Download Somatoform Disorders

Chapter 9：Neurosis(4)
Somatoform Disorders
Zhonghua Su, P.h D & MD
Jining Medical University
Introduction (1)
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According to the fourth edition of Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV), the somatoform
disorders are distinguished by physical symptoms suggesting a
medical condition, yet the symptoms are not fully explained by
the medical condition, by substance use, or by another mental
disorder.
The symptoms are severe enough to cause patients significant
distress or impaired social, occupational, or other functioning.
The physical symptoms of somatoform disorders are not
intentionally produced as are those of factitious disorders and
malingering, but no medical condition can fully explain the
somatic symptoms.
Clinicians must judge that the onset, severity, and duration of
symptoms are strongly linked to psychological factors to
diagnose a somatoform disorder.
Introduction (2)
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In DSM-IV, five specific somatoform disorders are recognized:
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somatization disorder, characterized by many physical complaints affecting
many organ systems;
conversion disorder, characterized by one or two neurological complaints;
hypochondriasis, characterized less by a focus on symptoms than by patients'
beliefs that they have a specific disease;
body dysmorphic disorder, characterized by a false belief or exaggerated
perception that a body part is defective; and
pain disorder, characterized by symptoms of pain that are either solely related
to or significantly exacerbated by psychological factors.
DSM-IV also has two residual diagnostic categories for somatoform disorders:
Undifferentiated somatoform disorder includes somatoform disorders not
otherwise described that have been present for 6 months or longer; and
somatoform disorder not otherwise specified is the category for somatoform
symptoms that do not meet any of the previously mentioned somatoform
disorder diagnoses.
Classification (DSM -IV)
somatization disorder,
 conversion disorder
 hypochondriasis
 body dysmorphic disorder
 pain disorder
 Undifferentiated somatoform disorder
 somatoform disorder not otherwise specified
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Introduction (3)
The categories of somatoform disorders are similar in
ICD-10 and DSM-IV, except that in ICD-10, body
dysmorphic disorder is a subcategory.
 ICD-10 also stresses that differential diagnosis of
somatoform disorders requires that a clinician know
the patient well.
 A patient's "degree of conviction" may be
temporarily lessened by a clinician's assurances and
by a physical examination, but the disorders are a
culturally accepted way of exhibiting physical illness
and explaining physical symptoms.
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Somatization Disorder
Introduction (1)
characterized by many somatic symptoms;
 distinguished by "a combination of pain,
gastrointestinal, sexual, and pseudoneurological
symptoms." ;
 begins before the age of 30;
 may continue for years;
 multiplicity of the complaints and the multiple organ
systems (differ from others);
 associated with significant psychological distress;
 impairment in social and occupational functioning;
 excessive medical-help seeking behavior.
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Introduction (2)--history
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Somatization disorder has been recognized since the time of
ancient Egypt. An early name for somatization disorder was
hysteria, a condition incorrectly thought to affect only women.
(The word hysteria is derived from the Greek word for uterus,
hystera.)
In the 17th century, Thomas Sydenham recognized that
psychological factors, which he called antecedent sorrows,
were involved in the pathogenesis of the symptoms.
In 1859, Paul Briquet, a French physician, observed the
multiplicity of the symptoms and the affected organ systems
and commented on the usually chronic course of the disorder.
Because of these astute clinical observations, the disorder was
called Briquet's syndrome for a time, although the term
somatization disorder became the standard in the United States
when the third edition of DSM (DSM-III) was introduced in
1980.
Epidemiology (1)
The lifetime prevalence of somatization disorder in the
general population is estimated to be 0.1 or 0.2 percent,
although several research groups believe that the actual
figure may be closer to 0.5 percent.
 Women with somatization disorder outnumber men 5 to
20 times, but the highest estimates may be due to the
early tendency not to diagnose somatization disorder in
male patients. Nevertheless, it is not an uncommon
disorder. With a 5-to-1 female-to-male ratio, the lifetime
prevalence of somatization disorder among women in the
general population may be 1 or 2 percent.
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Epidemiology (2)
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Among patients in the offices of general practitioners and
family practitioners, as many as 5 to 10 percent may meet the
diagnostic criteria for somatization disorder.
The disorder is inversely related to social position and occurs
most often among patients who have little education and low
income levels.
Somatization disorder is defined as beginning before age 30; it
most often begins during a person's teenage years.
Several studies have noted that somatization disorder
commonly coexists with other mental disorders.
Etiology
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Psychosocial Factors
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interpretations of the symptoms as social communication
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avoid obligations
express emotions
symbolize a feeling or a belief
the symptoms substitute for repressed instinctual impulses
A behavioral perspective
Biological Factors
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characteristic attention and cognitive impairments
decreased metabolism in the frontal lobes and in the nondominant
hemisphere
genetic components
Research into cytokines
Clinical Features (1)
many somatic complaints and long, complicated
medical histories
 most common symptoms :nausea and vomiting,
difficulty in swallowing, pain in the arms and legs,
shortness of breath unrelated to exertion, amnesia,
and complications of pregnancy and menstruation
 Patients frequently believe that they have been sickly
most of their lives.
