Korean Journal of Psychosomatic Medicine (정신신체의학)

Korean Psychosomatic Society (한국정신신체의학회)
권호 표지
DOI QR코드

DOI QR Code

Pharmacotherapy for Patients Complaining With Somatic Symptoms

신체증상을 호소하는 환자의 약물치료

  • Lee, Kyung-Kyu (Department of Psychiatry, College of Medicine, Dankook University)
  • 이경규 (단국대학교 의과대학 정신건강의학교실)
  • Received : 2021.11.09
  • Accepted : 2021.11.26
  • Published : 2021.12.31
Download PDF
⟨ Previous Next ⟩

Abstract

Patients complaining with somatic symptoms are very common in clinical practice, and are often consulted to medical department. But it is difficult to treat well. The treatment of somatic symptom disorder is multi-modal as none of the methods on their own provide a satisfactory outcome. The treatment of somatic symptoms disorders is complicated by lack of boundary, conceptual clarity, and overemphasis on psychosocial causation and effectiveness of psychological treatments. In clinical practice all classes of psychotropics are used to treat somatic symptoms disorder. Drugs such as tricyclic antidepressants, serotonin reuptake inibitors(SSRI), serotonin and noradrenalin reuptake inhibitors (SNRI), atypical antipsychotics are studied. The evidence indicates that these drugs are effective in somatic symptom disorders. All classes of antidepressants seem to be effective against somatic symptom disorders. SSRIs are more effective against hypochondriasis and body dysmorphic disorder, and SNRIs appear to be more effective than other antidepressants when pain is predominant. The author suggest that psychiatrists should know how to treat patients complaining with somatic symptoms by using not only psychotherapeutic approach but also pharmacological treatment. It will be helpful to reduce suffering and increase quality of life of these patients.

신체증상장애를 포함하여 다양하게 신체증상을 호소하는 환자는 여러 영역의 임상현장에서 자주 접할 수 있는 정신질환이지만 분류 및 개념이 명확하지 않음으로써 정확한 진단과 치료가 이뤄지지 못하는 경우가 많다. 치료는 환자에게서 원인을 찾거나 정신사회적 원인을 강조하면서 지나치게 인지행동치료를 포함한 정신치료에만 초점을 맞추기보다는 환자의 고통을 줄일 수 있는 대증요법을 시행하여야 한다. 정신사회적 원인론에 대한 과도한 강조는 신체증상장애 환자들에게 도움이 되지 않을 뿐만이 아니라 이 질환의 약물치료에 대한 이해 및 연구를 더욱 어렵게 할 뿐이다. 신체증상장애의 약물치료에 관한 연구는 개념과 경계의 불명확성, 그리고 기능성 신체증후군과의 중첩 등으로 인해 제대로 된 연구가 어렵다. 몇몇 체계적 연구들의 결과를 살펴보면 정신약물은 단기간에서는 효과적인 것으로 나타났다. 대부분의 항우울제가 신체증상을 호소하는 환자들에게 효과가 있으며, 선택적 세로토닌 재흡수 차단제는 신체추형장애 및 건강염려증에서 그리고 세로토닌 노르아드레날린 재흡수 차단제는 통증이 주된 증상인 환자들에게서 다른 항우울제보다 더 효과적이다. 정신건강의학과 의사들은 신체증상을 호소하는 환자들에게 적용할 수 있는 인지행동치료를 포함한 다양한 정신치료적 기법뿐만이 아니라 약물치료에서 정신약물 및 비정신약물의 사용을 잘 알고 사용함으로써 이 환자들을 도울 수 있을 것이다.

