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R.I.P. David Servan-Schreiber | ScienceBlogs
When Dr David Servan-Schreiber, left, was just 31 a routine MRI scan . of changing the sex of fish in the rivers it ends up contaminating. . My wife Anna and I couldn't agree on our son's upbringing and we were having problems in our marriage. I was losing my wife, my family, my work and my health. David Servan-Schreiber with his wife Gwenaelle and their son Charlie. A look at sexual dysfunction and thyroid disease, including diagnosing and treating. By his own account, Dr. David Servan-Schreiber was an arrogant young scientist at the University of Pittsburgh, busy, successful, "a rising star.
This is part I of a two-part article on somatization. The phenomenon of somatization, which results in unexplained physical complaints, is ubiquitous in primary care settings although it often goes unrecognized. Medical training emphasizes the identification and treatment of organic problems and may leave physicians unprepared to recognize and address somatoform complaints. As a process, somatization ranges from mild stress-related symptoms to severe debilitation.
Patients at the low end of the spectrum often respond to simple reassurance, but patients who are more impaired require interventions specifically designed to avoid unnecessary exposure to dangerous, costly and frustrating diagnostic procedures and treatments. In patients with somatoform disorders, emotional distress or difficult life situations are experienced as physical David servan schreiber wife sexual dysfunction. Patients who somatize present with persistent physical complaints for which a physiologic explanation cannot be found.
Failure to recognize this condition and manage it appropriately may lead to frustrating, and potentially dangerous interventions that generally fail to identify occult disease and do not reduce suffering. One study 4 estimated that patients with somatization disorder the most severe form of the condition generated medical costs nine times greater than those of the average medical patient.
Despite substantial amounts of medical attention, somatizing patients report high levels of disability and suffering. Traditional medical training is focused on the identification and treatment of organic disorders and leaves most physicians ill prepared for recognizing and managing patients who somatize. This first part of a two-part article provides an approach to diagnosing and understanding the process of somatization that may lead to more effective and satisfying relationships with these often-difficult patients.
Somatization is too often a diagnosis of exclusion. This is a costly and frustrating approach in patients with multiple and chronic complaints. It is much more effective to pursue a positive diagnosis of somatization when the patient presents with typical features. DSM-IV 7 defines several different somatoform disorders. However, somatization is not a specific disease but rather a process with a spectrum of expression.
The low end of the somatization spectrum includes stress-related exaggeration of common symptoms, such as headache, lightheadedness or low back pain in the context of, for example, a divorce, new family member or job. At the high end, it includes unrelenting problems that can leave patients completely disabled and withdrawn from most aspects of personal and occupational functioning.
The primary care physician's emotional response to a patient can serve as an early cue to pursue a somatization diagnosis.
A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person, or a sense of being overwhelmed by a patient who has had numerous evaluations by other physicians, may be a signal to the clinician to consider somatization in the differential diagnosis early in the patient's evaluation.
In addition, identifying the physician's reaction to somatizing patients may help prevent deterioration of the physician-patient relationship. Because the features of somatoform disorders are so variable, establishing specific diagnostic criteria, such as those listed in DSM-IV, can be difficult and may not be very useful.
Clinical experience and existing research on diagnostic criteria for the more severe forms of somatization suggest that only two features are necessary to establish a positive diagnosis of somatization in patients in primary care settings: Table 1 lists many of the symptoms and syndromes affecting patients with somatoform disorders.
Most of these symptoms also occur in patients with organic pathology. As isolated symptoms, they would require a full medical work-up. However, somatizing patients have too many symptoms, in too many organ systems, that last too long.
The intensity of the symptoms often strikes the physician as being out of proportion to the healthy appearance of the patient. The syndromes listed in Table 1 may be legitimate in many patients but are typically impossible to verify in somatizing patients. The primary care of patients who have bodily concerns. Arch Fam Med ;5: Psychiatric and psychosocial disorders have a strong association with somatoform disorders. Finding evidence of a psychiatric condition does not rule somatization in or rather, it can be a clue to diagnosis.
There is considerable evidence that patients with common psychiatric conditions such as depression and anxiety disorders may present to primary care physicians with nonspecific somatic symptoms, including fatigue, aches and pains, palpitations, dizziness and nausea. Second, patients with somatization disorder commonly have coexisting depression up to 60 percentanxiety disorders such as panic or obsessive-compulsive disorder up to 50 percentpersonality disorders up to 60 percent 916 or a substance abuse disorder.