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Clinical features -2
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Psychological distress and interpersonal problems are
prominent; anxiety and depression are the most prevalent
psychiatric conditions.
Suicide threats are common, but actual suicide is rare. If
suicide does occur, it is often associated with substance abuse.
Patients' medical histories are often circumstantial, vague,
imprecise, inconsistent, and disorganized. Patients classically
but not always describe their complaints in a dramatic,
emotional, and exaggerated fashion, with vivid and colorful
language; they may confuse temporal sequences and cannot
clearly distinguish current from past symptoms.
Female patients with somatization disorder may dress in an
exhibitionistic manner.
Patients may be perceived as dependent, self-centered, hungry
for admiration or praise, and manipulative.
Clinical features - 3
Somatization disorder is commonly associated with
other mental disorders, including major depressive
disorder, personality disorders, substance-related
disorders, generalized anxiety disorder, and phobias.
 The combination of these disorders and the chronic
symptoms results in an increased incidence of marital,
occupational, and social problems.
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Diagnosis criteria -1
A. A history of many physical complaints that occur over a
period of several years and result in treatment being
sought or significant impairment in functioning
beginning before age 30
B. Each of the following must have been met, with
individual symptoms occurring at any time during the
course of the disturbance:
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4 pain symptoms
2 gastrointestinal symptoms
1 sexual symptom
1 pseudoneurological symptom
Diagnosis criteria -2
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four pain symptoms: a history of pain related to at least four different
sites or functions (e.g., head, abdomen, back, joints, extremities, chest,
rectum, during menstruation, during sexual intercourse, during urination)
two gastrointestinal symptoms: a history of at least two gastrointestinal
symptoms other than pain (e.g., nausea, bloating, vomiting other than
during pregnancy, diarrhea, or intolerance of several different foods)
one sexual symptom: a history of at least one sexual or reproductive
symptom other than pain (e.g., sexual indifference, erectile or ejaculatory
dysfunction, irregular menses, excessive menstrual bleeding, vomiting
throughout pregnancy)
one pseudoneurological symptom: a history of at least 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 or lump in throat, aphonia,
urinary retention, hallucination, loss of touch or pain sensation, double
vision, blindness, deafness, seizures; dissociative symptoms such as
amnesia; or loss of consciousness other than fainting
Diagnosis criteria -3
C. Either 1 or 2:
1. After appropriate investigation, each of the
symptoms in Criterion B cannot be fully explained
by a known GMC or substance
2. When there is a related GMC, the physical
complaints or resulting social or occupational
impairment are in excess of what would be expected
from the history, physical examination, or laboratory
findings.
D. The symptoms are not intentionally produced or
feigned (as in Factitious Disorder or Malingering)
Differential diagnosis - 1
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nonpsychiatric medical conditions
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Many mental disorders
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multiple sclerosis, myasthenia gravis, systemic lupus
erythematosus, acquired immune deficiency syndrome
(AIDS), acute intermittent porphyria, hyperparathyroidism,
hyperthyroidism, and chronic systemic infections.
major depressive disorder, generalized anxiety disorder,
and schizophrenia
panic disorder
other somatoform disorders
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hypochondriasis, conversion disorder, and pain
somatization disorder,
Differential diagnosis - 2
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Clinicians must always rule out nonpsychiatric medical
conditions that may explain a patient's symptoms. Several
medical disorders often show nonspecific, transient
abnormalities in the same age group.
These medical disorders include multiple sclerosis, myasthenia
gravis, systemic lupus erythematosus, acquired immune
deficiency syndrome (AIDS), acute intermittent porphyria,
hyperparathyroidism, hyperthyroidism, and chronic systemic
infections.
The onset of multiple somatic symptoms in patients older than
40 should be presumed to be caused by a nonpsychiatric
medical condition until an exhaustive medical workup has
been completed.
Differential diagnosis - 3
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Many mental disorders are considered in the differential
diagnosis, which is complicated by the observation that at least
50 percent of patients with somatization disorder have a
coexisting mental disorder.
Patients with major depressive disorder, generalized anxiety
disorder, and schizophrenia may all have an initial complaint
that focuses on somatic symptoms.
In all these disorders, however, the symptoms of depression,
anxiety, or psychosis eventually predominate over the somatic
complaints.
Although patients with panic disorder may complain of many
somatic symptoms related to their panic attacks, they are not
bothered by somatic symptoms between panic attacks.
Differential diagnosis - 4
Among the other somatoform disorders,
hypochondriasis, conversion disorder, and pain
somatization disorder, patients with hypochondriasis
falsely believe that they have a specific disease,
whereas those with somatization disorder are
concerned with many symptoms.
 The symptoms of conversion disorder are limited to
one or two neurological symptoms rather than to the
wide-ranging symptoms of somatization disorder.
 Pain disorder is limited to one or two complaints of
pain symptoms.
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Course and prognosis
chronic and often debilitating
 begun before age 30 and have been present for
several years
 more than a year without seeking medical attention
 an association between periods of increased stress and
the exacerbation of somatic symptoms.
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Treatment
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regularly scheduled visits
Additional laboratory and diagnostic procedures be avoided.
emotional expressions
