somatoform disorders. group of disorders that includes physical symptoms for which an adequate...

SOMATOFORM DISORDERSSOMATOFORM DISORDERS

Group of disorders that includes physical symptoms for which an adequate medical explanation cannot be found

Psychological factors --> symptom’s onset, severity, duration

Not malingering or factitious disorder

Group of disorders that includes physical symptoms for which an adequate medical explanation cannot be found

Psychological factors --> symptom’s onset, severity, duration

Not malingering or factitious disorder

5 Specific somatoform disorders:1. Somatization DO2. Conversion DO3. Hypochondriasis4. Body Dysmorphic DO5. Pain DO

5 Specific somatoform disorders:1. Somatization DO2. Conversion DO3. Hypochondriasis4. Body Dysmorphic DO5. Pain DO

SOMATIZATION DISORDERSOMATIZATION DISORDER

Hysteria, Briquet’s SyndromeMany somatic symptomsMultiple complaints and organ systems

affectedChronic

Hysteria, Briquet’s SyndromeMany somatic symptomsMultiple complaints and organ systems

affectedChronic

Epidemiology Epidemiology

Lifetime prevalence = 0.1-0.2%F > M (5-20X) = 5:1

Lifetime prevalence = 0.1-0.2%F > M (5-20X) = 5:1

EtiologyEtiology

1. Psychosocial factors - social communication

2. Biological factors - attention and cognitive impairments

1. Psychosocial factors - social communication

2. Biological factors - attention and cognitive impairments

DiagnosisDiagnosis

Onset before the age of 30 yearsComplain of at least 4 pain sxs, 2 GI

sxs, 1 sexual sx, 1 pseudoneurological sx

No physical or laboratory explanation

Onset before the age of 30 yearsComplain of at least 4 pain sxs, 2 GI

sxs, 1 sexual sx, 1 pseudoneurological sx

No physical or laboratory explanation

Clinical FeaturesClinical Features

Many somatic complaints; long complicated medical history

Psychological distress: anxiety, depression

Common suicidal threatsMedical history is circumstantial, vague,

imprecise, inconsistent, disorganized

Many somatic complaints; long complicated medical history

Psychological distress: anxiety, depression

Common suicidal threatsMedical history is circumstantial, vague,

imprecise, inconsistent, disorganized

Patients are dependent, self-centered, hungry for admiration or praise

Common associated mental DO - MDD, PD, SRD, GAD, phobias

Patients are dependent, self-centered, hungry for admiration or praise

Common associated mental DO - MDD, PD, SRD, GAD, phobias

Differential DiagnosisDifferential Diagnosis

1. Non-psychiatric medical condition2. Mental DO - MDD, GAD,

schizophrenia3. Other somatization DO

1. Non-psychiatric medical condition2. Mental DO - MDD, GAD,

schizophrenia3. Other somatization DO

Course and PrognosisCourse and Prognosis

Chronic, debilitatingOnset before age 30 years

Chronic, debilitatingOnset before age 30 years

Treatment Treatment

Single identified MDVisits: regular, avoid additional

lab/diagnostic proceduresSomatic symptoms - emotional

expressionsPsychotherapy: individual, group

Single identified MDVisits: regular, avoid additional

lab/diagnostic proceduresSomatic symptoms - emotional

expressionsPsychotherapy: individual, group

CONVERSION DISORDERCONVERSION DISORDER

One or more neurological symptoms (paralysis, blindness, paresthesias)

Psychological factors --> onset, exacerbation

One or more neurological symptoms (paralysis, blindness, paresthesias)

