6

BRIEF RESUME OF INTENDED WORK:

6.1

NEED FOR STUDY:

-       About 25-30% of patients present themselves in general practice and specialized healthcare with medically unexplained somatic symptoms. The prevalence of these symptoms is the highest among the elderly, children and adolescents. ⁽¹⁾ Somatization disorder most frequently occur with symptoms of headache, stomach ache or various kinds of pain in the limbs that show high comorbidity with other mental disorders, predominantly with anxiety. SSDs are always multi causal issues where biological, social, environmental and psychological factors are interconnected in a complex manner.  ⁽¹⁾ 

-       Somatisation is one of the commonest psychiatric disorders in the community, although its prevalence has been difficult to measure. ⁽²⁾

-       We know that many symptoms (around 30%) presenting to General Practitioners do not have a cause identified. Many of these resolve within a few weeks, but some persist up to 5 years or more. The WHO study found that patients with five or more somatic symptoms had significantly increased morbidity and physical disability at follow-up, with little difference in outcome between patients with medically explained and unexplained symptoms. Thus, although finding or excluding organic disease is important, it is not the end of the story.  ⁽²⁾

-       Somatic symptoms are a frequent presentation of distress in general practice, and up to 30% of common somatic symptoms go undiagnosed. One of the interesting issues in somatisation is its relationship with depression and anxiety. In some patients the distress is “converted” successfully to somatic symptoms and concern, and emotional distress is low; in others the somatic symptoms are part of a general distress syndrome best characterised by depression and anxiety. Somatisation does significantly reduce the likelihood of General practitioners recognising depression or anxiety.  ⁽²⁾

-       Somatic Symptom Disorder (SSD) is a new disorder defined in the Diagnostic and Statistical Manual Fifth Edition (DSM-5), replacing somatoform and related disorders in the DSM-4 Text Revision with diagnostic criteria that are inclusive of a broad array of presentations.  ⁽³⁾The DSM-5 also removed somatization disorder, undifferentiated somatoform disorder, hypochondriasis, and pain disorder. Many patients that historically met the criteria for one of those conditions now meet criteria for SSD, based on these revisions. ⁽⁴⁾

6.2

REVIEW OF LITRATURE:

INTRODUCTION

-       Somatic symptom disorder (SSD) involves one or more physical symptoms accompanied by an excessive amount of time, energy, emotion, and/or behaviour related to the symptom that results in significant distress and/or dysfunction. Physical symptoms may or may or may not be explained by a medical condition. In previous editions of the Diagnostic and Statistical Manual of Mental Disorders, the diagnosis of somatic symptom disorder could not be made unless somatic symptoms were not able to be explained clinically. Additionally, previous editions did not include the requirement that certain psychobehavioral features be present for the diagnosis of somatic symptom disorder to be made. ⁽⁴⁾

-       The symptoms may or may not be associated with another medical condition. The diagnosis of somatic symptom disorder and a concurrent medical illness are not mutually exclusive, and these frequently occur together.  ⁽⁵⁾

-       The course of somatic symptom disorder is likely to be chronic and fluctuating and influenced by the number of symptoms, individual’s  age, level of impairment, and any comorbidity. The course is also influenced by personality traits, with less harm avoidance and greater cooperativeness associated with a shorter time to remission. ⁽⁵⁾

-       In the International Classification of Diseases, 11^th Revision (ICD-11), Somatic Symptom Disorder is classified under 6C20: Bodily Distress Disorder.  ⁽⁶⁾

CLINICAL FEATURES AND DIAGNOSTIC CRITERIA: 

-       Individuals with somatic symptom disorder typically have multiple, current, somatic symptoms that are distressing or result in significant disruption of daily life, although sometimes only one severe symptom, most commonly pain, is present. The symptoms sometimes represent normal bodily sensations or discomfort that does not generally signify serious disease. The individual’s suffering is authentic, whether or not it is medically explained.  ⁽⁵⁾

-       Individuals with somatic symptom disorder tend to have very high levels of worry about illness. They appraise their bodily symptoms as unduly threatening, harmful, or troublesome and often think the worst about their health. ⁽⁵⁾

-       The diagnostic criteria according to DSM 5-TR  [DIAGNOSTIC AND STATISTICAL MANUAL FIFTH EDITION] is as follows:  ⁽⁵⁾

     A. One or more somatic symptoms that are distressing or result in significant disruption of daily life. 

     B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: 

           1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms. 

           2. Persistently high level of anxiety about health or symptoms. 

           3. Excessive time and energy devoted to these symptoms or health concerns. 

Specify if:

            With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain. 

Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). 

      Specify if:

  Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months). 

Specify current severity: 

     Mild: Only one of the symptoms specified in Criterion B is fulfilled.

    Moderate: Two or more of the symptoms specified in Criterion B are fulfilled. 

    Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom). 