Psychotherapy, both individual and group
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decreases personal health care expenditures (50%)
decreasing their rates of hospitalization.
helped to cope with their symptoms
to express underlying emotions
to develop alternative strategies for expressing their feelings
Giving psychotropic medications
 with coexisting mental disorders
 Medication must be monitored
Hypochondriasis
Introduction
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In DSM-IV, hypochondriasis is defined as a person's
preoccupation with the fear of contracting, or the belief of
having, a serious disease.
This fear or belief arises when a person misinterprets bodily
symptoms or functions.
The term hypochondriasis is derived from the old medical term
hypochondrium, ("below the ribs") and reflects the common
abdominal complaints of many patients with the disorder.
Hypochondriasis results from patients' unrealistic or inaccurate
interpretations of physical symptoms or sensations, even
though no known medical causes can be found.
Patients' preoccupations result in significant distress to them
and impair their ability to function in their personal, social,
and occupational roles.
Epidemiology and etiology
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One recent study reported a 6-month prevalence of
hypochondriasis of 4 to 6 percent in a general medical clinic
population.
Men and women are equally affected by hypochondriasis.
Although the onset of symptoms can occur at any age, the
disorder most commonly appears in people 20 to 30 years of
age.
Some evidence indicates that the diagnosis is more common
among blacks than among whites, but social position,
education level, and marital status do not appear to affect the
diagnosis.
Clinical features-1
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Patients with hypochondriasis believe that they have a serious
disease that has not yet been detected, and they cannot be
persuaded to the contrary.
They may maintain a belief that they have a particular disease;
as time progresses, they may transfer their belief to another
disease.
Their convictions persist despite negative laboratory results,
the benign course of the alleged disease over time, and
appropriate reassurances from physicians.
Yet their beliefs are not so fixed as to be delusions.
Hypochondriasis is often accompanied by symptoms of
depression and anxiety and commonly coexists with a
depressive or anxiety disorder.
Clinical features-2
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Although DSM-IV specifies that the symptoms must be
present for at least 6 months, transient hypochondriacal states
can occur after major stresses, most commonly the death or
serious illness of someone important to the patient, or a serious
(perhaps life-threatening) illness that has been resolved but
that leaves the patient temporarily hypochondriacal in its wake.
Such states that last fewer than 6 months should be diagnosed
as somatoform disorder not otherwise specified.
Transient hypochondriacal responses to external stress
generally remit when the stress is resolved, but they can
become chronic if reinforced by people in the patient's social
system or by health professionals.
Diagnostic criteria-1
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The DSM-IV diagnostic criteria for hypochondriasis require that patients
be preoccupied with the false belief that they have a serious disease and
that the false belief be based on a misinterpretation of physical signs or
sensations .
The belief must last at least 6 months, despite the absence of pathological
findings on medical and neurological examinations.
The diagnostic criteria also stipulate that the belief not have the intensity of
a delusion (more appropriately diagnosed as delusional disorder) and that it
not be restricted to distress about appearance (more appropriately
diagnosed as body dysmorphic disorder).
The symptoms of hypochondriasis must be of an intensity that causes
emotional distress or impairs the patient's ability to function in important
areas of life.
Clinicians may specify the presence of poor insight; patients do not
consistently recognize that the concerns about disease are excessive.
DSM-IV diagnosis criteria for
ochondriasis
A.
B.
C.
D.
E.
F.
Preoccupation with fears of having, or the idea that one has, a serious
disease based on the person-misinterpretation of bodily symptoms
The preoccupation persists despite appropriate medical evaluation and
reassurance.
The belief in criterion A is not of delusional intensity (as in delusional
disorder, somatic type) and is not restricted to a circumscribed concern
about appearance (as in body dysmorphic disorder).
The preoccupation causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
The duration of the disturbance is at least 6 months.
The preoccupation is not better accounted for by generalized anxiety
disorder, obsessive-compulsive disorder, panic disorder, a major
depressive episode, separation anxiety, or another somatoform disorder.
Differential diagnosis-1
Hypochondriasis must be differentiated from
nonpsychiatric medical conditions, especially
disorders that show symptoms that are not necessarily
easily diagnosed.
 Such diseases include AIDS, endocrinopathies,
myasthenia gravis, multiple sclerosis, degenerative
diseases of the nervous system, systemic lupus
erythematosus, and occult neoplastic disorders.
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Differential diagnosis-2
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Hypochondriasis is differentiated from somatization disorder
by the emphasis in hypochondriasis on fear of having a disease
and emphasis in somatization disorder on concern about many
symptoms.
A subtle distinction is that patients with hypochondriasis
usually complain about fewer symptoms than do patients with
somatization disorder.
Somatization disorder usually has an onset before age 30,
whereas hypochondriasis has a less specific age of onset.
Patients with somatization disorder are more likely to be
women than are those with hypochondriasis, which is equally
distributed among men and women.
Differential diagnosis-3
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Hypochondriasis must also be differentiated from the other
somatoform disorders.
Conversion disorder is acute and generally transient and
usually involves a symptom rather than a particular disease.
The presence or absence of la belle indifference indifference is
an unreliable feature with which to differentiate the two
