今日の臨床サポート

身体化障害

著者: 吉邨善孝 川崎西口心療クリニック

監修: 上島国利 昭和大学

著者校正/監修レビュー済:2021/09/15
患者向け説明資料

概要・推奨   

  1. 身体化障害における薬物療法の有効性を検証したランダム化比較試験は検索されなかった。一般臨床の場面では、併存する精神疾患がある場合に、効果がみられる最低必要量で維持することがおそらく推奨される(推奨度2)。
  1. 身体化障害においては、認知行動療法による治療が推奨される(推奨度2)。
  1. 身体化障害においては、支持的精神療法などの心理療法による治療が推奨される(推奨度2)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
吉邨善孝 : 特に申告事項無し[2021年]
監修:上島国利 : 原稿料(大日本住友製薬)[2021年]

改訂のポイント:
  1.  定期レビューを行った(変更なし)

病態・疫学・診察

疾患情報  
  1. 身体化障害は、歴史的には、ヒステリー、またはブリケ症候群と呼ばれていた。30歳以前に発症し、何年にもわたって持続する多症状性の障害である。
 
身体化障害発症の機序

出典

img1:  著者提供
 
 
 
  1. 精神的ストレスや葛藤が精神症状としてではなく、身体症状として表出していると捉える。
  1. 反復性で多彩な身体愁訴(胃腸症状、疼痛症状、心肺症状、転換症状、性症状、女性生殖器症状など)がみられる。
  1. 生涯発生率は女性が0.2~2%、男性が0.2%である。
  1. 経過は長く、症状はしばしば消長する。寛解することはまれで、予後は不良である。
  1. 未治療の場合、身体症状は反復して出現し持続する。
問診・診察のポイント  
  1. まず詳細な病歴の聴取を行い、器質性疾患の否定から開始する。

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文献 

著者: G R Smith, R A Monson, D C Ray
雑誌名: N Engl J Med. 1986 May 29;314(22):1407-13. doi: 10.1056/NEJM198605293142203.
Abstract/Text The per capita expenditure for health care of patients with multiple physical symptoms but no apparent physical disease (somatization disorder) is up to nine times the average per capita amount. We conducted a randomized controlled trial to determine whether psychiatric consultation would reduce the medical costs of these patients, without effecting a substantial change in patient outcome. Thirty-eight patients were randomly assigned to treatment or control groups and studied prospectively for 18 months. Treatment consisted of a psychiatric consultation and suggestions on management given to primary physicians. After nine months, the control group was crossed over to receive treatment with the same intervention. After the psychiatric consultation, the quarterly health care charges in the treatment group declined by 53 percent (P less than 0.05). In contrast, the charges in the control group showed wide variations but no overall change. The quarterly charges in the control group were significantly higher than those in the treatment group (P less than 0.05). After the control group was crossed over to receive treatment, their quarterly charges declined by 49 percent (P less than 0.05). The reductions in expenditures in both groups were due largely to decreases in hospitalization. We conclude that psychiatric consultation in the care of patients with somatization disorder reduced subsequent health care expenditures without inducing changes in health status or patients' satisfaction with their health care.

PMID 3084975  N Engl J Med. 1986 May 29;314(22):1407-13. doi: 10.1056・・・
著者: Christina M van der Feltz-Cornelis, Titus W D P Van Os, Harm W J Van Marwijk, Albert F G Leentjens
雑誌名: J Psychosom Res. 2010 Jun;68(6):521-33. doi: 10.1016/j.jpsychores.2009.10.012. Epub 2010 Jan 15.
Abstract/Text OBJECTIVE: Psychiatric consultation in primary care is meant to enhance and improve treatment for mental disorder in that setting. An estimate of the effect for different conditions as well as identification of particularly effective elements is needed.
METHODS: Database search for randomized controlled trials (RCTs) on psychiatric consultation in primary care. Validity assessment and data extraction according to Cochrane criteria were performed by independent assessors in duplicate. Meta-analysis was performed.
RESULTS: Data were collected from 10 RCTs with a total of 3408 included patients with somatoform disorder or depressive disorder, which compared psychiatric consultation to care as usual (CAU). Meta-analysis irrespective of condition showed a weighted mean indicating a combined assessment of illness burden as outcome of psychiatric consultation, compared to CAU, of 0.313 (95% CI 0.190-0.437). The effect was especially large in somatoform disorder (0.614; 95% CI 0.206-1.022). RCTs in which after the consult, consultation advice was given by means of a consultation letter, showed a combined weighted mean effect size of 0.561 (95% CI 0.337-0.786), while studies not using such a letter showed a small effect of 0.210 (95% CI 0.102-0.319). Effects are highest on utilization of health care services with 0.507 (95% CI 0.305-0.708).
CONCLUSION: Psychiatric consultation in the primary care setting is effective in patients with somatoform and depressive disorder. Largest effects are seen in reduction of utilization of health care services.