Keywords

References

  1. Kroenke K. Patients presenting with somatic complaints: epidemiology, psychiatric co-morbidity and management. Int J Methods Psychiatr Res 2003;12:34-43. https://doi.org/10.1002/mpr.140
  2. Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry 2005;62:903-910. https://doi.org/10.1001/archpsyc.62.8.903
  3. Bass C, Benjamin S. The management of chronic somatisation. Br J Psychiatry 1993;162:472-480. https://doi.org/10.1192/bjp.162.4.472
  4. Bass C, Peveler R, House A. Somatoform disorder: Severe psychiatric illnesses neglected by psychiatrists. Br J Psychiatry 2001;179:11-14. https://doi.org/10.1192/bjp.179.1.11
  5. Chaturvedi SK, Upadhyaya MP, Rao S. Somatic symptoms in a community clinic. Indian J Psychiatry 1988;30:369-374.
  6. Fink P, Rosendal M. Recent developments in the understanding and management of functional somatic symptoms in primary care. Curr Opin Psychiatry 2008;21:182-188. https://doi.org/10.1097/YCO.0b013e3282f51254
  7. Jeffery LJ, Kroenke K. Prevalence, impact and prognosis of multisomatoform disorder in primary care: a 5-year follow-up study. Psychosom Med 2008;70:430-434. https://doi.org/10.1097/PSY.0b013e31816aa0ee
  8. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: Incidence, evaluation, therapy and outcome. Am J Med 1989;86:262-266. https://doi.org/10.1016/0002-9343(89)90293-3
  9. Noyes R Jr, Holt CS, Kathol RG. Somatization. Diagnosis and management. Arch Fam Med 1995;4:790-795. https://doi.org/10.1001/archfami.4.9.790
  10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Publishing;2000.
  11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, DC: American Psychiatric Publishing;2013.
  12. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization;1992.
  13. Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med 2007;69:881-888. https://doi.org/10.1097/PSY.0b013e31815b00c4
  14. Noyes R Jr, Happel RL, Muller BA, Holt CS, Kathol RL, Sieren LR, Amos JJ. Fluvoxamine for somatoform disorders: an open trial. Gen Hosp Psychiatry 1998;20:339-344. https://doi.org/10.1016/S0163-8343(98)00044-9
  15. Lee KK. Psychotherapy for patients complaining with somatic symptoms. Psychoanalysis 2013;24:78-85.
  16. Somashekar B, Jainer A, Wuntakal B. Psychopharmacotherapy of somatic symptoms disorder. Int Rev psychiatry 2013;25:107-115. https://doi.org/10.3109/09540261.2012.729758
  17. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999;354:936-939. https://doi.org/10.1016/S0140-6736(98)08320-2
  18. Henningsen P. Management of somatic symptom disorder. Dialogues Clin Neurosci 2018;20:23-31. https://doi.org/10.31887/DCNS.2018.20.1/phenningsen
  19. Kleinstauber M, Witthoft M, Hiller W, Steffanowski A, Lambert M, Meinhardt G, Lieb K. Pharmacological interventions for somatoform disorders in adults. Cochrane Database Syst Rev 2013;7.
  20. Fallon BA. Pharmacotherapy of somatoform disorders. J Psychosom Res 2004;56:455-460. https://doi.org/10.1016/S0022-3999(03)00631-7
  21. O'Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained medical symptoms and syndromes. J Fam Pract 1999;48:980-990.
  22. Sumathipala A. What is the evidence for the efficacy of treatment for somatoform disorder? A critical review of previous intervention studies. Psychosom Med 2007;69:889-900. https://doi.org/10.1097/PSY.0b013e31815b5cf6
  23. Delargy MA, Peatfield RC, Burt AA. Successful rehabilitation in conversion paralysis. Br Med J 1986;292:1730-1731. https://doi.org/10.1136/bmj.292.6537.1730
  24. Speed J. Behavioral management of conversion disorder: retrospective study. Arch Phys Med Rehabil 1996;77:147-154. https://doi.org/10.1016/S0003-9993(96)90159-8
  25. Trieschmann RB, Stolov WC, Montgomery ED. An approach to the treatment of abnormal ambulation resulting from conversion reaction. Arch Phys Med Rehabil 1970;51:198-206.
