rheumatology Department

Dr O’Rourke gave an update on the current waiting list position for new RA patients with recent improvements now sits at 15 months (down from 30 months), with those awaiting DEXA / MRI now at 12 months. In addition, whilst there has been recent positive progress in staffing levels, he outlined those shortfall areas that still exist to reduce the “waiting list” issue. The rheumatology department have a triage system which allows them to see more urgent cases quickly (eg) newly diagnosed early RA which needs early and aggressive treatment to prevent joint damage.

Risk factors for RA

Dr O’Rourke went on to discuss RA Risk factors. At the top of the group are two primary genetic factors followed by a list of over 12 “Higher Risk” factors….. of note here were:- Female Gender also Pregnancy and 12 months after giving birth; Occupational risks related to dust (mining, oil, woodwork, electrical, asbestos); Lifestyle factors (Smoking, High BMI, Coffee Consumption). Some developing evidence show that there may be a link between gum disease and development of RA.

Dr O’Rourke then gave an insight as to how RA is classified and the various systems that are used to evaluate severity. Two main organisations ACR (American College Rheumatology) and EULAR (European League against Rheumatism) have combined resources to produce a harmonised scoring system that provides some common classification criteria against which presenting symptoms can be measured, scored and which treatment pathway to take based on the outcome. The newly simplified scoring system aims: - Initially to REDUCE Disease activity, which through time PREVENTS structural damage, which then through remission, DECREASES disability. These factors are then translated into the recognised DAS28 scoring system which when used to indicate exactly where an individual lies within the goals above which dictate / prioritise immediacy and type of treatment.

Future of RA treatment

Looking to the future of RA treatment, the audience learned of a variety of current scientific initiatives and advancements that aim to help and assist with the earliest diagnosis of RA, perhaps even long before physical symptoms have appeared.

Gene screening to maximise treatment

Gene screening, currently in use in America, could help predict which drugs would be most effective for a given patient, which then enables the most effective treatment to be used right from the start.  Leading on from this, Dr O’Rourke suggested that at some time in the future, everyone could have their complete genome screened with the result showing what diseases or ailments they may be predisposed to. This is more likely to be reality in the coming years, something that would have been the realms of science fiction 25 years ago.

An RA vaccine?

Again, currently in progress is the possibility of a vaccine to prevent RA. Research in Australia is developing a vaccine to re-educate the immune system and the T-Cells (which currently attack in RA) to act in support of the immune system and prevent attack. Whilst an outcome may be a long way off and hugely expensive currently, it may be reality in within most of our lifetimes.

Cannabis based painkillers

To conclude, another therapy currently under evaluation (and common practice in many countries) is the use of Cannabis based Medicine (CBM) to treat and alleviate the symptoms of RA. Dr O’Rourke gave examples from USA and Israel of how CBM treatment has been proven to reduce and eliminate pain in RA. Medicine is administered primarily through tablets or sprays so that the purity and dosage can be guaranteed, CBM has been shown in clinical trials to reduce symptoms across a range of “traditional” RA measures. Cannabis based painkillers have been shown to have significantly less side effects than many traditional painkillers. Dr O’Rourke pointed out the CBM is not currently available in Ireland in any form.

Other health professionals

Next up was a presentation from Dr Siafullah Khan from Mullingar Dental Centre. Dr Khan is qualified in Special Care Dentistry. Dr Khan gave an overview of how Special Care dentistry can be of benefit to those with Mental or Physical challenges. He mentioned that something as simple as scheduling the “right” appointment time can be helpful for those that may, for instance, experience stiffness in the morning, making an afternoon appointment a better option.

Kevin Conneely, Chartered Physiotherapist from Health Step Physio based at Whelehans Pharmacy suggested that physiotherapy treatment can help maintain or increase range of movement for those with mobility issues. Physiotherapy can also help people understand the limitations that RA presents, which in itself can be a benefit in helping people help themselves.

To conclude, the final speaker of the evening was Eamonn Brady, MPSI, Pharmacist at Whelehans Pharmacy who gave an initial overview of medications used to manage RA. So, initially, looking at medication to reduce pain and then drugs aimed at slowing down the progression of the disease, pointing out that whilst there is no cure for RA, the correct and appropriate use of medication can have a significant positive effect on living with the condition. Supporting Dr O’Rourke earlier position that the earliest possible diagnosis is ideal and then the initial introduction of DMARD’s (Disease Modifying Anti-Rheumatic Drugs) to slow disease progression.

Eamonn highlighted that paracetamol is rarely effective against the pain of RA but may be used to augment other pain killers while waiting for longer term solutions like DMARDs to work. He cautioned however against the long term use of codeine based medications such as tramadol and Solpadeine^® and potential addiction risks.

Moving on to discuss NSAID’s (Non-Steroidal Anti-Inflammatory drugs), Eamonn indicated that whilst these offered relief, they would not affect the progression of RA and should not be used longer term. Giving examples such as diclofenac and etoricoxib, Eamonn stated that these should not be given to patients with heart problems or who had a high stroke risk.

Eamonn went on to discuss DMARD’s in more detail, giving an overview of how they work and, as they slow down the progress of the disease, the benefit of early referral. DMARD’s treatment can only be initiated by consultant, so, some of the initiatives mentioned earlier by Dr O’Rourke to speed the process of GP – Consultant referral will help massively.

Commonly used DMARDs include methotrexate, hydroxychloroquine and sulfasalazine. They can be slow to work, however Eamonn stressed the need to maintain the treatment as it can take some time to find the right one and for the benefit to materialise. A key point regarding Methotrexate was that it should only be taken weekly.

To conclude Eamonn discussed the various Biological treatment injections available. Traditionally, these would be a “last resort” for those with severe RA, however, with medical advances, these are now being promoted earlier to improve response to treatment overall. Mostly given by sub-cutaneous injection, can biologics can be used in conjunction with DMARD’s if needs be. In Ireland, Enbrel^® and Humira^® would be the most commonly used biological brands. More than 650 RA patients now take biological treatment at the Midlands RA Service.

Local Support

Westmeath Branch of Arthritis Ireland supports a vibrant community of 17,000 people living with Arthritis in the County.  The committee is made up of people living with arthritis so they understand the challenges that a chronic condition brings.  Your local committee are here to support you and offers a wide range of activities, information and training that will help you to live well with arthritis. If you have any further queries, Westmeath Branch contacts are: Margaret Egerton, Chairperson 0857587171 or Secretary 0871413225 (Branch Phone). You can follow the Westmeath Branch of Arthritis Ireland on Facebook.

Check www.arthritisireland.ie or Locall 1890 252 846 for more information