1
|
Abstract
SummaryThis article discusses a cognitive–behavioural therapy (CBT) approach to the treatment of medically unexplained symptoms that is based on the ‘five areas’ model of CBT. We describe a typical course of therapy and some of the common problems encountered during treatment. Emphasis is placed on the practical management of these conditions, and the focus is on symptoms as opposed to cause. We believe that this approach is widely applicable and could be used in a large range of settings to tackle these debilitating conditions. In writing this article we intended to provide an overview of patients with medically unexplained symptoms. The article would be of interest to staff within liaison psychiatry departments looking to set up a medically unexplained symptoms service and general psychiatry teams who may have contact with patients presenting with somatic symptoms. Psychiatric teams without access to a liaison department may also find this article interesting.
Collapse
|
2
|
Pattarini JM, Scarborough JR, Lee Sombito V, Parazynski SE. Primary Care in Extreme Environments: Medical Clinic Utilization at Antarctic Stations, 2013-2014. Wilderness Environ Med 2016; 27:69-77. [PMID: 26948556 DOI: 10.1016/j.wem.2015.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 11/21/2015] [Accepted: 11/23/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The unique challenges posed by the Antarctic environment include both physiological and psychological stressors to the individual as well as the limited onsite medical capabilities available to address them. This report compares medical clinic utilization among 3 US Antarctic stations to identify differences in diagnostic frequency and utilization of clinic resources under current medical prescreening regimes for summer and winter seasons. METHODS Clinic data from 3 Antarctic locations (McMurdo Station, Amundsen-Scott South Pole Station, and Palmer Station) for the 2013-2014 Antarctic year were reviewed for patient encounter frequency by season, and provider-assigned visit diagnostic category. Differences between relative diagnosis frequencies among stations were analyzed, and per-capita clinic utilization was compared. RESULTS The McMurdo clinic recorded 1555 patient encounters, with South Pole Station reporting 744 and Palmer with 128 encounters over the year. The most frequent reasons for clinic visits were orthopedic and dermatologic, with increased visits at McMurdo for respiratory illness and at the more remote locations for neurologic complaints and insomnia. Altitude-related visits were reported only at McMurdo and South Pole stations. CONCLUSIONS The clinic volume predictably correlated with station population. Insomnia and headache complaints, reported only at the South Pole Station, are likely associated with the increased elevation at that site, although they could be attributable to psychological stress from the isolated environment. Although the majority of cases could not be prevented with current screening, we suggest several changes to the current concept of operations that may decrease medical utilization and provide significant improvements to health care delivery on the ice.
Collapse
Affiliation(s)
- James M Pattarini
- University of Texas Medical Branch, Department of Preventive Medicine and Community Health, Galveston, Texas (Dr Pattarini).
| | - Jullian R Scarborough
- University of Texas Medical Branch, Center for Polar Medical Operations, Galveston, Texas (Ms Scarborough; Mr Sombito; and Dr Parazynski)
| | - V Lee Sombito
- University of Texas Medical Branch, Center for Polar Medical Operations, Galveston, Texas (Ms Scarborough; Mr Sombito; and Dr Parazynski)
| | - Scott E Parazynski
- University of Texas Medical Branch, Center for Polar Medical Operations, Galveston, Texas (Ms Scarborough; Mr Sombito; and Dr Parazynski)
| |
Collapse
|
3
|
Régny P, Cathébras P. [Conversion disorder in an internal medicine department: A series of 37 cases]. Encephale 2016; 42:150-5. [PMID: 26827119 DOI: 10.1016/j.encep.2014.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 11/24/2014] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To describe the clinical characteristics of a series of patients presenting conversion disorder in a general internal medicine ward and outpatient clinic, the arguments retained by the physicians in favour of the diagnosis, the somatic and psychiatric co-morbidities, the management and the outcome of the disorder. METHODS We report the study of 37 patients diagnosed with conversion disorder in an internal medicine department of a French university hospital over a period of 14 years. We retrospectively reviewed the charts of the patients and contacted their primary care physicians to obtain follow-up data. No structured instrument was used for the diagnosis of conversion disorder or for the assessment of psychiatric comorbidities. RESULTS As expected, patients were mostly young females, although a great variety of age, gender, and socio-cultural background was observed. Motor symptoms predominated (62%). A relevant psychogenic factor was explicitly mentioned in only 43% of the cases. In many cases, organic disease was also present, and an organic cause for the symptom initially considered as conversion was suspected in 3 cases. Depressive and anxious disorders were present respectively in 38% and 35% of cases. A pain complaint was associated in half of the cases. Among patients for whom follow-up data is available, conversion symptoms persisted or recurred in 70% of cases and were associated with a poor quality of life. CONCLUSION This case series confirms that the DSM-IV-TR criterion of "psychogenicity" (later abandoned in DSM-5) is highly problematic in clinical practice. It suggests a close relationship between conversion disorder and unexplained chronic pain.