  26. Fishbain DA, Cutler RB, Rosomoff HL. Do antidepressants have an analgesic effect in psychogenic pain and somatoform pain disorder? A meta-analysis. Psychosom Med 1998;60:503-509. https://doi.org/10.1097/00006842-199807000-00019
  27. Lynch ME. Antidepressants as analgesics: a review of randomized controlled trials. J Psychiatry Neurosci 2001;26:30-36.
  28. Sussman N. SNRIs versus SSRIs: mechanisms of action in treating depressions and painful physical symptoms. Primary Care Companion J Clin Psychiatry 2003;5:19-26. https://doi.org/10.4088/PCC.v05n0105
  29. Han C, Pae C, Lee B, Ko Y, Masand PS, Patker AA, Patkar AA, Joe S, Jung I. Venlafaxine versus mirtazapine in the treatment of undifferentiated somatoform disorder: a 12 week prospective, open-label, randomized, parallel-group trial. Clin Drug Investig 2008;28:251-261. https://doi.org/10.2165/00044011-200828040-00006
  30. Han C, Pae CU, Lee BH, Ko Y, Masand PS, Patkar AA, Jun I. Fluoxetine versus sertraline in the treatment of patients with undifferentiated somatoform disorder: a randomized, open-label, 12-week, parallel-group trial. Prog Neuropsychopharmacol Biol Psychiatry 2008;32:437-444. https://doi.org/10.1016/j.pnpbp.2007.09.014
  31. Muller JE, Wentzel I, Koen L, Niehaus DJH, Seedat S, Stein DJ. Escitalopram in the treatment of multisomatoform disorder: A double-blind placebo-controlled trail. Int Clin Psychopharmacol 2008;23:43-48. https://doi.org/10.1097/YIC.0b013e32825ea301
  32. Luo Y, Zhang MY, Wu WY, Li CB, Lu Z, Li QW. A randomized double-blind clinical trial on analgesic efficacy of fluoxetine for persistent somatoform pain disorder. Prog Neuropsychopharmacol Biol Psychiatry 2009;33:1522-1525. https://doi.org/10.1016/j.pnpbp.2009.08.013
  33. Muller T, Mannel M, Murck H, Rahlfs VW. Treatment of somatoform disorders with St John's wort: a randomized double-blind and placebo-controlled trial. Psychosom Med 2004;66: 538-547. https://doi.org/10.1097/01.psy.0000128900.13711.5b
  34. Volz HP, Murck H, Kasper S, Moller HJ. St. John's wort extract (LI160) in somatoform disorders: results of a placebo-controlled trial. Psychopharmacology 2002;164:294-300. https://doi.org/10.1007/s00213-002-1171-6
  35. Schreiber S, Bleich A, Pick CG. Venlafaxine and mirtazapine: Different mechanisms of antidepressant action, common opioid-mediated antinociceptive effects-A possible opioid involvement in severe depression. J Mol Neurosci 2002;18:143-149. https://doi.org/10.1385/JMN:18:1-2:143
  36. Fallon BA, Liebowitz MR, Salman E, Schneier FR, Jusino C, Hollander E, Klein DF. Fluoxetine for hypochondriacal patients without major depression. J Clin Psychopharmacol 1993; 13:438-441.
  37. Fallon BA, Petkova E, Skritskaya N, Sanchez-Lacay A, Schneier F, Vermes D, Cheng J, Liebowitz MR. A doublemasked, placebo-controlled study of fluoxetine for hypochondriasis. J Clin Psychopharmacol 2008;28:638-645. https://doi.org/10.1097/JCP.0b013e31818d21cf
  38. Fallon BA, Schneier FR, Marshall R, Campeas R, Vermes D, Goetz D, Liebowitz MR. The pharmacotherapy of hypochondriasis. Psychopharmacol Bull 1996;32:607-611.
  39. Greeven A, van Balkom AJ, Visser S, Merkelbach JW, van Rood YR, van Dyck R, Van der Does AJW, Zitman FG, Spinhoven P. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. Am J Psychiatry 2007;164:91-99. https://doi.org/10.1176/appi.ajp.164.1.91
  40. Wesner RB, Noyes R. Imipramine: an effective treatment for illness phobia. J Affect Disord 1991;22:43-48. https://doi.org/10.1016/0165-0327(91)90082-4
  41. Pilowsky L. The response to treatment in hypochondriacal disorders. Aust N Z J Psychiatry 1968;2:88-92. https://doi.org/10.3109/00048676809159218