Psychological factors --> onset, exacerbation


F:M = 2:1 - 5:1Onset is any age (common during

adolescence and young adults)Rural population, little educated, low IQ,

low SE group, military personelComorbid with MDD, anxiety,

schizophrenia

F:M = 2:1 - 5:1Onset is any age (common during

adolescence and young adults)Rural population, little educated, low IQ,

low SE group, military personelComorbid with MDD, anxiety,

schizophrenia

Etiology Etiology

1. Psychoanalytic - repression of unconscious conflict/anxiety --> physical sx

Nonverbal means of controlling and manipulating

1. Biological factors - hypomentabolism of dominant hemisphere

impaired hemispheric communication

1. Psychoanalytic - repression of unconscious conflict/anxiety --> physical sx

Nonverbal means of controlling and manipulating

1. Biological factors - hypomentabolism of dominant hemisphere

impaired hemispheric communication

Diagnosis Diagnosis

Symptoms or deficits affecting neurological functions

Psychological factors --> onset, exacerbations

Not intentionally feigned or produced

Symptoms or deficits affecting neurological functions

Psychological factors --> onset, exacerbations

Not intentionally feigned or produced


Most common symptoms: paralysis, blindness, mutism

Most commonly associated with passive-aggressive, dependent, antisocial and histrionic PDs

Most common symptoms: paralysis, blindness, mutism

Most commonly associated with passive-aggressive, dependent, antisocial and histrionic PDs

1. Sensory Sxs: anesthesia and paresthesia, esp extremities

distribution usually inconsistent with central or peripheral neuro dse

characteristic stocking and glove anesthesia or hemianesthesia (along the midline)

organs of special senses - deafness, blindness, tunnel vision --> N neuro exam

1. Sensory Sxs: anesthesia and paresthesia, esp extremities

distribution usually inconsistent with central or peripheral neuro dse

characteristic stocking and glove anesthesia or hemianesthesia (along the midline)

organs of special senses - deafness, blindness, tunnel vision --> N neuro exam

2. Motor Sxs: abnormal movements, gait disturbance, weakness, paralysis

generally worsen by attention3. Seizure Sxs: pseudoseizure4. Mixed presentation

2. Motor Sxs: abnormal movements, gait disturbance, weakness, paralysis

generally worsen by attention3. Seizure Sxs: pseudoseizure4. Mixed presentation

Other associated features: Primary gain: represent an unconscious

psychological conflict Secondary gain: accrue tangible

advantages & benefits Le belle indifference: unconcerned about

what appears to be a major impairment Identification: unconsciously model their

sxs on those someone important to them

Other associated features: Primary gain: represent an unconscious

psychological conflict Secondary gain: accrue tangible

advantages & benefits Le belle indifference: unconcerned about

what appears to be a major impairment Identification: unconsciously model their

sxs on those someone important to them


Rule out medical disorder: thorough medical and neuro work-up

25-50% diagnosed with conversion DO --> neuro or non-psychiatric medical DO

1. Neuro DO - dementia, brain tumors, degenerative dse, basal ganglia dse

2. Psychiatric DO - schiz, deprssive DO, other somatoform, malingering, factitious DO

Rule out medical disorder: thorough medical and neuro work-up

25-50% diagnosed with conversion DO --> neuro or non-psychiatric medical DO

1. Neuro DO - dementia, brain tumors, degenerative dse, basal ganglia dse

2. Psychiatric DO - schiz, deprssive DO, other somatoform, malingering, factitious DO


90-100% resolve in few days to less than a month

Good prognosis: sudden onset, easily identifiable stressor, good premorbid adjustment, no comorbid psychiatric or medical DO

25-50% --> neuro or non-psychiatric DO

90-100% resolve in few days to less than a month

Good prognosis: sudden onset, easily identifiable stressor, good premorbid adjustment, no comorbid psychiatric or medical DO

25-50% --> neuro or non-psychiatric DO

Treatment Treatment

Spontaneously resolveInsight-oriented supportive or behavioral

therapy

Spontaneously resolveInsight-oriented supportive or behavioral

therapy

HYPOCHONDRIASISHYPOCHONDRIASIS

Unrealistic or inaccurate interpretations of physical symptoms or sensations --> preoccupation and fear that they have serious disease

Significant distress; impaired function

Unrealistic or inaccurate interpretations of physical symptoms or sensations --> preoccupation and fear that they have serious disease

