Somatoform Disorders
Characteristics:
- Recurrent multiple complaints that are not fully explained by the physical factors and that result in medical attention or physical impairment
- Chronic (↑ history)
- Before age 30
- Associated with significant psychological stress
- Aka “Briquets syndrome”
- Epidemiology:
- Women > Men
- Pts of the family doctor
- Begins before age 30 and most often in their teens
- 2/3 of the pts have other psychiatric symptoms
- Commonly associated with personality traits or disorders such as:
Avoidant
Paranoid
Self-defeating
Rigid
- ↑ risk for Bipolar I and substance abuse
- Etiology UNKNOWN
- Biological Factors – faulty perception of somatosensory inputs due to attention and cognitive impairment
- Genetic – runs in families, esp 1st degree relatives
DSM-IV Criteria :
1. A history of many physical complaints before age 30 that can occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning
2. Each of the following criteria must be met with individual symptoms occurring at any time during the course of the disturbance
Four pain symptoms – history of pain related to at least four different sites or functions (head, abdomen, back, joints, extremities, chest, rectum, during menstruation/sex/urination)
Two GI symptoms- history of at least 2 GI symptoms other than pain (nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance to certain foods)
One sexual symptom- other than pain (sexual indifference, erectile/ejaculatory dysfunction, irregular menses, excessive bleeding, vomiting throughout pregnancy)
One pseudoneurological symptom- one symptom or deficit suggesting a neurological condition not limited to pain. (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing, etc.)
3. Either a or b
a. after appropriate investigation, each of the symptoms in criterion B cannot fully be explained by known general medicine- condition or direct effects of a substance
b. when there is related general medicine condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from history, PE or labs
4. Sx are not intentionally feigned or produced
5. Differential
Features useful in discriminating between somatization disorder and physical illness
involvement of multiple organ systems
early onset and chronic course without development of physical signs
absence of characteristic lab abnormalities
Somatization d/o pts have more guilt, suicide, self-deprecation, confused thinking, etc.
Physical d/o:
MS, SLE, AIP (acute intermittent porphyria), hyperparathyroidism, myasthenia g, AIDS, chronic systemic infections
Psychiatric d/o
Major depression, generalized anxiety, schizophrenia, hypochondriasis, conversion d/o, and pain d/o
***Serious debilitating condition!!!!!! Complications include divorce, suicidal attempts, ↑↑ surgical operations, drug dependence, etc.
- Treatment
Establish a therapeutic alliance w/ pt
Educate pts regarding manifestations of somatization disorder
Provide consistent reassurance
Anti-depressents, anti-anxiety agents (sometimes)
Treated by single doc
Psychotherapy
Conversion Disorder characterized by the presence of one or more neurological
symptoms that can not be explained by a known neurological or medical disorder
*Diagnosis requires that psychological factors be associated with that initiation or exacerbation of symptoms
- Etiology people exposed to ↑↑ trauma (esp child abuse)
- Conversion of psychological conflict into a somatic symptom
- 1/3 with Hx of sexual abuse, esp incestuous
- youngest or youngest of sex in sib order
- more frequent in relatives of individuals with conversion disorder
- Female relatives >> Male relatives (2:1)
- Clinical Features
- Sensory symptoms- anesthesia, paresthesia, deafness, blindeness, tunnel vision
- Motor symptoms- abnormal movements and gait disturbances (atasia-abasia), weakenss, paralysis, tremors, jerks
- Seizures
- Primary gain- anxiety is theoretically reduced by keeping an internal conflict or need out of awareness by symbolic expression of an unconscious wish as a conversion symptom
- Secondary gain – conversion symptoms allow avoidance of noxious activities or obtaining of otherwise unattainable support
Ex. I have a test today, but I don’t feel well so I think I will call in sick
- La belle indifference- severe acute onset of symptoms but the pt is indifferent or passive
- Identification- symptoms manifest themselves when the pt has found someone with an illness they can identify with
Ex. Hubby with right arm paralysis died 1 yr ago and the wife feels guilty and she now has right sided paralysis
- Differential
Neurological illness on follow-up
Physical illness and conversion are not mutually exclusive
Most reliable predictor of history is a previous conversion d/o
First occurring in middle age should increase suspicion
Neurological/Physical Medical d/o
MS – consider blindness secondary to optic neuritis w/ initially normal fundi
Guillan-Barre ( weakness in arms and legs may be inconsistent)
Myasthena gravis
eriodic paralysis