conditions.
Pain disorder is chronic, as is hypochondriasis, but the
symptoms are limited to complaints of pain.
Patients with body dysmorphic disorder wish to appear normal
but believe that others notice that they are not, whereas those
with hypochondriasis seek out attention for their presumed
diseases.
Differential diagnosis-4
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Hypochondriacal symptoms can also occur in patients with depressive
disorders and anxiety disorders.
If a patient meets the full diagnostic criteria for both hypochondriasis and
another major mental disorder, such as major depressive disorder or
generalized anxiety disorder, the patient should receive both diagnoses,
unless the hypochondriacal symptoms occur only during episodes of the
other mental disorder.
Patients with panic disorder may initially complain that they are affected by
a disease (for example, heart trouble), but careful questioning during the
medical history usually uncovers the classic symptoms of a panic attack.
Delusional hypochondriacal beliefs occur in schizophrenia and other
psychotic disorders but can be differentiated from hypochondriasis by their
delusional intensity and by the presence of other psychotic symptoms.
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In addition, schizophrenic patients' somatic delusions tend to be bizarre,
idiosyncratic, and out of keeping with their cultural milieus.
Differential diagnosis-5
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Hypochondriasis is distinguished from factitious
disorder with physical symptoms and from
malingering in that patients with hypochondriasis
actually experience and do not simulate the symptoms
they report.
Course and prognosis
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The course of hypochondriasis is usually episodic; the
episodes last from months to years and are separated by
equally long quiescent periods.
There may be an obvious association between exacerbations of
hypochondriacal symptoms and psychosocial stressors.
Although well-conducted large outcome studies have not yet
been reported, an estimated one third to one half of all patients
with hypochondriasis eventually improve significantly.
A good prognosis is associated with a high socioeconomic
status, treatment-responsive anxiety or depression, the sudden
onset of symptoms, the absence of a personality disorder, and
the absence of a related nonpsychiatric medical condition.
Most children with hypochondriasis recover by late
adolescence or early adulthood.
Treatment-1
Patients with hypochondriasis are usually resistant to
psychiatric treatment although some accept this
treatment if it takes place in a medical setting and
focuses on stress reduction and education in coping
with chronic illness.
 Among such patients, group psychotherapy is the
modality of choice, in part because it provides the
social support and social interaction that seem to
reduce their anxiety.
 Individual insight-oriented psychotherapy may be
useful, but is generally unsuccessful.
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Treatment-2
Frequent, regularly scheduled physical examinations
are useful to reassure patients that their physicians are
not abandoning them and that their complaints are
being taken seriously.
 Invasive diagnostic and therapeutic procedures should
only be undertaken, however, when objective
evidence calls for them.
 When possible, the clinician should refrain from
treating equivocal or incidental physical examination
findings.
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Treatment-3
Pharmacotherapy alleviates hypochondriacal
symptoms only when a patient has an underlying
drug-responsive condition, such as an anxiety
disorder or major depressive disorder.
 When hypochondriasis is secondary to another
primary mental disorder, that disorder must be treated
in its own right.
 When hypochondriasis is a transient situational
reaction, clinicians must help patients cope with the
stress without reinforcing their illness behavior and
their use of the sick role as a solution to their
problems.
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Body dysmorphic
disorder
Introduction-1
DSM-IV defines body dysmorphic disorder as a
preoccupation with an imagined defect (for example,
a misshapen nose) or an exaggerated distortion of a
minimal or minor defect in physical appearance.
 To be considered a mental disorder, the preoccupation
must cause patients significant distress or be
associated with impairment in the patient's personal,
social, or occupational life.
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Introduction-2
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The disorder was recognized and named dysmorphophobia
more than 100 years ago by Emil Kraepelin, who considered it
a compulsive neurosis; Pierre Janet called it obsession de la
honte du corps (obsession with shame of the body).
Freud wrote about the condition in his description of the WolfMan, who was excessively concerned about his nose.
Although dysmorphophobia was widely recognized and
studied in Europe, it was not until the publication of DSM-III
in 1980 that dysmorphophobia, as an example of a typical
somatoform disorder, was specifically mentioned in the United
States diagnostic criteria.
In DSM-IV, the condition is known as body dysmorphic
disorder, because the DSM editors believed that the term
dysmorphophobia inaccurately implied the presence of a
behavioral pattern of phobic avoidance.
Epidemiology
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The cause of body dysmorphic disorder is unknown.
The high comorbidity with depressive disorders, a higher-than-expected
family history of mood disorders and obsessive-compulsive disorder, and
the reported responsiveness of the condition to serotonin-specific drugs
indicate that in at least some patients the pathophysiology of the disorder
may involve serotonin and may be related to other mental disorders.
Stereotyped concepts of beauty emphasized in certain families and within
the culture at large may significantly affect patients with body dysmorphic
disorder.
In psychodynamic models, body dysmorphic disorder is seen as reflecting
the displacement of a sexual or emotional conflict onto a nonrelated body
part.
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Such an association occurs through the defense mechanisms of repression,
dissociation, distortion, symbolization, and projection.
Clinical features
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The most common concerns involve facial flaws, particularly those