Copyright 2010 Elsevier Inc. All rights reserved.
PMID 20488268  J Psychosom Res. 2010 Jun;68(6):521-33. doi: 10.1016/j.・・・
著者: Bernd Löwe, Robert L Spitzer, Janet B W Williams, Monika Mussell, Dieter Schellberg, Kurt Kroenke
雑誌名: Gen Hosp Psychiatry. 2008 May-Jun;30(3):191-9. doi: 10.1016/j.genhosppsych.2008.01.001.
Abstract/Text OBJECTIVE: To determine diagnostic overlap of depression, anxiety and somatization as well as their unique and overlapping contribution to functional impairment.
METHOD: Two thousand ninety-one consecutive primary care clinic patients participated in a multicenter cross-sectional survey in 15 primary care clinics in the United States (participation rate, 92%). Depression, anxiety, somatization and functional impairment were assessed using validated scales from the Patient Health Questionnaire (PHQ) (PHQ-8, eight-item depression module; GAD-7, seven-item Generalized Anxiety Disorder Scale; and PHQ-15, 15-item somatic symptom scale) and the Short-Form General Health Survey (SF-20). Multiple linear regression analyses were used to investigate unique and overlapping associations of depression, anxiety and somatization with functional impairment.
RESULTS: In over 50% of cases, comorbidities existed between depression, anxiety and somatization. The contribution of the commonalities of depression, anxiety and somatization to functional impairment substantially exceeded the contribution of their independent parts. Nevertheless, depression, anxiety and somatization did have important and individual effects (i.e., separate from their overlap effect) on certain areas of functional impairment.
CONCLUSIONS: Given the large syndrome overlap, a potential consideration for future diagnostic classification would be to describe basic diagnostic criteria for a single overarching disorder and to optionally code additional diagnostic features that allow a more detailed classification into specific depressive, anxiety and somatoform subtypes.

PMID 18433651  Gen Hosp Psychiatry. 2008 May-Jun;30(3):191-9. doi: 10.・・・
著者: T Kendrick, J Chatwin, C Dowrick, A Tylee, R Morriss, R Peveler, M Leese, P McCrone, T Harris, M Moore, R Byng, G Brown, S Barthel, H Mander, A Ring, V Kelly, V Wallace, M Gabbay, T Craig, A Mann
雑誌名: Health Technol Assess. 2009 Apr;13(22):iii-iv, ix-xi, 1-159. doi: 10.3310/hta13220.
Abstract/Text OBJECTIVES: To determine (1) the effectiveness and cost-effectiveness of selective serotonin reuptake inhibitor (SSRI) treatment plus supportive care, versus supportive care alone, for mild to moderate depression in patients with somatic symptoms in primary care; and (2) the impact of the initial severity of depression on effectiveness and relative costs. To investigate the impact of demographic and social variables.
DESIGN: The study was a parallel group, open-label, pragmatic randomised controlled trial.
SETTING: The study took place in a UK primary care setting. Patients were referred by 177 GPs from 115 practices around three academic centres.
PARTICIPANTS: Patients diagnosed with new episodes of depression and potentially in need of treatment. In total, 602 patients were referred to the study team, of whom 220 were randomised.
INTERVENTIONS: GPs were asked to provide supportive care to all participants in follow-up consultations 2, 4, 8 and 12 weeks after the baseline assessment, to prescribe an SSRI of their choice to patients in the SSRI plus supportive care arm and to continue treatment for at least 4 months after recovery. They could switch antidepressants during treatment if necessary. They were asked to refrain from prescribing an antidepressant to those in the supportive care alone arm during the first 12 weeks but could prescribe to these patients if treatment became necessary.
MAIN OUTCOME MEASURES: The primary outcome measure was Hamilton Depression Rating Scale (HDRS) score at 12-week follow-up. Secondary outcome measures were scores on HDRS at 26-week follow-up, Beck Depression Inventory, Medical Outcomes Study Short Form-36 (SF-36), Medical Interview Satisfaction Scale (MISS), modified Client Service Receipt Inventory and medical record data.
RESULTS: SSRIs were received by 87% of patients in the SSRI plus supportive care arm and 20% in the supportive care alone arm. Longitudinal analyses demonstrated statistically significant differences in favour of the SSRI plus supportive care arm in terms of lower HDRS scores and higher scores on the SF-36 and MISS. Significant mean differences in HDRS score adjusted for baseline were found at both follow-up points when analysed separately but were relatively small. The numbers needed to treat for remission (to HDRS > 8) were 6 [95% confidence interval (CI) 4 to 26)] at 12 weeks and 6 (95% CI 3 to 31) at 26 weeks, and for significant improvement (HDRS reduction > or = 50%) were 7 (95% CI 4 to 83) and 5 (95% CI 3 to 13) respectively. Incremental cost-effectiveness ratios and cost-effectiveness planes suggested that adding an SSRI to supportive care was probably cost-effective. The cost-effectiveness acceptability curve for utility suggested that adding an SSRI to supportive care was cost-effective at the values of 20,000 pounds-30,000 pounds per quality-adjusted life-year. A poorer outcome on the HDRS was significantly related to greater severity at baseline, a higher physical symptom score and being unemployed.
CONCLUSIONS: Treatment with an SSRI plus supportive care is more effective than supportive care alone for patients with mild to moderate depression, at least for those with symptoms persisting for 8 weeks and an HRDS score of > or = 12. The additional benefit is relatively small, and may be at least in part a placebo effect, but is probably cost-effective at the level used by the National Institute for Health and Clinical Excellence to make judgements about recommending treatments within the National Health Service. However, further research is required.

