Disorders of Somatic and Musculoskeletal Pain



Disorders of Somatic and Musculoskeletal Pain


Bethany A. Marston

David M. Siegel





KEY WORDS



  • Central sensitization


  • Functional pain


  • Musculoskeletal pain


  • Pain amplification


  • Somatic symptoms

Adolescent and young adult (AYA) patients who present with somatic illnesses as well as those who present with complaints of physical pain who lack clear or sufficient physical findings to explain their symptoms are a challenge to the physician. There are many potential explanations for such symptoms, but these can be difficult to accurately diagnose or manage, and some remain incompletely understood.


PSYCHOSOMATIC DISORDERS


Adjustment Disorder

Adjustment disorder is an excessive or exaggerated reaction to an identifiable life stressor. It is more than would be expected and can manifest as physical, psychological, and/or cognitive symptoms and impairment.

Potential stressors for AYAs that can lead to excessive and abnormal reactions include the following somatic symptoms:



  • Physical changes of puberty


  • The cognitive developmental progression from concrete to formal operational thinking


  • Changing demands and expectations in the family, and social, academic, and vocational realms

Milder and more time-limited psychological disequilibrium can also precipitate bodily discomfort and lead to physical complaints such as light-headedness, nausea, headache, palpitations, and so on. All of these are commonly associated with emotional distress and may serve in the patient’s mind as “legitimate” reasons to see the clinician; more acceptable to the patient and family than overtly expressed psychological problems.


Psychophysiological Disorders

In psychophysiological disorders, physical symptoms are observable and often fall into biological processes that are understood by the clinician and the disease course is clearly influenced by psychological function. For example, the patient with asthma experiences increased bronchospasm when under stress, leading to increased episodes of coughing, wheezing, and shortness of breath.

Although managing and optimally preventing these exacerbations is not necessarily easy or rapidly accomplished, the connection between the psychological and the physical, once shared with and understood by the patient and family, is not typically rejected or denied. The “medical legitimacy” of the primary physiological disorder (i.e., asthma) represents a common ground of acceptance between clinician and patient/family and also provides the clinician with a familiar and well-understood template for medical treatment. Beyond the strictly medical treatment, however, the clinician must attempt to facilitate the AYAs and parent(s) successfully identifying sources of stress and anxiety that contribute to inadequate control of the primary disease and its symptoms. This exploration may very well be enigmatic and may require open-ended questions, thoughtful probing, and multiple visits. Sometimes, referral to a health psychologist or medical family therapist is productive.


Somatic and Related Disorders

Complaints of significant somatic symptoms without identifiable biomedical etiology are frequent in AYA patient encounters and had previously been classified as somatoform somatization disorder. However, the Diagnostic and Statistical Manual of the American Psychiatric Association, 5th edition (DSM-5) articulates a new categorization template. This new template is clearer and provides a useful set of diagnostic labels and descriptions, recognizing that the majority of these patients present to medical as opposed to mental health settings. This group of conditions is now referred to as somatic symptom and related disorders, they all share the “prominence of somatic symptoms associated with significant distress and impairment.”1 Beginning with the most common, these include:



  • Somatic symptom disorder: Persistent (>6 months) somatic symptom(s) that cause psychosocial impairment, with persistent thoughts about the seriousness of symptoms, anxiety about symptoms or general health, or excessive time and energy devoted to symptoms or health concerns. Incorporation of affective, cognitive, and behavioral components rather than just somatic symptoms alone is central in making the diagnosis.

    The newer criteria for somatic symptom disorder require the presence of a symptom or symptoms with associated excessive or disproportionate thoughts, feelings, or behaviors that surround these, and the emphasis is on this disruptive or maladaptive response.2 The symptom may be medically “explained” or not. This category encompasses most of those previously diagnosed with somatization disorder, undifferentiated somatoform disorder, and some of those with hypochondriasis, and DSM-5 further posits that the revised labels may be less stigmatizing, particularly in the case of hypochondriasis. The prior category of somatization disorder was also cumbersome and restrictive, requiring a complex tally of symptoms in different categories, while undifferentiated somatoform disorder was so broad as to be of questionable clinical usefulness. Some
    in the field have concerns that the current definitions may lead to overdiagnosis of somatic symptom disorder in those with medical illness.3


  • Illness anxiety disorder: Persistent (>6 months) preoccupation with having a serious undiagnosed illness, anxiety about health, or excessive health behaviors or maladaptive avoidance of situations perceived as health threats, accompanied by minimal somatic symptoms and not better explained by another disorder


  • Conversion disorder: Neurologic symptoms that are found, after appropriate neurological assessment, to be incompatible with neurological pathophysiology


  • Psychological factors affecting other medical disorders: Presence of one or more clinically significant psychological or behavioral factors that adversely affect a medical condition by increasing the risk for suffering, death, or disability


  • Factitious disorder: The falsification of medical or psychological signs and symptoms in oneself or others that are associated with the individual taking surreptitious actions to misrepresent, simulate, or cause signs or symptoms of illness or injury in the absence of obvious external rewards.

    In contrast to somatoform disorders, in which symptoms are associated with unconscious conflict, factitious disorders are those of conscious falsification of symptoms and signs to create a sick role, thought to be motivated by the need to be cared for. Factitious disorders, especially those that are chronic, such as Munchausen syndrome and particularly Munchausen syndrome by proxy,4 are serious and in some instances difficult to distinguish from somatoform conditions. These also need to be distinguished from malingering, which is not considered a psychiatric condition, in which there is conscious and intentional exaggeration or falsification of symptoms for an obvious secondary gain.