involving specific parts (for example, the nose).
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One study found that, on average, patients had concerns about four body
regions during the course of the disorder. The specific body part may
change during the time a patient is affected with the disorder.
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Common associated symptoms include ideas or frank delusions of reference ,
either excessive mirror checking or avoidance of reflective surfaces, and
attempts to hide the presumed deformity.
The effects on a person's life can be significant; almost all affected patients
avoid social and occupational exposure.
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Sometimes the concern is vague and difficult to understand, such as extreme
concern over a "scrunchy" chin.
As many as one third of the patients may be housebound because of worry
about being ridiculed for the alleged deformities,
and as many as one fifth attempt suicide.
As previously discussed, comorbid diagnoses of depressive disorders and
anxiety disorders are common, and patients may also have traits of
obsessive-compulsive, schizoid, and narcissistic personality disorders.
Diagnosis criteria
A.
B.
C.
Preoccupation with an imagined defect in
appearance. If a slight physical anomoly is present,
the person-concern is markedly excessive.
The preoccupation causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
The preoccupation is not better accounted for by
another mental disorder (e.g., dissatisfaction with
body shape and size in anorexia nervosa).
Diagnostic Criteria
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Preoccupation with an imagined
defect in appearance. If a slight
physical anomoly is present, the
person-concern is markedly
excessive.
The preoccupation causes
clinically significant distress or
impairment in social, occupational,
or other important areas of
functioning.
The preoccupation is not better
accounted for by another mental
disorder (e.g., dissatisfaction with
body shape and size in anorexia
nervosa).
想象的外表缺陷的先
占观念。如果有轻微
身体异常，但患者的
关心明显过份。
 上述先占观念导致具
有临床意义的痛苦或
社会、职业或其它重
要功能损害。
 上述先占观念不能由
其它精神障碍解释
（如神经性厌食症对
体形或身材的不满）
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Differential diagnosis-1
Distortions of body image occur in anorexia nervosa,
gender identity disorders, and some specific types of
brain damage (for example, neglect syndromes); body
dysmorphic disorder should not be diagnosed in these
situations.
 Body dysmorphic disorder must also be distinguished
from a person's normal concern about appearance.
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In body dysmorphic disorder, however, a person
experiences significant emotional distress and functional
impairment because of the concern.
Differential diagnosis-2
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Although distinguishing between a strongly held idea and a
delusion is difficult, if a patient's preoccupation with the
perceived body defect is, in fact, of delusional intensity, the
appropriate diagnosis is delusional disorder, somatic type.
Other diagnostic considerations are narcissistic personality
disorder, depressive disorders, obsessive-compulsive disorder,
and schizophrenia.
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In narcissistic personality disorder, concern about a body part is only a
minor feature in the general constellation of personality traits.
In depressive disorders, schizophrenia, and obsessive-compulsive
disorder, the other symptoms of these disorders usually evidence
themselves in short order, even when the initial symptom is excessive
concern about a body part.
Course and prognosis
The onset of body dysmorphic disorder is usually
gradual.
 An affected person may experience increasing
concern over a particular body part until the person
notices that functioning is being affected.
 Then the person may seek medical or surgical help to
address the presumed problem.
 The level of concern about the problem may wax and
wane over time, although the disorder is usually
chronic if left untreated.
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Treatment
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Treatment of patients with body dysmorphic disorder with
surgical, dermatological, dental, and other medical procedures
to address the alleged defects is almost invariably unsuccessful.
Although tricyclic drugs, monoamine oxidase inhibitors, and
pimozide (Orap) have been reported to be useful in individual
cases, a larger body of data indicate that serotonin-specific
drugs-for example, clomipramine (Anafranil) and fluoxetine
(Prozac)-are effective in reducing symptoms in at least 50
percent of patients.
In any patient with a coexisting mental disorder, such as a
depressive disorder or an anxiety disorder, the coexisting
disorder should be treated with the appropriate
pharmacotherapy and psychotherapy.
How long treatment should be continued when the symptoms
of body dysmorphic disorder have remitted is unknown.
Pain disorder
Introduction
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In DSM-IV, pain disorder is defined as the presence of pain
that is "the predominant focus of clinical attention."
Psychological factors play an important role in the disorder.
The primary symptom is pain, in one or more sites, which is
not fully accounted for by a nonpsychiatric medical or
neurological condition.
The symptoms of pain are associated with emotional distress
and functional impairment.
The disorder has been called somatoform pain disorder,
psychogenic pain disorder, idiopathic pain disorder, and
atypical pain disorder.
Epidemiology
Low back pain has disabled an estimated 7 million
people;
 more than 8 million physician office visits annually;
 Female : male=2:1;
 The peak ages of onset are in the fourth and fifth
decades;
 most common in people with blue-collar occupations;
 genetic inheritance or behavioral mechanisms are
possibly involved;
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Clinical features-1
Patients with pain disorder do not constitute a
uniform group but, instead, are a heterogeneous
collection of people with low back pain, headache,
atypical facial pain, chronic pelvic pain, and other
kinds of pain.
 A patient's pain may be posttraumatic, neuropathic,
neurological, iatrogenic, or musculoskeletal; to meet
a diagnosis of pain disorder, however, the disorder
must have a psychological factor that is judged to be
significantly involved in the pain symptoms and their
ramifications.