Myoglobinuric myopathy
Polymyositis
Other acquired myopathies
Hallucinations and pseudohallucinations
Non-psychiatric medical d/o
Somatization, hypochondriasis, pain, Malingering and Factitious disorders
- Course and Prognosis
- Onset is generally from late childhood to early adulthood
- Generally acute
- Self-limited
- Good prognosis- acute onset withpresence of clearly identifiable stress at the time of onset; shot interval b/t onset and treatment, no comorbid psychiatric condition, no ongoing litigation, and good intelligence
- Poorer prognosis- seizures and tremor
- Treatment
- Direct confrontation is not recommended
Hypochondriasis NOT preoccupation with symptoms themselves, but fear of having a serious disease based on misinterpretation of bodily signals
- Epidemiology- Men and women; 20-30 yrs old
- Etiology- aggressive and hostile; these can be transferred into complaints
- Differential – AIDS, endocrinopathies, myasthenia gravis, multiple sclerosis, SLE, occult neoplastic disorders, degenerative diseases of the nervous system
- Course and Prognosis- 66% show a chronic fluctuating course; usually episodic; episodes can be months or years and are separated by long quiescent periods and are usually associated with stressors
- Good prognosis- high SES, treatment-responsive anxiety or depression, sudden onset, absence of personality disorders, no psych medical conditions
- Treatment- resistant to psychiatric treatments
Body Dysmorphic Disorder- preoccupation with a body defect or an exaggerated distortion of a minimal or minor defect and persists even after medical reassurances; must cause significant distress or be associated with impairment in the patients personal, social, or occupational life
- Clinical Description- imagined flaws of the face or head, including various defects in the hair (too much or too little), skin, shape of the face, or facial features ( usually preoccupied with the shoulders and above – places people can see)
- Overlap with depressive disorder and OCD
- Epidemiology
- 2 of pts seeking corrective cosmetic surgery
- Age of onset = 15-20 yrs
- Women > Men
- More common in the unmarried
- Etiology
- Mood disorders
- Schizophrenia
- OCD
- Social phobia
- Coexist with other mental disorders (Depression 90%, Anxiety disorders 70%)
- Differential Diagnosis
1. Anorexia nervosa, Schizophrenia, OCD
2. Gender identity disorder
3. Brain damage
4. Narcissistic personality disorder
5. Normal concern about one’s appearance
- Course and Prognosis
Gradual onset TQ!!!!
Onset may have 2 peaks
Chronic condition with waxing and waning of intensity, but rarely full remission
Multiple preoccupations are typical
Highly incapacitating
- Treatment
- Surgery, derm, or dental treatments are usually unsuccessful
- Behavior therapy and dynamic psychotherapy
- Pharmacotherapy = Neuroleptics (Pimozide) and Antidepressents (MAOI’s, SSRI’s)
- Clomipramine, fluoxetine are effective in reducing symptoms in about 50% of patients
- Treatment of anxiety and depression
Pain Disorder- the presence of pain in one or more sites that is not fully accounted for by a nonpsychiatric medical or neurological condition; accompanied by emotional distress and functional impairement and the disorder has a possible causal relation with psychological factor
- Long history of surgical and medical care
- Pain can be complicated by drug abuse
- Patients often deny other sources of emotional dysphoria
- Pain disorder can be a picture of somatization disorder, depressive disorders, and anxiety disorders
- Pain-stress cycle
- Attempts to correct and correct the cause of pain
- Increased dependency on medication, docs, and others
- Increased frustration and self-doubt
- Demoralization (sense of failure, decreased esteem, hopelessness, increased pain)
- Ineffective intervention
Epidemiology
MOST FREQUENT COMPLAINT IN MEDICAL PRACTICE
Low back pain has diabled an estimated 7 million people
Twice as frequent in women as in men
Peak ages of onset are in the 40-50 years
Gate control theory:
Serotonin is probably the main NT in the descending inhibitory pathway; Endorphin deficiency seems to correlate with the augmentation of incoming sensory stimuli; mechanism in the dorsal horn
Undifferentiated Somatoform Disorder
- Presence of one or more clinically significant medically unexplained somatic symptoms with a duration of 6 months or more that are not better accounted for by another mental disorder; impacts social fxn
VII. Somatoform Disorder NOS
- Somatoform symptoms that do not meet the criteria for any specific somatoform disorder – true residual category
- NO MINIMAL DURATION
VIII. As per the “Specified Disorders”
Parameters could not be expected to be uniform for a residual category such as somatoform disorder NOS because it represents a grouping of diverse disorders
Tags: anesthesia, Avoidant, blindeness, Briquets syndrome, deafness, Paranoid, paresthesia, pseudoneurological symptom, Psychotherapy, Somatization, tunnel vision