  42. Magarinos M, Zafar U, Nissenson KK, Blanco C. Epidemiology and treatment of hypochondriasis. CNS Drugs 2002;16:9-22. https://doi.org/10.2165/00023210-200216010-00002
  43. Perugi G, Giannotti D, Di Vaio S, Frare F, Saettoni M, Cassano GB. Fluvoxamine in the treatment of body dysmorphic disorder (dysmorphophobia). Int Clin Psychopharmacol 1996;11:247-254. https://doi.org/10.1097/00004850-199612000-00006
  44. Phillips KA, Dwight MM, McElroy SL. Efficacy and safety of fluvoxamine in body dysmorphic disorder. J Clin Psychiatry 1998;59:165-171. https://doi.org/10.4088/JCP.v59n0404
  45. Phillips KA, Najar F. An open label study of citalopram in body dysmorphic disorder. J Clinl Psychiatry 2003;64:715-720. https://doi.org/10.4088/JCP.v64n0615
  46. Phillips KA, Albertini RS, Rasmussen SA. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry 2002;59:381-388. https://doi.org/10.1001/archpsyc.59.4.381
  47. Hollander E, Allen A, Kwon J, Aronowitz B, Schmeidler J, Wong C, Simeon D. Clomipramine vs desipramine crossover trail in body dysmorphic disorder: Selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry 1999;56:1033-1039. https://doi.org/10.1001/archpsyc.56.11.1033
  48. Phillips KA, Albertini RS, Siniscalchi JM, Khan AH, Robinson M. Effectiveness of pharmacotherapy for body dysmorphic disorder: a chart -review study. J Clin Psychiatry 2001;62: 721-727. https://doi.org/10.4088/JCP.v62n0910
  49. Altamura AC, DiRosa A, Ermentini A, Guaraldi GP, Invvernizzi G, Rudas N, Tacchini G. Levosulpiride in somatoform disorders: a double blind placebo-controlled cross-over study. Int J Psychiatry Clin Pract 2003;7:155-159. https://doi.org/10.1080/13651500310001833
  50. Nagoshi Y, Tominaga T, Fukui K. Effect of aripiprazole augmentation for treatment-resistant somatoform disorder: a case series. J Clin Psychopharmacol 2014;34:397-398. https://doi.org/10.1097/JCP.0000000000000063
  51. Nagoshi Y, Tominaga T, Fukui K. Blonanserin augmentation for treatment-resistant somatic symptom disorder: a case series. Clin Neuropharmacol 2016;39:112-114. https://doi.org/10.1097/WNF.0000000000000134
  52. Mula M, Pini S, Cassano GB. The role of anticonvulsant drugs in anxiety disorders: a critical review of the evidence. J Clin Psychopharmacol 2007;27:263-272. https://doi.org/10.1097/jcp.0b013e318059361a
  53. Stahl SM. Anticonvulsants as anxiolytics, part 2: pregabalin and gabapentin as alpha(2)delta ligands at voltage-gated calcium channels. J Clin Psychiatry 2004;65:460-461. https://doi.org/10.4088/JCP.v65n0401
  54. Chesler EJ, Ritchie J, Kokayeff A, Lariviere WR, Wilson SG, Mogil JS. Genotype-dependence of gabapentin and pregabalin sensitivity: the pharmacogenetic mediation of analgesia is specific to the type of pain being inhibited. Pain 2003;106:325-335. https://doi.org/10.1016/S0304-3959(03)00330-0
  55. Garcia-Campayo J, Sanz-Carrillo C. Gabapentin for the treatment of patients with somatization disorder. J Clin Psychiatry 2001;62:474. https://doi.org/10.4088/JCP.v62n0612a
  56. Guglielmo R, Martinotti G, Janiri L. Gabapentin as Add-On Treatment for Somatoform Disorder: a Case Report. Clin Neuropharmacol 2012;35:45-46. https://doi.org/10.1097/WNF.0b013e31823e669b
  57. Harnack D, Scheel M, Mundt A, Kupsch A, Heinz A, Strohle A. Pregabalin in patients with antidepressant treatment-resistant Somatoform disorders-a case series. J Clin Psychopharmacol 2007;27:537-539. https://doi.org/10.1097/JCP.0b013e31814e5e84
  58. Garcia-Campayo J, Sanz-Carrillo C. Topiramate as a treatment for pain in multisomatoform disorder patients: an open trial. Gen Hosp Psychiatry 2002;24:417-421. https://doi.org/10.1016/S0163-8343(02)00205-0
  59. Johansen ML, Risor MB. What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies. Patient Educ Couns 2017;100:647-654. https://doi.org/10.1016/j.pec.2016.11.015