Clinical features-2

Patients with pain disorder often have long histories of medical
and surgical care.




They visit many physicians, request many medications, and may be
especially insistent in their desire for surgery.
Indeed, they can be completely preoccupied with their pain and cite it
as the source of all their misery.
Such patients often deny any other sources of emotional
dysphoria and insist that their lives are blissful except for their
pain.
Their clinical picture can be complicated by substance-related
disorders, because these patients attempt to reduce the pain
through the use of alcohol and other substances.
Clinical features-3

At least one study has correlated the number of pain symptoms
to the likelihood and severity of symptoms of somatization
disorder, depressive disorders, and anxiety disorders.



Major depressive disorder is present in about 25 to 50 percent of all
patients with pain disorder,
and dysthymic disorder or depressive disorder symptoms are reported
in 60 to 100 percent of the patients.
Some investigators believe that chronic pain is almost always a
variant of a depressive disorder, a masked or somatized form
of depression.

The most prominent depressive symptoms in patients with pain
disorder are anergia, anhedonia, decreased libido, insomnia, and
irritability; diurnal variation, weight loss, and psychomotor retardation
appear to be less common symptoms.
Diagnostic criteria




The DSM-IV diagnostic criteria for pain disorder require the
presence of clinically significant complaints of pain .
The complaints of pain must be judged to be significantly
affected by psychological factors, and the symptoms must
result in a patient's significant emotional distress or functional
impairment (for example, social or occupational).
DSM-IV requires that the pain disorder be associated primarily
with psychological factors or with both psychological factors
and a general medical condition.
DSM-IV further specifies that pain disorder associated solely
with a general medical condition be diagnosed as an Axis III
condition and also allows clinicians to specify whether the
pain disorder is acute or chronic, depending on whether the
duration of symptoms has been 6 months or more.
DSM-IV diagnosis criteria for pain
disorder
A.
B.
C.
Pain in one or more anatomical
sites is the predominant focus of
the clinical presentation and is of
sufficient severity to warrant
clinical attention.
The pain causes clinically
significant distress or impairment
in social, occupational, or other
important areas of functioning.
Psychological factors are judged
to have an important role in the
onset, severity, exacerbation, or
maintenance of the pain.
A.
B.
C.
一个或多个解剖部位的疼
痛是临床表现的突出焦点，
其严重程度足以引起临床
注意。
疼痛引起具有临床意义的
痛苦或社会、职业或其它
重要功能受损。
可以判断心理因素对疼痛
的发生、严重性、加剧或
持续有重要作用。
DSM-IV diagnosis criteria for pain
disorder
D.
E.
The symptom or deficit is
not intentionally produced
or feigned (as in factitious
disorder or malingering
The pain is not better
accounted for by a mood,
anxiety, or psychotic
disorder and does not meet
criteria for dyspareunia.
D.
E.
症状或缺陷并非故意
制造或伪装的（如在
做作性障碍或诈病时
那样）。
疼痛不能用心境、焦
虑或精神病性障碍解
释，也不符合性交困
难（即性交疼痛的标
准）。
标明类型

与心理因素相关的疼痛障碍


可以判断在疼痛的发生、严重程度、恶化或疼痛的持
续过程中，心理因素起了重要作用。（如有躯体疾病
存在，在疼痛的发生、严重程度、恶化或疼痛的持续
过程中，躯体疾病并没有起到重要作用）。如果也符
合躯体化障碍的标准，则不诊断这一类型的疼痛障碍。
与心理因素和躯体疾病二者相关的疼痛障碍

可以判断在疼痛的发生、严重程度、恶化或疼痛的持
续过程中，心理因素和躯体疾病均起了重要作用。
Differential diagnosis-1

Purely physical pain can be difficult to distinguish
from purely psychogenic pain, especially because the
two are not mutually exclusive.



Physical pain fluctuates in intensity and is highly sensitive
to emotional, cognitive, attentional, and situational
influences.
Pain that does not vary and is insensitive to any of these
factors is likely to be psychogenic.
When pain does not wax and wane and is not even
temporarily relieved by distraction or analgesics, clinicians
can suspect an important psychogenic component.
Differential diagnosis-2





Pain disorder must be distinguished from other somatoform
disorders, although some somatoform disorders can coexist.
Patients with hypochondriacal preoccupations may complain
of pain, and aspects of the clinical presentation of
hypochondriasis, such as bodily preoccupation and disease
conviction, can also be present in patients with pain disorder.
Patients with hypochondriasis tend to have many more
symptoms than do patients with pain disorder, and their
symptoms tend to fluctuate more than do the symptoms of
patients with pain disorder.
Conversion disorder is generally short lived, whereas pain
disorder is chronic. In addition, pain is, by definition, not a
symptom in conversion disorder.
Malingering patients consciously provide false reports, and
their complaints are usually connected to clearly recognizable
goals.
Course and prognosis