Finally, several studies have suggested an association between somatization and a history of sexual or physical abuse in a significant proportion of patients. Table 2 summarizes the typical diagnostic features of somatization. Perhaps the greatest challenge in making the diagnosis is that the presence of somatization does not exclude the presence of an organic medical condition. Therefore, medical conditions must constantly be considered, even in patients with somatization.
Patients with chronic debilitating medical conditions often have features similar to those associated with somatoform disorders. However, when the symptoms appear to be in excess of the medical condition and other features of somatization are present, the physician's approach should be adjusted to address somatization in addition to appropriate work-up and treatment of the medical condition.
At this point, a colleague's second opinion may be helpful in confirming the diagnosis of somatization and its relationship to the existing organic pathology. To optimize care and limit frustration for patients and physicians, the investigation of patients with multiple vague somatic complaints should follow a standard process Table 3.
After performing an initial medical evaluation, reviewing medical records and evaluating the patient for common psychiatric conditions, the presence of the typical features of somatization Table 2 may be sufficient to allow a firm diagnosis of somatization. Although achieving this diagnosis may require more than a single office visit, over the long run this systematic process will prevent many unnecessary acute office visits, evaluations in the emergency department, telephone calls and frustrating arguments.
No one fully understands the pathophysiology of somatization. However, four psychologic mechanisms are frequently discussed. Understanding them can help physicians develop with patients and direct care more effectively. The mechanisms tend to be independent, and individual patients may show evidence of a single mechanism or any combination of the four mechanisms. Worries about physical disease can focus the patient's attention on common variations in bodily sensations to the degree that they become disturbing and unpleasant.
The perception of such altered sensations then seems David servan schreiber wife sexual dysfunction exacerbate the patient's concerns, which further increases anxiety and amplifies the sensations. This mechanism is well established in the pathophysiology of panic attacks and has also been documented in the
David servan schreiber wife sexual dysfunction of somatization.
When a family David servan schreiber wife sexual dysfunction is under stress, identifying one person as a patient may provide a focus that stabilizes the family system and alleviates feelings of anxiety within the family.
Members know how to interact with each other in the context of the illness. The patterns of behavior may become recurrent, and family rules about how each member should act are formed. The patterns may become dysfunctional when one member takes on the role of being weak and defective. The physician may reinforce this troublesome dynamic by focusing medical attention on the somatizing patient's disability and illness.
The family system often has a powerful tendency to resist change, even though changes, such as improved health or function of the identified patient, may be desired.
In somatizing patients, complaints wax and wane in response to stressful life situations. The physician should remember this subconscious need when experiencing the urge to try yet another empiric treatment. Dissociation corresponds to the mind's ability, as displayed in hypnosis, to have complete and detailed sensory experiences in the absence of actual sensory stimulation. Neuroimaging studies David servan schreiber wife sexual dysfunction dissociative experiences such as dreams and flashbacks experiencing a past event if it were recurring in the present suggest that David servan schreiber wife sexual dysfunction same sensory areas of the central nervous system that are activated by external events may also be activated by such internal experiences.
Patients with somatization report having dissociative symptoms much more commonly than patients with other psychiatric conditions. It therefore likely that some somatized symptoms also result from dissociation activation of somatic representations of pain or
David servan schreiber wife sexual dysfunction other physical sensations in the central nervous system in the absence of actual physical stimulation.
The phenomenon may be analogous to phantom limb pain: Somatization is the experience of physical symptoms in relation to emotional distress.
It is common, costly and frustrating to patients as well as to physicians, who are trained to focus on organic etiologies. Our simple and effective approach to making a positive diagnosis of somatization in primary care settings relies on only two essential criteria: Mechanisms commonly thought to explain somatization in primary care patients include amplification of normal body sensations, the expression of emotional distress constrained by cultural and familial rules, and dissociation.
Understanding these mechanisms facilitates the development of empathy, which is essential to an effective physician-patient relationship. Already a member or subscriber? He completed his medical degree at Laval University in Canada, completed a residency in psychiatry at the University of Pittsburgh School of Medicine, and received a Ph. He received his medical degree from the University of Pittsburgh School of Medicine and completed a family practice residency at Shadyside Hospital. He completed his medical degree at the University of Pennsylvania School of Medicine, Philadelphia, and completed residency training in internal medicine at the University of Pittsburgh School of Medicine.
