Download SOMATOFORM DISORDERS 1. Define Somatoform Disorder

SOMATOFORM DISORDERS
1. Define Somatoform Disorder:
Formerly, “hysteria.” Patients unconsciously convert psychological or emotional
distress into physical symptoms. Intermediate between “real” disease and clear
simulation, a process of magnification and elaboration of physical responses to emotion.
Psychological factors affecting medical condition. Runs in families, more common in
women.
2. List and Describe the major clinical features of somatoform disorders, including:
Somatization disorder: Characterized by a history of at least 8 physical symptoms,
including pain, GI, sexual, and neurological symptoms, usually chronic, without
discernible cause. Often, patients are Alexithemic, or unable to articulate their
feelings, and demonstrate a low emotional awareness. Varies by culture, social factors,
and learning. The primary gain of the somatization is to express unacceptable
emotions as physical symptoms to avoid dealing with them. Secondary gain results
from the attention gained by the patient’s symptoms, and the resulting abdication of
responsibility.
Conversion disorder: Symptoms replace conflict. The sudden, dramatic loss of motor
or sensory function. For example, non-anatomic paralysis. Patients appear
unconcerned about their serious physical symptoms: la belle indifference. Many have
antecedent brain disorders. Symptoms occur in site of previous trauma in self or close
other (i.e. where dad broke his arm). Common in unsophisticated patients. Example: “I
woke up this morning blind, but I’m cool with it. I feel basically fine. By the way, I saw
my husband with another woman last night. But like I said, no worries.”
Hypochondriasis: Fear of having a serious illness. Similar etiology to other disorders
characterized by recurrent unwanted thoughts and behaviors (like OCD). SSRI’s help.
Equally occurs in men and women. Patients are hyperaware and hyper responsive to
physiologic events. Ideational more than symptomatic. Patients often able to give an
“organ recital,” listing their every bodily process.
Body Dysmorphic Disorder: Imagined ugliness. Not to be confused with Anorexia
Nervosa or transsexualism. Patients are preoccupied with minor or imagined physical
defects in physical appearance, usually face or head. Plastic Surgeons’ worst
nightmare, because they are rarely happy with results, and often find more physical
reasons to be unhappy. Shares features of OCD, Depression. SSRI’s help, as does
support and cognition and exposure therapy. Patients may specifically suffer from
Muscle Dysmorphia: “I’m chronically scrawny,” or Body Integrity Identity Disorder: “I
want my hand amputated.” Example of general BDD: “My nose is too big for my head,
and my nostrils are shaped funny, and my first five surgeries didn’t do the trick, so I’m
going back for more.”
Somatoform Pain Disorders: Psychogenic pain, in the absence of tissue pathology.
More frequently in women (onset 30s and 40s), associated with depression. May be
chronic. Characterized by protracted, intense pain without physical explanations, may
accompany a real but minor medical condition. Patients are at risk for pain medication
dependency.
3. Discuss three clinical approaches to the management of somatoform disorders:
Listen attentively to patient’s complaints, and review the symptoms with the patient.
Make sure they know that their distress is real to you, the physician. Collect past
medical records. Share with the patient how you are diagnosing him, what you are
looking for, and establish are shared set of expectations. Schedule regular visits, at first
weekly, then more spread apart, with one physician, not multiple specialists for every
complaint. Listen to the patient’s complaints and discuss them, then move the
discussion to more general topics, like current emotional and psychosocial stressors.
Make functional goals, like in the management of pain disorders to minimize the impact
of the pain on daily life, but not to increase pain medication or resolve pain. Also helpful
may be a multidisciplinary approach, where all of the patient’s care takers are in
communication, in order to prevent the patient from playing one against the other, or
trying to get more meds. SSRI’s are also helpful for many of the subsets of somatoform
disorders. Individual and group therapy help, as does hypnosis, behavioral and
cognitive therapy. Relational therapy is based on the idea that somatoform disorders
develop within the setting of the family, and should be treated in this environment.
However, because most of these patients show up most frequently in the primary care
setting, this is a good place to treat somatoform disorders. There is no cure, and
symptoms often return in time.