The pain in pain disorder generally begins abruptly and
increases in severity for a few weeks or months.
The prognosis varies, although pain disorder can often be
chronic, distressful, and completely disabling.
When psychological factors predominate in pain disorder, the
pain may subside with treatment or after the elimination of
external reinforcement.
The patients with the poorest prognoses, with or without
treatment, have preexisting characterological problems,
especially pronounced passivity; are involved in litigation or
receive financial compensation; use addictive substances; and
have long histories of pain.
Treatment (1)

General consideration




discuss the issue of psychological factors early in treatment;
explain how various brain circuits that are involved with
emotions;
fully understand that the patient's experiences of pain are
real.
Pharmacotherapy




Analgesic medications are not generally helpful;
Sedatives and antianxiety agents are not especially
beneficial;
Antidepressants (TCA, SSRIs) are useful;
Amphetamine used as an adjunct to SSRIs.
Treatment (2)

Behavioral therapy




Biofeedback can be helpful;
Hypnosis, transcutaneous nerve stimulation, and dorsal
column stimulation have been used;
Nerve blocks and surgical ablative procedures are
ineffective
Psychotherapy




develop a solid therapeutic alliance;
not confront somatizing patients;
examine its interpersonal ramifications in the patient's life;
Cognitive therapy
Treatment (3)

Pain control programs





Multidisciplinary pain units use many modalities;
physical therapy and exercise;
offer vocational evaluation and rehabilitation;
Concurrent mental disorders are diagnosed and treated;
dependent on analgesics and hypnotics are detoxified.
Neurasthinia
Introduction-1
The term neurasthenia was introduced in the 1860s by
the American neuropsychiatrist George Miller Beard,
who applied it to a condition characterized by chronic
fatigue and disability.
 The term neurasthenia ("nervous exhaustion") is not
now used frequently, but it does appear in psychiatric
literature and remains a diagnostic entity in the 10th
revision of International Statistical Classification of
Diseases and Related Health Problems (ICD-10).

Introduction-2
In ICD-10, neurasthenia is classified as one of the
neurotic disorders.
 According to current nosology in the United States,
the disorder is not considered a distinct diagnosis.
 In the fourth edition of Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV), neurasthenia
is categorized as undifferentiated somatoform
disorder.

Introduction-3



The disorder is a prime example of cultural differences
influencing the classification and manifestations of diseases.
Neurasthenia is an accepted condition in Europe and Asia,
where it is characterized by fatigue, headache, insomnia, and
other vague somatic complaints and is thought to result from
chronic stress rather than from unconscious psychological
conflicts.
In many cultures (especially China), in which people resist
being categorized as having a mental disorder, neurasthenia is
a preferred diagnosis. Thus, the disorder is most commonly
diagnosed in eastern Asia.
Epidemiology-1
Difficulties in investigating the epidemiology of
neurasthenia stem from the fact that it occurs in
connection with other conditions, such as anxiety,
depression, and somatoform disorders, and it has not
been sufficiently studied as an independent disorder.
 Beard considered neurasthenia one of the most
frequently observed conditions in the 19th century
United States, although no statistics were available to
support his observation.
 A 1994 study in Switzerland showed a prevalence
rate (using ICD-10) of 12 percent in that country.

Epidemiology-2



Studies have indicated that the major symptoms-fatigue and
heightened concerns with bodily symptoms-are most
commonly appear in people who are socially and economically
deprived, although the disorder is no more prevalent in this
group than in others and may, in fact, occur more frequently in
higher socioeconomic groups.
Precursors of neurasthenia in the form of "growing pains,"
fatigue, and sleep disturbances appear in children.
Beard believed childhood to be one of the peak periods for the
onset of the disorder, the other being middle age (adults 40 to
65 years of age).
Diagnostic criteria-1




According to ICD-10, neurasthenia is not used as a diagnostic
category in all countries.
In the United States, for example, many of the cases so
diagnosed would meet the criteria for depressive disorder,
somatoform disorder, or anxiety disorder.
Some patients, however, have such varied symptoms that
neurasthenia is the preferred diagnosis.
These patients may be diagnosed using the ICD-10 diagnostic
criteria, or they may receive a diagnosis of undifferentiated
somatoform disorder according to the DSM-IV criteria.
Diagnostic criteria-2
Neurasthenia is characterized by a wide variety of
signs and symptoms.
 The most common findings are chronic weakness and
fatigue, aches and pains, and general anxiety or
"nervousness."
 Beard, Freud, and others described a plethora of
patients' reported complaints. The symptoms are real
to patients.
 As Beard stated: "They are not imaginary. They have
a real objective existence and cannot be willed away."

Diagnostic criteria-3




ICD-10 describes two types of the disorder, with substantial overlap
between them.
In one type, the main feature is a complaint of increased fatigue after
mental effort, often associated with some decrease in occupational
performance or coping efficiency in daily tasks. The mental fatigability is
typically described as an unpleasant intrusion of distracting associations or
recollections, difficulty in concentrating, and generally inefficient thinking.
In the other type, the emphasis is on feelings of bodily or physical
weakness and exhaustion after only minimal effort, accompanied by
muscular aches and pains and inability to relax.
In both types, other unpleasant physical feelings, such as dizziness, tension
headaches, and a sense of general instability, are common. Worry about
decreasing mental and bodily well-being, irritability, anhedonia, and
varying degrees of both depression and anxiety may be present. Sleep is
frequently disturbed in its initial and middle phases, but hypersomnia may
also be prominent.
Diagnostic criteria-4
If the DSM-IV criteria are used, neurasthenia would
be associated with one of the two forms of
undifferentiated somatoform disorders,
 that is, with the group of physical complaints
including chronic fatigue and loss of appetite.

