The biggest cause of frustration for both doctors and patients may really be a treatable mental health condition

Peggy Banks
July 31, 2020

Comorbid Mental Health Screening

We have all had occasional aches and pains we can’t explain, but for those with a somatic symptom disorder (SSD), the pains can cause significant distress. Whether physical (specific pain) or general (fatigue), SSD patients are not pretending, their suffering is real and interferes with their daily life. Patients with chronic and severe SSD spend more days in bed per month than patients with several major medical disorders. This chronic condition can last for years and usually starts before the age of 30, although it can begin in adolescence. Diagnosing can be difficult since people with SSD can and do get other serious medical conditions. Providing adequate mental health screening reduces both patient and physician stress and frustration that accompanies these diagnoses.

Fear of Severe Medical Illness leads to SSD

Temporary stressors such as job loss, divorce, etc. can lead to symptoms such as headaches or back pain. These acute symptoms generally resolve once the stress factors resolve, and minimal treatment is generally required; 70% of patients reported improvement within 2 weeks. Patients who fail to improve beyond the 3-month mark are twice as likely to fear they have an undiagnosed, severe medical illness. Approximately 20% to 25% of patients who suffer from chronic or recurrent symptoms often present with continued issues at 5-year follow-ups.

People with the chronic sub-type of SSD are characterized by a history of more than one persistent somatic symptom associated with a high level of functional impairment. They access medical care at high rates, yet their distress is rarely improved. They may do “physician shopping”, hoping to finally find someone to help them. Many receive unnecessary and invasive somatic examinations while psychological factors are generally left unexplored. They may feel the treatment they received from their doctor was inadequate and they may be left with feelings of unease and frustration about the evaluations provided. And most importantly, they don’t respond to the treatment provided and/or they may have adverse sensitivities and feelings surrounding it.

Critical to accurately diagnose for both physical and mental health

Relapsing/remitting forms of somatization are typified by periods of somatic symptoms associated with repetitive stressor situations (problems with marriage, job, children, etc.), episodes of anxiety and depression, and impairment with daily functioning. Accurate diagnosis is important to prevent negative consequences such as job loss, marital problems, and financial problems. Delays in diagnosis and intervention can lead to worsening affective and anxiety symptoms.

The American Journal of Psychiatry: Unfortunately, psychiatrists are likely the last in the long line of doctors to see somatoform symptom disorder patients. Because of this, it is important that doctors in other disciplines, such as primary care and neurology, be aware of cases showing interaction between somatoform disorders, comorbid mental illness, and suicide.

Somatic Symptom Disorder and Other Comorbid Conditions

Comorbid mental health conditions are of great concern when patients have a Somatic Symptom Disorder. In primary care settings, over 70% of patients with major depression present mainly with physical complaints rather than symptoms of depression. 73% of primary care patients with depression or anxiety presented solely with SSD. For these patients, feelings of hopelessness can lead to suicide attempts or simply trouble dealing with the stresses of daily life. Substance abuse may be used to help them cope with their symptoms. Relationships with family members, friendships, and at work may become stressed as the person’s symptoms continue with no helpful medical treatment in sight.

Although there is no way to prevent this disorder, a correct diagnosis can help a person avoid excessive medical testing or unnecessary medication. Mental Health screening for Somatic Symptom Disorder as well as comorbid conditions is required and attempting to solve this problem with laboratory tests will fail as nothing specifically medical exists to test for, for example; tests to check for diseases that can look like somatic symptom disorder, such as multiple sclerosis and systemic lupus erythematosus (lupus), or syndromes such as fibromyalgia, chronic fatigue syndrome and irritable bowel syndrome. The following statistics from ScienceDirect highlights the rate of mental and physical comorbidity:

In addition to fatigue and sleep disturbances, nonspecific musculoskeletal complaints and gastrointestinal problems can be the presenting symptoms of depression.
Primary care providers do not recognize depression in about 50% of depressed patients.

Stigma regarding mental illness and mental health treatment can make patients reticent about expressing feelings of sadness and more comfortable reporting somatic symptoms.

In addition, a somatic presentation of depression is more common in patients who do not have an ongoing relationship with the physician. Without a trusting relationship, self-disclosure of psychological complaints is less likely.

Another barrier to an accurate diagnosis is that depression, anxiety, and medical conditions often coexist, complicating the clinical picture. 75% of depressed patients had comorbid anxiety, somatization or both; 57% of the patients with anxiety had comorbid depression, somatization; or both and 54% of the patients with somatization had comorbid depression, anxiety or both.

Costs & Prevalence of Somatic Symptom Disorder

In 2013, Somatic Symptom Disorder replaced 3 diagnoses; this was a significant change to DSM-5 criteria:

Hypochondriasis
Somatization disorder
Undifferentiated somatoform disorder/pain disorder

A study from 2005 found that for Somatization Disorder alone, the cost was over twice that of patients without a Somatization Disorder.

Somatization Patients…

…had 2 to 3 times as many hospitalizations, major outpatient procedures, and emergency department visits per year as those without somatization. They also averaged 1.5 times as many primary care visits and 1.7 times as many specialist visits as nonsomatizers. Their total annual medical care costs were $6354 as opposed to $2762 for nonsomatizers.

Smith and coauthors showed that health care utilization and cost decreased by more than 50% when primary care physicians effectively treated their patients who had unexplained medical symptoms.
A retrospective review of more than 13,000 psychiatric consultations found that somatization disorder resulted in more disability and unemployment than any other psychiatric illness.

Importance of Early diagnosis

So why don’t people seek treatment in the early stages before it becomes a stage 4 problem? In general, it is because they don’t recognize the symptoms. 84% of the time, between the first signs of mental illness and first treatment, symptoms are not recognized. Screening all patients in a primary care setting for comorbid mental health conditions is key.

Treatment

People with this disorder may avoid seeking treatment from a mental health professional. Provide informational hand-outs and educate patients about the connection between the brain and body so they understand how stress, physical illness and emotional problems often co-occur. The earlier a person can be diagnosed, the easier it will be to help the person deal with the effects. There is some evidence that cognitive behavioral therapy (CBT) can help reduce symptoms and address associated anxiety or depression. Antidepressant medication or other psychiatric medication can provide relief from the physical symptoms, and referrals to psychotherapy can help the person deal with or manage chronic physical discomfort. Stress management and relaxation techniques may also be helpful.

Patients with more severe somatization may benefit from a psychiatric referral. Abrupt referral to a behavioral health consultant may leave the patient with feelings of abandonment. Patients are more likely to accept a referral when the provider emphasizes how it will help both the patient and the doctor to find ways to relieve suffering and improve coping with illness. Scheduling a follow-up visit with the primary care physician is recommended to discuss recommendations for further treatment and alleviate feelings of abandonment. Continued mental health screening by the primary care provider will give the patient further sense of continuity.

About Connected Mind

Connected Mind is a privately held company based out of McKinney, TX. Working with a team of psychologists, we developed Connected Mind with Fast Check technology. Designed solely for use as a computerized screening, it is the first tool of its kind to simultaneously screen for multiple conditions at the same time while minimizing questions. The tool was validated by a team of researchers working as independent consultants from the University of North Texas.