Collapse
Affiliation(s)
- P Régny
- Service de médecine interne, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - P Cathébras
- Service de médecine interne, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France.
| |
Collapse
|
4
|
Cottencin O. Conversion disorders: psychiatric and psychotherapeutic aspects. Neurophysiol Clin 2013; 44:405-10. [PMID: 25306080 DOI: 10.1016/j.neucli.2013.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 09/16/2013] [Accepted: 09/29/2013] [Indexed: 10/26/2022] Open
Abstract
Hysteria is still stigmatized and frequently associated with lying or malingering. However, conversion disorder is not malingering, nor factitious disorder. The first step for the clinician faced with suspected conversion disorder is to make a positive diagnosis, which is in fact an integral part of treatment. In the emergency situation, it is important to look for an underlying somatic disorder. Although no specific treatment exists, there is a consensus in favor of a positive role of psychotherapy. First of all, the main problem is to explain to patients that their physical complaint has a psychological cause. In order to deliver the diagnosis in the most appropriate and useful manner, physicians have to first convince themselves before trying to convince patients. Combined consultation (medicine and psychiatry) is a useful tool to help patients. With or without combined consultation, this approach requires patience and open-mindedness to motivate patients to recognize the value of psychotherapy. Coordination between specialists and general practitioners is an important part of this treatment, which frequently requires long-term intervention.
Collapse
Affiliation(s)
- O Cottencin
- Department of psychiatry and addiction medicine, hôpital Fontan 2, university hospital of Lille, university Lille 2, CHU of Lille, 1, rue Verhaeghe, 59037 Lille cedex, France.
| |
Collapse
|
5
|
Abstract
Post-traumatic stress disorder (PTSD) is associated with both (1) 'ill-defined' or 'medically unexplained' somatic syndromes, e.g. unexplained dizziness, tinnitus and blurry vision, and syndromes that can be classified as somatoform disorders (DSM-IV-TR); and (2) a range of medical conditions, with a preponderance of cardiovascular, respiratory, musculoskeletal, neurological, and gastrointestinal disorders, diabetes, chronic pain, sleep disorders and other immune-mediated disorders in various studies. Frequently reported medical co-morbidities with PTSD across various studies include cardiovascular disease, especially hypertension, and immune-mediated disorders. PTSD is associated with limbic instability and alterations in both the hypothalamic- pituitary-adrenal and sympatho-adrenal medullary axes, which affect neuroendocrine and immune functions, have central nervous system effects resulting in pseudo-neurological symptoms and disorders of sleep-wake regulation, and result in autonomic nervous system dysregulation. Hypervigilance, a central feature of PTSD, can lead to 'local sleep' or regional arousal states, when the patient is partially asleep and partially awake, and manifests as complex motor and/or verbal behaviours in a partially conscious state. The few studies of the effects of standard PTSD treatments (medications, CBT) on PTSD-associated somatic syndromes report a reduction in the severity of ill-defined and autonomically mediated somatic symptoms, self-reported physical health problems, and some chronic pain syndromes.
Collapse
Affiliation(s)
- Madhulika A Gupta
- Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
| |
Collapse
|
6
|
Driver-Dunckley E, Stonnington CM, Locke DE, Noe K. Comparison of Psychogenic Movement Disorders and Psychogenic Nonepileptic Seizures: Is Phenotype Clinically Important? PSYCHOSOMATICS 2011; 52:337-45. [DOI: 10.1016/j.psym.2011.01.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 10/25/2010] [Accepted: 10/27/2010] [Indexed: 11/25/2022]
|
7
|
Sirri L, Fava GA, Wise TN. Psychiatric classification in the setting of medical disease: comparing the clinical value of different proposals. J Psychosom Res 2011; 70:493-5. [PMID: 21624570 DOI: 10.1016/j.jpsychores.2010.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 10/12/2010] [Accepted: 10/21/2010] [Indexed: 11/16/2022]
|
8
|
Grimaldi I, Dubuc M, Kahane P, Bougerol T, Vercueil L. Anxiety and depression in psychogenic movement disorder and non-epileptic seizures: a prospective comparative study. Rev Neurol (Paris) 2010; 166:515-22. [PMID: 20056263 DOI: 10.1016/j.neurol.2009.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 08/25/2009] [Accepted: 10/27/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study compared anxiety and depression in patients presenting with psychogenic non-epileptic seizures (PNES) with those suffering from psychogenic movement disorders (PMD) to assess the link between these psychiatric pathologies and neurological symptoms. METHODS This clinically descriptive, prospective study involved consecutive patients who fulfilled the clinical and video-EEG criteria for PNES and PMD, and who were recruited over an 18-month period. Semi-structured (according to DSM-IV criteria) psychiatric interviews and self-evaluation using the Beck Depression Inventory and Spielberger State-Trait Anxiety Inventory were carried out. Clinical follow-up was conducted 8-12 months after the first evaluation. RESULTS A total of 17 patients were recruited: nine presented with PNES; and eight had PMD. Both patient groups had similar demographic and clinical data as well as depression and personality disorders. Although not statistically significant, there was a trend towards an increased prevalence of a familial medical history of epilepsy and a higher incidence of anxiety disorders among patients with PNES. CONCLUSION The data from this prospective study underscore the clinical and psychiatric similarity between PNES and PMD patients. Further studies involving a larger number of subjects should confirm, from a statistical point of view, the differences suggested in the present investigation and, in particular, the greater incidence of anxiety disorders in PNES patients and the presence of an epileptic parent as a risk factor for PNES.