Signs and symptoms reported by
patients with neurasthenia


















General fatigue
Exhaustion
General anxiety
Difficulty concentrating
Physical aches and pains
Dizziness
Headache
Intolerance of noise (hyperacusis) or bright
lights
Chills
Indigestion
Constipation or diarrhea
Flatulence
Palpitations
Extrasystole
Tachycardia
Excess sweating
Flushing of skin
Dysmenorrhea
















Sexual dysfunction, eg, erectile disorder,
anorgasmia
Paresthesia
Insomnia
Poor memory
Pessimism
Chronic worry
Fear of disease
Irritability
Feelings of hopelessness
Dry mouth or hypersalivation
Arthralgias
Heat insensitivity
Dysphagia
Pruritus
Tremors
Back pain
Differential Diagnosis-1

Neurasthenia must be distinguished from anxiety disorders,
depressive disorder, and the somatoform disorders, which
include somatization disorder, conversion disorder,
hypochondriasis, body dysmorphic disorder, and pain disorder.




Because so many signs and symptoms of neurasthenia overlap with and
appear in each of these disorders, differential diagnosis may be
exceedingly difficult.
For example, patients with anxiety disorder do not uncommonly have
depressive symptomatology;
patients with hypochondriasis often complain of anxiety;
and patients with body dysmorphic disorder can have somatic
complaints.
Differential Diagnosis-2



Clinicians must rigorously apply the diagnostic criteria for
anxiety, depressive, and somatoform disorders before making a
diagnosis of neurasthenia.
Hallmarks of neurasthenia are a patient's emphasis on
fatigability and weakness and concern about lowered mental
and physical efficiency (in contrast to the somatoform
disorders, in which bodily complaints and preoccupation with
physical disease dominate the picture).
If the neurasthenic syndrome develops in the aftermath of a
physical illness (particularly influenza, viral hepatitis, or
infectious mononucleosis), the diagnosis of the illness should
also be recorded. Chronic fatigue syndrome, discussed below,
must also be considered.
Course and prognosis-1





Neurasthenia most often occurs during adolescence or middle
age.
Untreated, the disorder is usually chronic, and patients may
become incapacitated by one or more symptoms so that all
areas of functioning become impaired.
In childhood, difficulties in school functioning, including poor
grades and truancy, are likely.
In adulthood, work performance deteriorates, or patients may
become so disabled that work is impossible.
Similarly, social, marital, and interpersonal relationships suffer.
Course and prognosis-2
Beard believed that with treatment (such as it was in
the 1860s) "the majority can be relieved or
substantially cured."
 The range of therapeutic options now available is
broad, and with treatment the prognosis should be
favorable; but the long-term prognosis is unknown.
 For cases first diagnosed in childhood, the prognosis
without treatment is guarded, chronicity of symptoms
being the most likely outcome.
 Sometimes it is difficult to distinguish the prodromal
signs of schizophrenia or bipolar disorder from
neurasthenia.

Treatment-1






The key concept in the current treatment of neurasthenia is clinicians'
understanding that a patient's symptoms are not imaginary.
The symptoms are objective and are produced by emotions that influence
the autonomic nervous system, which in turn affects body functions.
Stress can cause structural change in an organ system, and the result can be
life threatening.
Therapy must therefore begin with a careful medical workup to determine
whether a patient's somatic symptoms are amenable to therapy, and if so,
what treatment is likely to produce the best results.
Patients should be reassured that the administration of medication
(analgesics, laxatives, and so on) to relieve medical symptoms will be
successful, but only when combined with concurrent psychotherapeutic
intervention.
Patients must be helped to recognize the stresses in their lives and the
coping mechanisms they use to deal with these stresses, to gain insight into
the interaction between mind and body. Without such insight-oriented
psychotherapy, the neurasthenic condition is likely to continue unabated.
Treatment-2






The availability of psychopharmacological agents has markedly improved
therapeutic options.
Serotonergic agents (such as fluoxetine [Prozac]), which have both an
antidepressant and an antianxiety effect, are the most useful class of drugs. Newer
antidepressants, such as nefazodone (Serzone) and mirtazapine (Remeron), are also
effective.
Mirtazapine is reported to have distinct sedative properties in addition to being an
antidepressant and may be especially useful for neurasthenia.
Physicians should take care in prescribing drugs with abuse potential, such as
benzodiazepines, because of these patients' predilection for self-medication and
drug misuse.
Such drugs may be useful, for brief periods and under careful supervision, to deal
with overwhelming anxiety, phobias, or insomnia. Similarly, small doses of
analeptics, such as amphetamine (Dexedrine) or methylphenidate (Ritalin), may
help to treat chronic fatigue and anhedonia.
Testosterone replacement can be tried in men with demonstrated testosterone
deficiency, but long-term treatment with testosterone is associated with serious
adverse side effects, such as prostatic cancer.