Address correspondence to David Servan-Schreiber, M. Reprints are not available from the authors. This two-part article is partially based on a previously published paper
David servan schreiber wife sexual dysfunction by the first author: Coping effectively with patients who somatize.
Women's Health Primary Care ;1: The prevalence of symptoms in medical outpatients and the adequacy of therapy. The prevalence of somatization in primary care. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: Patients with multiple unexplained symptoms.
Their characteristics, functional health, and health care utilization. Somatization in the community: Am J Public Health. J Gen Intern Med. Diagnostic and statistical manual of mental disorders. American Psychiatric Association, Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. The relationship between self-rated health and depressive symptoms in an epidemiological sample of community-dwelling older adults.
J Am Geriatr Soc. Profile of depressive symptoms in younger and older medical inpatients with major depression. A comparison of somatic complaints among depressed and non-depressed older persons. Correlates of Beck Depression Inventory David servan schreiber wife sexual dysfunction in an ambulatory elderly population:
This is part I of a two-part article on somatization. The phenomenon of somatization, which results in unexplained physical complaints, is ubiquitous in primary care settings although it often goes unrecognized. Medical training emphasizes the identification and treatment of organic problems and may leave physicians unprepared to recognize and address somatoform complaints.
As a process, somatization ranges from mild stress-related symptoms to severe debilitation. Patients at the low end of the spectrum often respond to simple reassurance, but patients who are more impaired require interventions specifically designed to avoid unnecessary exposure to dangerous, costly and frustrating diagnostic procedures and treatments.
In patients with somatoform disorders, emotional distress or difficult life situations are experienced as physical symptoms.
Patients who somatize present with persistent physical complaints for which a physiologic explanation cannot be found. Failure to recognize this condition and manage it appropriately may lead to frustrating, costly and potentially dangerous interventions that generally fail to identify occult disease and do not reduce suffering.
One study 4 estimated that patients with somatization disorder the most severe form of the condition generated medical costs nine times greater than those of the average medical patient. Despite substantial amounts of medical attention, somatizing patients report high levels of disability and suffering. Traditional medical training is focused on the identification and treatment of organic disorders and leaves most physicians ill prepared for recognizing and managing patients who somatize.
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What I need to do?By his own account, Dr. David Servan-Schreiber was an arrogant young scientist at the University of Pittsburgh, busy, successful, "a rising star. David Servan-Schreiber was dying from a brain tumour – his last wish was to David Servan-Schreiber with his wife Gwenaelle and their son..
This copy is for your personal non-commercial use only. By his own account, Dr. David Servan-Schreiber was an arrogant young scientist at the University of Pittsburgh, busy, successful, "a rising star in American psychiatry," when — by accident — his own brain cancer was revealed.
He got the bad news about the tumour when the one of the student volunteers in his research experiment failed to show up and Servan-Schreiber, then 31, stepped in to have his brain scanned using magnetic resonance imaging.
Servan-Schreiber believed in hard science and was contemptuous of what we would call natural healing methods. Still, he asked his oncologist what he might do to help himself — diet or exercise, perhaps — but the doctor waved him off, saying he could do what he liked.
There was no scientific proof that those efforts could help prevent a relapse. After surgery, he returned to his old habits, such as hurriedly grabbing a Coke, chili con carne and a bagel for lunch and scarfing them down in the elevator.
A few years later the cancer came back; that time, in addition to surgery, he also underwent a year of chemotherapy.
To support its young researchers, the university hospital allowed them to use its MRI scanners in the late evenings to map the brain activity of "guinea pig" students, who would lie in the scanners doing difficult cognitive puzzles. When one evaluate subject failed to portray up, David agreed to take his place in the machine. His colleagues brought David the obstinate news that they had discovered a walnut-sized carcinoma in his prefrontal cortex.
David received conventional treatment and the cancer went into remission, only to return. He reported being told: Live your spark of life normally … If your tumour comes back, we'll detect it early. These beliefs led to him write Healing Without Freud or Prozac first published in French in Armed services, and titled Instinct to Heal in the US and his masterwork, Anticancer , which was translated into 35 languages, with more than 1m copies printed and a restraint on the New York Times bestseller list.
He focused on a tonic diet and lifestyle, including exercise, yoga, vegetables, country-like tea and the avoidance of inflammatory foods.
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