There are some general principles that can apply to how the clinician approaches AYAs when the above clinical entities are under consideration.



  • Biopsychosocial assessment: Biomedical and psychosocial factors must be evaluated at the onset. This will allow the clinician to understand the psychological stressors and conflicts, as well as the biomedical elements that together serve to limit the differential diagnosis. It also makes the eventual diagnosis of a psychosomatic disorder more acceptable to families in that this conclusion does not arise late in the evaluation process, that is, diagnosis of exclusion. Elements of the assessment include:



    • Detailed history focused on the presenting symptoms: It is important not to neglect the symptoms that brought the patient and family to the provider. Focusing on the symptoms can give the AYAs the message that the provider is taking their concerns seriously, and does not need to reinforce the perception of medical illness.


    • Physical examination focused on symptoms


    • Laboratory and imaging studies: These should be chosen on the basis of the history and physical examination and should be limited to the least number of minimally invasive tests required to clarify the diagnosis or rule out important alternate possibilities.


  • Evaluation for psychiatric disease: Mood disorders (especially major depression, anxiety disorders), and even schizophrenia can all manifest with somatization, and sometimes physical symptoms may be the only complaints with which the AYAs initially present. When further questioning and interaction with the patient and family support the presence of significant psychiatric illness, formal mental health consultation is warranted. A less severe mood or anxiety disorder uncovered during the evaluation of somatic complaints may be managed by the adolescent/young adult care provider.


  • Evaluation for personality disorders: Beyond Axis I psychiatric diagnoses, somatic symptoms/somatic symptom disorder can also be associated with certain personality (Axis II) disorders. Those patients with enduring attitudes and habitual patterns of response that characterize obsessive-compulsive personality disorder or histrionic personality disorder are at higher risk for developing somatic symptom disorder. Adolescents with personality traits of dependency or neurotic preoccupation with self also have a greater tendency to experience and describe unexplained physical symptoms. The diagnosis of personality disorders per se, however, is generally not applicable to those under 18 years of age.


  • Evaluation of environmental factors: In addition to personality disorders, environmental factors can also underlie the emergence and perpetuation of various chronic pain syndromes. Somatic complaints in parents, family members, or peer contacts should be examined as possible models for, and contributors to, the patient’s own symptoms and behaviors. Cultural norms and expectations might also reinforce a form of illness and an expression of distress that emphasizes and serves to support physical pain. An awareness on the part of providers as to the patient’s cultural milieu is critical in placing preoccupation with somatic symptoms (as well as many other behaviors) in appropriate context.

Other aspects of a teen or young adult’s present or past experience might also bear on somatic symptoms and provide insights for the provider into the possible meaning for the behavior. For example, a patient whose early life experience did not include consistent parental support and caretaking (or were exposed to overt trauma and/or abuse) might develop physical symptoms as a means to meet dependency needs. When these patients become increasingly demanding about diagnostic evaluations, and angry and hostile with the clinician about the lack of a physical diagnosis or the inadequacy of treatment, these emotions may actually be expressions of deeper and unconscious feelings about early caretakers that are now displaced onto the clinician.

In summary, important areas to help the practitioner understand somatic symptoms without biomedical explanation include the following:



  • Symptoms of mental illness or psychiatric diagnosis


  • Association with personality traits or disorder


  • Modeling or reinforcement of somatic symptom behavior by the family, peer, or cultural environment


  • Placement of somatic symptoms in the context of the patient’s present or past experiences, circumstances, and culture


FUNCTIONAL PAIN DISORDERS


Fibromyalgia

Fibromyalgia and juvenile fibromyalgia are conditions of chronic widespread musculoskeletal pain. This disorder sometimes goes by other names, and precise definitions vary.


Epidemiology



  • Estimates of prevalence vary, but US-based hospital-based pediatric rheumatology clinics report that 7.65% of new patients seen were diagnosed with fibromyalgia5 and in the community a 1% to 6% prevalence has been reported.6,7


  • The clinical characteristics of the condition are similar regardless of age, though the developmental and psychosocial differences between adolescence and adulthood bear on the disease’s impact and some aspects of treatment.


Clinical Presentation



  • The predominant complaint is chronic widespread musculoskeletal pain defined as affecting the upper and lower as well as left and right sides of the body.


  • Most patients describe poor sleep quality, fatigue, mood disruption, and difficulty concentrating.



  • Many will have other somatic manifestations including headache, irritable bowel or other abdominal symptoms, dysmenorrhea, subjective swelling or color changes, dizziness, or multiple chemical sensitivities8


  • Symptoms may develop additively over time, and may not be recognized early due to relatively normal physical exam findings, but can have profound effects on function. Because of this, many patients present with concerns about arthritis, lupus, or other underlying rheumatologic conditions, and patients and families are often frustrated when no ready explanation for these symptoms is found on routine testing.



Pathophysiology

A biopsychosocial model, considering both biologic and environmental factors, is useful for understanding the effects of fibromyalgia on function and approaches to management. Although the factors that cause juvenile fibromyalgia are incompletely understood, pain processing appears to be altered in several ways in adult fibromyalgia and related conditions, and much of this research probably applies equally to younger patients.

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Sep 7, 2016 | Posted by in ONCOLOGY | Comments Off on Disorders of Somatic and Musculoskeletal Pain

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