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Somatic Symptoms: Mental Health Approach and Differential Diagnosis

November 2008

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Table of Contents

  1. Introduction
  2. Screening for Somatic Symptoms
  3. Assessment, Diagnosis and Management
  4. Insomnia
    1. Assessment and Diagnosis
    2. Management
      1. Nonpharmacologic Treatment
      2. Pharmacologic Treatment
  5. Pain
    1. Assessment and Diagnosis
    2. Management
      1. Patient Response to Pharmacologic Pain Treatment
      2. Pain, Fatigue and Depression
      3. Pain in Substance Users
  6. Fatigue
    1. Assessment and Diagnosis
    2. Management
  7. Appetite and Weight Loss
    1. Assessment and Diagnosis
    2. Management
  8. Sexual Dysfunction
    1. Assessment and Diagnosis
    2. Management
  9. References
  10. Further Reading


I. Introduction

Many HIV-infected people experience somatic symptoms, including insomnia, pain, fatigue, poor appetite, weight changes, and sexual dysfunction. Although somatic symptoms are rarely life threatening, they occur frequently, are often overlooked, are difficult to treat, and adversely affect quality of life. Somatic symptoms are not diagnostic of any particular disorders. Instead, they are commonly multifactorial and often coexist with medical and/or psychiatric conditions.

This chapter addresses the presentation, effects, and management of somatic symptoms from a mental health perspective that includes discussion of medical causes. The importance of assessing patients for medical causes of somatic symptoms cannot be overstated, particularly when multiple symptoms present concomitantly. Any of the symptoms could be an indication of a medical condition, mental health disorder, or both. For example, symptoms such as abdominal pain, fatigue, and weight loss require careful assessment. Untreated or undertreated mental health disorders can worsen patients' somatic symptoms and result in substantial emotional suffering, possibly leading to serious morbidity, even suicide.

Comprehensive medical diagnostic and treatment considerations for HIV-infected adults are available in the Clinical Guidelines for the Treatment of HIV-Infected Adults.


II. Screening for Somatic Symptoms

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Recommendation:

Clinicians should assess for new somatic symptoms at each visit with direct questions that elicit accurate responses from patients.

Routine screening for somatic symptoms is essential because some patients may not consider their symptoms important until significant morbidity has resulted. In addition, the multifactorial nature of somatic symptoms may prevent patients from precisely articulating their symptoms. Clinicians should assess for new somatic symptoms at each visit with direct questions that elicit accurate responses from patients.

The questions listed below are included in the Patient Health Questionnaire 15-Item Somatic Symptom Severity Scale (PHQ-15) and detail symptoms that account for 90% of somatic symptoms encountered in the primary care setting.1

During the past 4 weeks, how much have you been bothered by any of the following problems?

  1. Stomach pain
  2. Back pain
  3. Pain in your arms, legs, or joints (knees, hips, etc.)
  4. Menstrual cramps or other problems with your periods [Women only]
  5. Headaches
  6. Chest pain
  7. Dizziness
  8. Fainting spells
  9. Feeling your heart pound or race
  10. Shortness of breath
  11. Pain or problems during sexual intercourse
  12. Constipation, loose bowels, or diarrhea
  13. Nausea, gas, or indigestion
  14. Feeling tired or having low energy
  15. Trouble sleeping

These questions are scored as 0 ("not bothered"), 1 ("bothered a little"), and 2 ("bothered a lot") to help clinicians determine both the number of symptoms a patient may be experiencing and the severity of the symptoms. Total PHQ-15 scores of 5, 10, and 15 represent cutoff values for low, medium, and high somatic symptom severity, respectively.


III. Assessment, Diagnosis and Management

Recommendations:

Clinicians should:

  • Assess for common medical and mental health disorders associated with somatic symptoms when patients present with somatic complaints (see Table 1)
  • Review and update medication lists to identify possible drug-drug interactions or side effects that may be responsible for somatic symptoms

Clinicians should treat both the underlying cause of the somatic symptoms and the symptoms themselves.