ETIOLOGY:

-       Persons with this disorder augment and amplify their somatic sensations; they have low thresholds for, and low tolerance of, physical discomfort. ⁽⁷⁾

-       The psychodynamic school of thought holds that aggressive and

hostile wishes toward others are transferred (through repression and displacement) into physical complaints. The anger of patients with this disorder originates in past disappointments, rejections, and losses, but the patients express their anger in the present by soliciting the help and concern of other persons and then rejecting them as ineffective. ⁽⁷⁾

-       This disorder is also viewed as a defense against guilt, a sense of innate badness, an expression of low self-esteem, and a sign of excessive self-concern. Pain and somatic suffering thus become means of atonement and expiation (undoing) and can be experienced as deserved punishment for past wrongdoing (either real or imaginary) and for a person’s sense of wicked ness and sinfulness. ⁽⁸⁾

^-                Association between somatic symptoms and psychological distress:  From the psychoanalytic perspective, somatisation is “a conversion of emotional stress into somatic stress”. This is confirmed in a study where 66% of participants attributed psychological distress or a combination of psychological and physical problems as the source of their somatic complaints. Also, showed that almost 60% of patients with anxiety or depression reported greater somatisation than 29.6% of those with somatisation reporting increased anxiety or depression. This imply that somatisation and psychological distress may have a reciprocal influence on each other, with the latter having a greater influence on the former.  ⁽⁹⁾

DIFFERENTIAL DIAGNOSIS:  ⁽⁸⁾

      Somatic symptom disorder must be differentiated from non-psychiatric medical conditions before making a psychiatric diagnosis. Some psychiatric disorders that need to be differentiated are: 

-       Illness anxiety disorder,

-       Conversion disorder

-       Factitious disorder

-       Body dysmorphic disorder

-       Delusional disorder

 HOMOEOPATHIC APPROACH 

Mental diseases of Somatopsychic type (§215): The diseases that arise after the decline of the corporeal symptoms thereby increasing the symptoms of the derangement of the mind and disposition that attains the most one sidedness. ⁽¹⁰⁾

Once the symptoms of the previous disease has been collected, these can be mixed with the existing corporeal and mental symptoms. Thus, the totality is formed. To this complete picture of the disease, the medicine capable of producing strikingly similar (especially to the mental symptoms) have to be selected. The final remedy must be an anti-psoric one, which will complete the cure. (§217-220)

Mental diseases of Psychosomatic type (§225): Mental diseases that arise as a result of prolonged emotional disturbances and different psychological depressions like continued anxiety, worry, vexation, wrongs and frequent occurrence of greater fear and fright. Such diseases may be of recent origin and may not have developed fully into corporeal diseases. But if left untreated they may damage the body. ⁽¹⁰⁾

Such mental diseases of psychic origin can be treated by means of psychological remedies like confidence building, friendly exhortations, sensible advice and a well disguised deception. This has to be always supported by good diet and regimen. Radical anti-psoric treatment has to be given to avoid any type of recurrences. (§ 226-227)

According to § 215-216 Hahnemann considers mental disease as one sided diseases of the chronic type affecting the whole psychosomatic entity.  ⁽¹⁰⁾

Common suitable homeopathic drugs for Somatic symptom disorder:  ⁽¹¹⁾

-       Anacardium, Argentum nitricum, Arsenicum album, Asafoetida, Belladonna, Cannabis indica, Cocculus, Gelsemium, Ignatia, Kali phosphoricum, Moschus, Nux moschata, Platina, Pulsatilla, Tarentula, Valeriana, etc.

6.3

OBJECTIVES OF STUDY

1.     To understand Somatic Symptom Disorder in adults of 25 to 55 years age group and its Homoeopathic Management.

2.     2.  To understand the precipitating psychological factors in somatic complaints.

7

MATERIALS AND METHODS

7.1

SOURCE OF DATA

·      O.P.D of C.D. PACHCHIGAR Homoeopathic college & hospital.

·      Peripheral centre, and regular camp visit of C.D. PACHCHIGAR Homeopathic medical college & hospital.

·      Data will be collected via interview processes, this process includes guidelines mentioned in the organon of medicine, and case-taking will be done with reference to aphorisms number 83 to 104 as explained by Dr. Samuel Hahnemann.

7.2

MATERIAL:

Textbooks of Psychiatry, Book of organon of medicine, philosophy, Materia medica, repertory, all homoeopathic books & literature related to topic, software & soft or hard research material.

7.3

METHOD OF COLLECTION OF DATA:

1.    Study type: Experimental study

2.    Study design: Prospective study

3.    Study population: patients from OPD of C. D. Pachchigar Homoeopathic Hospital and from peripheral OPDs.

4.    Sample size: 30 patients.

5.    Sampling techniques: Non-Probability Purposive sampling.

6.    Study duration: 9 months.

7.    Selection criteria:

v Inclusion criteria:

-  Patient covering DSM-5 criteria for somatic symptom disorder.

-  Patient of 25 to 55 year age group.

-  Both sexes will be included.

-  Economical class: Patients of all economical class would be included.

- Patients with any other psychiatric comorbidity.

v Exclusion criteria:

- Below 25 and above 55 year of age group is excluded.

- Patients with delusional disorders.

- Patients who are non-compliant.

v Data analysis and methods:

- Scale of study: PHQ-15 [Patient Health Questionnaire – 15]

- Improved: Subjects showing a clinically marked decreased in the score of respective scale with a decrease in the intensity of the somatic symptom/s.

- Not Improved: No clinically favourable improvement after medicinal interventions. Adults with aggravated scores in their respective scoring scales.

- Left the treatment: Subjects who will not maintain regular follow-ups till advised to discontinue treatment.

8

Bibliography