PMID 19401066  Health Technol Assess. 2009 Apr;13(22):iii-iv, ix-xi, 1・・・
著者: P G O'Malley, J L Jackson, J Santoro, G Tomkins, E Balden, K Kroenke
雑誌名: J Fam Pract. 1999 Dec;48(12):980-90.
Abstract/Text OBJECTIVE: To determine the efficacy of antidepressant therapy for unexplained symptoms or symptom syndromes.
SEARCH STRATEGIES: We identified original studies through searching MEDLINE, EMBASE, PsycLIT, the Federal Research in Progress database, and The Cochrane Library. We also searched the bibliographies of primary and review articles for additional studies.
SELECTION CRITERIA: We excluded trials of patients with neuropathic, oncologic, or degenerative joint pain. Independent duplicate review of 392 articles identified 94 relevant reports of randomized trials involving 6595 patients across 6 symptom syndromes. Independent duplicate assessment was made for inclusion and data abstraction. Meta-analysis was performed on extractable placebo-controlled data.
MAIN RESULTS: Of 94 included trials, most studied either tricyclic antidepressants, antiserotonin antidepressants, selective serotonin reuptake inhibitors (SSRIs), or multiple agents for the treatment of the following syndromes: headache (50), fibromyalgia (18), functional gastrointestinal syndromes (13), idiopathic pain (11), tinnitus (2), and chronic fatigue (2). The quality of the studies was fair (mean score = 4.8 on a scale of 0 to 8). A majority of the studies (69%) demonstrated benefit for at least one outcome measure. Symptom improvement typically did not correlate with depression response in the few studies where it was assessed. Meta-analysis of all extractable data showed a substantial benefit from antidepressants: For the dichotomous outcome of improvement, the odds ratio was 3.4 (95% confidence interval [CI], 2.6 - 4.5), and for continuous outcomes, the standardized mean difference was 0.87 (95% CI, 0.59-1.14). The absolute percentage difference in improvement between the antidepressant and placebo arms was 32%, yielding a number needed to treat of 3 to improve one person's symptoms. Meta-regression indicated no differential effect across the classes of antidepressants; however, onbivariate tally tricyclic studies were associated with a greater likelihood of efficacy than SSRI studies (P = .02).
CONCLUSIONS: Antidepressants can be effective for various physical symptoms and symptom syndromes. The relation of outcome to depression and the efficacy of SSRIs needs further study.

PMID 10628579  J Fam Pract. 1999 Dec;48(12):980-90.
著者: Lesley A Allen, Robert L Woolfolk, Javier I Escobar, Michael A Gara, Robert M Hamer
雑誌名: Arch Intern Med. 2006 Jul 24;166(14):1512-8. doi: 10.1001/archinte.166.14.1512.
Abstract/Text BACKGROUND: Patients diagnosed as having somatization disorder (SD) who present with a lifetime history of multiple, medically unexplained physical symptoms represent a significant challenge to health care providers. To date, no psychotherapeutic or pharmacologic intervention has been found to produce clinically meaningful improvement in symptoms or functioning of patients with SD. We examined the efficacy of cognitive-behavioral therapy (CBT) for SD.
METHODS: Eighty-four participants meeting criteria for SD were randomly assigned to 1 of 2 conditions: (1) standard medical care augmented by a psychiatric consultation intervention or (2) a 10-session, manualized, individually administered CBT regimen added to the psychiatric consultation intervention. Assessments were conducted at baseline and 3, 9, and 15 months after baseline. The primary outcome measure was the severity scale of the Clinical Global Impression Scale for Somatization Disorder (CGI-SD). Secondary outcome measures were responder status as determined by clinical ratings, self-reported measures of physical functioning and somatic symptoms, and health care utilization assessed via medical records.
RESULTS: Fifteen months after baseline, somatization symptoms were significantly less severe in the group treated with CBT (0.84 points on the CGI-SD 7-point scale) (P<.001). Patients treated with CBT also were significantly more likely to be rated as either very much improved or much improved than patients treated with only augmented standard medical care (40% [n = 17] vs 5% [n = 2]). Cognitive-behavioral therapy was associated with greater improvements in self-reported functioning and somatic symptoms and a greater decrease in health care costs.
CONCLUSION: For patients diagnosed as having SD, CBT may produce clinical benefits beyond those that result from the current state-of-the-art treatment.