Clinicians should refer patients to a psychiatrist or clinical psychologist when:

  • The cause of the somatic complaints cannot be fully explained by comprehensive diagnostic tests
  • There is significant mental distress in response to the symptoms, regardless of whether an underlying cause has been identified

Once the presence of somatic symptoms has been established, the cause of the symptoms should be determined (see Table 1). Baseline and annual physical examination and mental health and substance use screening can ensure that possible underlying etiologies are identified and that patients receive timely treatment for any comorbid disorders.

The distinction between a medical disorder and a mental health disorder is not always clear. For example, depression accompanies a variety of medical disorders and is independently associated with physiological changes in the body. Back pain, headache, abdominal pain, weight loss, and fatigue can all be somatic manifestations of depression. Shortness of breath, palpitations, abdominal pain, and dizziness can be manifestations of anxiety. Schizophrenia, bipolar mania, and other psychiatric disorders can all present with somatic symptoms.


Key Point

Identification of a medical disorder does not exclude the existence of a mental health or substance use disorder. Poor physical health is frequently accompanied by a mental health disorder, particularly depression.2


Patients with mental health disorders may also present with somatic delusions. A somatic delusion is a false fixed belief of suffering from a disease that does not exist. For example, the depressed patient may say, My body is rotting inside. Somatic symptoms and somatic delusions, in the context of severe mental health disorders, can lead to self-destructive behaviors, including intentional or unintentional self-harm or suicide. Early identification and appropriate referral and treatment can be lifesaving in these cases.

For a comprehensive discussion regarding suicide assessment and treatment, refer to Suicidality and Violence in Patients With HIV/AIDS. Information regarding depression and mania can be found in Depression and Mania in Patients With HIV/AIDS.

Assignment of symptoms to malingering or somatoform disorders, such as hypochondriasis, requires a careful initial assessment for other causes. When malingering or a somatoform disorder is suspected, consultation with a psychiatrist may be necessary for confirmation.


Table 1: Assessment for Disorders Associated With Somatic Symptoms
Medical Assessment
Physical examination
Laboratory assessment
  • Immunologic and virologic assessment
    • CD4 count
    • Viral load
    • Significant decline in immune function and high levels of viremia are often associated with somatic complaints
 
  • Hematologic assessment
    • Neutropenia and anemia can be detected by complete blood count with a differential
 
  • Metabolic assessment
    • Muscle enzyme elevations
    • Abnormal hormonal levels (especially testosterone levels)
    • Electrolyte imbalances
    • Liver enzyme elevations
    • Thyroid dysfunction
    • Vitamin deficiencies, including B12 and folate
 
  • Syphilis screening
    • Syphilis screening can help identify acute versus latent infection
    • Acute syphilitic meningitis, as well as neurosyphilis, may result in physical or mental (or both) symptoms
Mental Health and Substance Use Assessment
Mental health assessment
  • Assess for the following:
    • Cognitive impairment
    • Depression
    • Anxiety
    • Sleep habits
    • Appetite
    • Post-traumatic stress disorder
    • Psychosocial status
    • Suicidal/violent ideation
    • Past psychiatric history, including diagnoses, hospitalizations, and psychotropic medications
Substance use assessment
  • Types of drugs; past and current use
    • Street drugs -- Marijuana, cocaine, heroin, methamphetamine, MDMA/ecstasy
    • Illicit use of prescription drugs
    • Alcohol
    • Tobacco
    • Frequency of use and usual route of administration
  • Risk behaviors -- Drug/needle sharing, exchanging sex for drugs, sexual risk-taking while under the influence of drugs or alcohol
  • Toxicology screening (with the patient's consent) may detect acute intoxication, addiction, or withdrawal


The management of somatic symptoms in combination with existing chronic illnesses, drug side effects and interactions, and the psychological and emotional state of the patient is a clinical challenge. When physical health disorders are accompanied by mental health disorders, it is important to treat both simultaneously. Knowledge about potential drug-drug interactions, dosing, and side effects is essential. Psychiatric medications and psychotherapy may be required in addition to medical treatment.

Refer to Interactions Between HIV-Related Medications And Psychotropic Medications: Indications And Contraindications.

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This article was provided by New York State Department of Health AIDS Institute.
 
See Also
Articles for Mental Health Professionals

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