Significant distress; impaired function


F = MOnset at any age

F = MOnset at any age

Etiology Etiology

1. Misinterpretation of bodily symptoms2. Social learning model3. Variant form of other mental disorder -

depression and anxiety DO (80%)4. Aggressive and hostile wishes

1. Misinterpretation of bodily symptoms2. Social learning model3. Variant form of other mental disorder -

depression and anxiety DO (80%)4. Aggressive and hostile wishes

Diagnosis Diagnosis

Preoccupied with false belief based misinterpretation of physical s/sxs

At least 6 monthsNot a delusion or restricted to distress

of appearance

Preoccupied with false belief based misinterpretation of physical s/sxs

At least 6 monthsNot a delusion or restricted to distress

of appearance


Believe that they have a serious disease not yet detected

Conviction persist despite negative lab results, benign course, reassurances

Usually with depression and anxiety

Believe that they have a serious disease not yet detected

Conviction persist despite negative lab results, benign course, reassurances

Usually with depression and anxiety

Differential Diagnosis Differential Diagnosis

1. Non-psychiatric medical condition2. Other somatoform disorders3. MDD, anxiety DO, schiz, other

psychotic DO

1. Non-psychiatric medical condition2. Other somatoform disorders3. MDD, anxiety DO, schiz, other

psychotic DO


Episodic, months to yearsGood prognosis: high SE class,

treatment-responsive anxiety or depression, sudden onset, (-) PD, (-) related non-psychiatric medical condition

Episodic, months to yearsGood prognosis: high SE class,

treatment-responsive anxiety or depression, sudden onset, (-) PD, (-) related non-psychiatric medical condition

Treatment Treatment

Usually resistant to psychiatric treatment Focus on stress reduction and education in

coping with chronic illnessGroup psychotherapyRegular scheduled PE

Usually resistant to psychiatric treatment Focus on stress reduction and education in

coping with chronic illnessGroup psychotherapyRegular scheduled PE

BODY DYSMORPHIC DOBODY DYSMORPHIC DO

Preoccupation with an imagined bodily defect or an exaggerated distortion of a minimal or minor defect

Causes significant distress; impaired function

Preoccupation with an imagined bodily defect or an exaggerated distortion of a minimal or minor defect

Causes significant distress; impaired function


Rare; poorly studiedMost common age of onset: 15-30 yoF > M, unmarriedCommonly coexists with other mental

DO (MDD, anxiety, psychotic DOs)

Rare; poorly studiedMost common age of onset: 15-30 yoF > M, unmarriedCommonly coexists with other mental

DO (MDD, anxiety, psychotic DOs)

Etiology Etiology

SerotoninCultural and social effectsPsychodynamic models

SerotoninCultural and social effectsPsychodynamic models

Diagnosis Diagnosis

Preoccupied with an imagined defect in appearance or an overemphasis of a slight defect

Significant emotional distress; impaired functioning

Preoccupied with an imagined defect in appearance or an overemphasis of a slight defect

Significant emotional distress; impaired functioning


Most common concerns: facial flawsCommon associated symptoms: ideas

of reference, attempts to hide deformity, excessive mirror checking or avoidance

Avoid social or occupational exposureHousebound; attempt suicideTraits: O-C, schizoid, narcissistic PDComorbid: depression, anxiety DO

Most common concerns: facial flawsCommon associated symptoms: ideas

of reference, attempts to hide deformity, excessive mirror checking or avoidance

Avoid social or occupational exposureHousebound; attempt suicideTraits: O-C, schizoid, narcissistic PDComorbid: depression, anxiety DO