Collapse
Affiliation(s)
- I Grimaldi
- Clinique psychiatrique, CHU de Grenoble, pavillon Dominique-Villars, Grenoble, France.
| | | | | | | | | |
Collapse
|
9
|
Guidetti V, Galli F, Sheftell F. Headache attributed to psychiatric disorders. HANDBOOK OF CLINICAL NEUROLOGY 2010; 97:657-62. [PMID: 20816461 DOI: 10.1016/s0072-9752(10)97055-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The association between psychiatric illness and headache is widely recognized. "Headache attributed to psychiatric disorder" is a new category of secondary headache introduced in the 2004 revision of the International Classification of Headache Disorders (ICHD-II) (Headache Classification Subcommittee of the International Headache Society, 2004). It represents a new, but not conclusive, step toward a better systematization of the topic "headache and psychological factors." From the early 1990s the involvement of psychological factors in headache disorders has been clearly identified as "psychiatric comorbidity." The current conceptualization of the term implies an association, more than casual, but likely not causal, between an index disease or disorder and one or more coexisting physical or psychological pathologies. Additionally, clarifying the direction, meaning, and weight of comorbidities has pathophysiological, nosological, course, and treatment implications. However, the study of comorbidity may present a series of difficulties related to the current understanding of the etiology and pathophysiology of diseases at the center of our attention. Sometimes, as happens in the subject of headache, we proceed against a background where many issues need to be clarified. In this chapter, we analyze the past and current literature, tracing the line from "migraine personality" to "psychiatric comorbidity" to "headache attributed to psychiatric disorders." Questions related to etiology, pathophysiology, and treatment options are discussed for different headache subtypes.
Collapse
Affiliation(s)
- Vincenzo Guidetti
- Department of Child and Adolescent Neurology, Psychiatry and Rehabilitation, "Sapienza", University of Rome, Rome, Italy.
| | | | | |
Collapse
|
10
|
Mainio A, Hakko H, Niemelä A, Koivukangas J, Räsänen P. Somatization Symptoms Are Related to Right-Hemispheric Primary Brain Tumor: A Population-Based Prospective Study of Tumor Patients in Northern Finland. PSYCHOSOMATICS 2009; 50:331-5. [DOI: 10.1176/appi.psy.50.4.331] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
11
|
Neuropsychology and clinical neuroscience of persistent post-concussive syndrome. J Int Neuropsychol Soc 2008; 14:1-22. [PMID: 18078527 DOI: 10.1017/s135561770808017x] [Citation(s) in RCA: 259] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Revised: 08/16/2007] [Accepted: 08/16/2007] [Indexed: 01/17/2023]
Abstract
On the mild end of the acquired brain injury spectrum, the terms concussion and mild traumatic brain injury (mTBI) have been used interchangeably, where persistent post-concussive syndrome (PPCS) has been a label given when symptoms persist for more than three months post-concussion. Whereas a brief history of concussion research is overviewed, the focus of this review is on the current status of PPCS as a clinical entity from the perspective of recent advances in the biomechanical modeling of concussion in human and animal studies, particularly directed at a better understanding of the neuropathology associated with concussion. These studies implicate common regions of injury, including the upper brainstem, base of the frontal lobe, hypothalamic-pituitary axis, medial temporal lobe, fornix, and corpus callosum. Limitations of current neuropsychological techniques for the clinical assessment of memory and executive function are explored and recommendations for improved research designs offered, that may enhance the study of long-term neuropsychological sequelae of concussion.
Collapse
|
12
|
Sirri L, Fabbri S, Fava GA, Sonino N. New Strategies in the Assessment of Psychological Factors Affecting Medical Conditions. J Pers Assess 2007; 89:216-28. [PMID: 18001223 DOI: 10.1080/00223890701629649] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Laura Sirri
- a Department of Psychology , University of Bologna , Bologna , Italy
| | - Stefania Fabbri
- a Department of Psychology , University of Bologna , Bologna , Italy
| | - Giovanni A. Fava
- a Department of Psychology , University of Bologna , Bologna , Italy
| | - Nicoletta Sonino
- b Department of Psychiatry , State University of New York at Buffalo
| |
Collapse
|