PMID 16864762  Arch Intern Med. 2006 Jul 24;166(14):1512-8. doi: 10.10・・・
著者: Kurt Kroenke
雑誌名: Psychosom Med. 2007 Dec;69(9):881-8. doi: 10.1097/PSY.0b013e31815b00c4.
Abstract/Text OBJECTIVE: To review the evidence from randomized clinical trials (RCTs) that have focused on the treatment of patients with Diagnostic and Statistical Manual of Mental Disorders, 4(th) Edition (DSM-IV) somatoform disorders. Although somatoform disorders are among the most common mental disorders presenting in the general medical setting, the strength of evidence for specific treatments has not been well synthesized.
METHODS: MEDLINE search of articles published in English from 1966 to 2006, using the following search terms: randomized clinical trial, somatoform disorders, somatization disorder, undifferentiated somatoform disorder, hypochrondriasis, conversion disorder, pain disorder, and body dysmorphic disorder.
RESULTS: A total of 34 RCTs involving 3922 patients were included. Two thirds of the studies involved somatization disorder (n = 4 studies) and lower threshold variants, such as abridged somatization disorder (n = 9) and medically unexplained symptoms (n = 10). Cognitive behavioral therapy (CBT) was effective in most studies (11 of 13), as were antidepressants in a small number (4 of 5) of studies. RCTs examining a variety of other treatments showed benefit in half (8 of 16) of the studies, the most consistent evidence existing for a consultation letter to the primary care physician. Effective treatments have been established for all somatoform disorders except conversion disorder (1 of 3 studies showing benefit) and pain disorder (no studies reported).
CONCLUSION: CBT is the best established treatment for a variety of somatoform disorders, with some benefit also demonstrated for a consultation letter to the primary care physician. Preliminary but not yet conclusive evidence exists for antidepressants.

PMID 18040099  Psychosom Med. 2007 Dec;69(9):881-8. doi: 10.1097/PSY.0・・・
著者: A E Speckens, A M van Hemert, P Spinhoven, K E Hawton, J H Bolk, H G Rooijmans
雑誌名: BMJ. 1995 Nov 18;311(7016):1328-32.
Abstract/Text OBJECTIVE: To examine the additional effect of cognitive behavioural therapy for patients with medically unexplained physical symptoms in comparison with optimised medical care.
DESIGN: Randomised controlled trial with follow up assessments six and 12 months after the baseline evaluation.
SETTING: General medical outpatient clinic in a university hospital.
SUBJECTS: An intervention group of 39 patients and a control group of 40 patients.
INTERVENTIONS: The intervention group received between six and 16 sessions of cognitive behavioural therapy. Therapeutic techniques used included identification and modification of dysfunctional automatic thoughts and behavioural experiments aimed at breaking the vicious cycles of the symptoms and their consequences. The control group received optimised medical care.
MAIN OUTCOME MEASURES: The degree of change, frequency and intensity of the presenting symptoms, psychological distress, functional impairment, hypochondriacal beliefs and attitudes, and (at 12 months of follow up) number of visits to the general practitioner.
RESULTS: At six months of follow up the intervention group reported a higher recovery rate (odds ratio 0.40; 95% confidence interval 0.16 to 1.00), a lower mean intensity of the physical symptoms (difference -1.2; -2.0 to -0.3), and less impairment of sleep (odds ratio 0.38; 0.15 to 0.94) than the controls. After adjustment for coincidental baseline differences the intervention and control groups also differed with regard to frequency of the symptoms (0.32; 0.13 to 0.77), limitations in social (0.35; 0.14 to 0.85) and leisure (0.36; 0.14 to 0.93) activities, and illness behaviour (difference -2.5; -4.6 to -0.5). At 12 months of follow up the differences between the groups were largely maintained.
CONCLUSION: Cognitive behavioural therapy seems to be a feasible and effective treatment in general medical patients with unexplained physical symptoms.

PMID 7496281  BMJ. 1995 Nov 18;311(7016):1328-32.

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