Anorexia nervosa, gender identity DO, brain damage

Delusional DO, somatic typeNarcissistic PD, depressive DO, OCD,

schizophrenia

Anorexia nervosa, gender identity DO, brain damage

Delusional DO, somatic typeNarcissistic PD, depressive DO, OCD,

schizophrenia


Gradual onsetUsually chronic

Gradual onsetUsually chronic

Treatment Treatment

Serotonin-specific drugs - clomipramine, fluoxetine

Treat coexisting mental DO

Serotonin-specific drugs - clomipramine, fluoxetine

Treat coexisting mental DO

PAIN DISORDERPAIN DISORDER

Psychogenic pain DOPain in one or more sites --> no non-

psychiatric medical or neurological condition

Emotional distress; functional impairment

Psychogenic pain DOPain in one or more sites --> no non-

psychiatric medical or neurological condition

Emotional distress; functional impairment


F > MPeak onset on 4th to 5th decadesBlue-collar occupation, 1st degree

relatives

F > MPeak onset on 4th to 5th decadesBlue-collar occupation, 1st degree

relatives

Etiology Etiology

1. Psychodynamic: expression of intrapsychic conflict

defense mechanism-displacement, substitution, repression

2. Behavioral: reinforced with reward and inhibited when ignored/punished

3. Interpersonal: manipulation and gaining advantages

4. Biological: 5HT and endorphins

1. Psychodynamic: expression of intrapsychic conflict

defense mechanism-displacement, substitution, repression

2. Behavioral: reinforced with reward and inhibited when ignored/punished

3. Interpersonal: manipulation and gaining advantages

4. Biological: 5HT and endorphins

Diagnosis Diagnosis

Significant complaints of painEmotional distress and functional

impairment

Significant complaints of painEmotional distress and functional

impairment


Collection of different histories of various pains

Pain maybe post-traumatic, neuropathic, neurological, iatrogenic, musculoskeletal

(+) psychological factor Long history of medical and surgical care,

visits many MDs, requests many meds Complicated by SRD MDD: 25-50% of patients

Dysthymic or depressive DO sxs - 60-100%

Collection of different histories of various pains

Pain maybe post-traumatic, neuropathic, neurological, iatrogenic, musculoskeletal

(+) psychological factor Long history of medical and surgical care,

visits many MDs, requests many meds Complicated by SRD MDD: 25-50% of patients

Dysthymic or depressive DO sxs - 60-100%


1. Physical pain VS Psychogenic pain1. Physical Pain: fluctuates in intensity,

highly sensitive to emotional, cognitive, attentional and situational influence

2. Psychogenic Pain: does not vary, insensitive to any of above factors, does not wax or wane, not temporarily relieved by distraction

2. Other somatoform DO

1. Physical pain VS Psychogenic pain1. Physical Pain: fluctuates in intensity,

highly sensitive to emotional, cognitive, attentional and situational influence

2. Psychogenic Pain: does not vary, insensitive to any of above factors, does not wax or wane, not temporarily relieved by distraction

2. Other somatoform DO


Abrupt onset and increases in severityAbrupt onset and increases in severity

Treatment Treatment

Address rehabilitationPAIN IS REAL

Pharmacotherapy - antidepressant Behavioral therapy Psychotherapy Pain control program

Address rehabilitationPAIN IS REAL

Pharmacotherapy - antidepressant Behavioral therapy Psychotherapy Pain control program

UNDIFFERENTIATED SOMATOFORM DO

UNDIFFERENTIATED SOMATOFORM DO

One or more physical complaints that can’t be explained by known medical condition

Doesn’t meet the diagnostic criteria for any somatoform DO

At least 6 monthsSignificant emotional distress and

impaired functioning

One or more physical complaints that can’t be explained by known medical condition

Doesn’t meet the diagnostic criteria for any somatoform DO

At least 6 monthsSignificant emotional distress and

impaired functioning

2 types of somatoform pattern:1. Involving ANS: CV, GI, urogenital, derma

sxs2. Involving sensations of fatigue or

weakness (neurasthenia): mental or physical fatigue, physical weakness and exhaustion

2 types of somatoform pattern:1. Involving ANS: CV, GI, urogenital, derma

sxs2. Involving sensations of fatigue or

weakness (neurasthenia): mental or physical fatigue, physical weakness and exhaustion

somatoform disorders. group of disorders that includes physical symptoms for which an adequate...

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