Download Somatoform Disorders

Somatoform
Disorders
Jacob Alexander
Senior Lecturer/Consultant
Psychiatrist
CHSA
Introduction
• Group of illnesses where bodily signs
and symptoms are a major focus
• Believed to originate from faulty
mind-body interactions- the brain
sends signals that impinge on the
patients awareness falsely
suggesting a serious problem in the
body
• The symptoms are medically
unexplained
• Patients are convinced that their
suffering comes from some type of
undetected and untreated bodily
derangement
Historical background…….
• “Somatoform” derived from Greek “soma” – body
• Grouped together for the first time in the DSM III in 1980
• Observed for a long time before that and several terms
used to refer to these disorders including neurasthenia,
hysteria and Briquet’s syndrome
• Some famous contributors-Jean Marie Charcot, Paul
Briquet, Sigmund Freud
Somatoform disorders
1. Somatization disorders- multiple organ system
involvement
2. Conversion disorders- neurological complaints
3. Hypochondriasis- worried about being sick with a
particular illness rather than a focus on physical
symptoms
4. Body dysmorphic disorder- dissatisfaction with a body
part
5. Persistent somatoform pain disorder- pain is the main
complaint
6. Undifferentiated somatoform disorder
7. Somatoform disorder not otherwise specified
Somatization disorder
A- many physical symptoms
- starting before the age of 30
- occur over a period of years
- leads to multiple medical consultations
and other attempts at seeking treatment
-significant impairment in social,
occupational, or other areas of
functioning
B -4 pain symptoms- related to at least 4
different sites or functions
-2 gastrointestinal symptoms other than
pain
-1sexual or reproductive symptom
-1 pseudoneurological symptom
Somatization disorder
C- despite appropriate
investigation, the symptoms
cannot be fully explained by a
known general medical condition
or the direct effects of a
substance
-when there is a related general
medical condition, the physical
complaints or resulting social or
occupational impairment are in
excess of what could be
expected from the history,
physical examination, or
laboratory findings.
D- the symptoms are not
intentionally produced or feigned
Somatization disorder- some facts
• Commoner in women (life time prevalence
0.2-2% of women and 0.2% of men)
• 5-10 % of patients presenting to a GP
• Inversely related to social position
• Usually beginning in teenage years
• Often co-morbid with other mental dis.depression and anxiety
• Common personality traits-avoidant,
paranoid, self-defeating, obsessivecompulsive
Somatization disorderaetiology
Psychodynamic
factors
Learning theory
Social/Cultural factors
Biological factors
Genetic factors
Cytokines
Somatization disorder-clinical
features (commonest)
Common characteristics of presenting problem
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Long, complicated medical histories-confused time frames
Patients frequently report they have been sickly all their life
Psychological and interpersonal problems
Suicide threats common but rarely acted upon
Dramatic and emotional presentation of history and appearance
Self centred, hungry for admiration, manipulative
Commonest Symptoms reported
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Nausea and vomiting other than during pregnancy
Pain in the arms and legs
Shortness of breath unrelated to exertion
Amnesia
Complications of pregnancy and menstruation
Somatization disorder-DD, course
and prognosis
Differential Diagnosis
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Genuine illness
Psychiatric syndromes-depression, anxiety
Life stressors with associated psychophysiological symptoms
Other somatoform disorders
Voluntary psychogenic symptoms or syndromes
Course
• chronic, undulating and relapsing illness
• Rarely fully remits- unusual for patients to be symptom free for more
than a year
• Not more likely than others to develop a medical illness at 20 yr follow
up
Somatization disorder-treatment
• Single, identified physician as primary care giver
• Regular, scheduled visits usually at monthly intervals
• Keep interviews brief with a partial physical exam for
each new symptom expressed
• Generally avoid lab/diagnostic investigations
• Once diagnosed view these problems as being
communications of emotional distress
• Try and raise awareness of these symptoms being
responses to psychological pressures and see if you can
motivate patient to see a mental health clinician
• Individual or group psychotherapy
Somatization disorder- tasks of
psychotherapy
• Decrease the patients
personal health
expenditures
• Help to cope with their
symptoms
• Assist with expressing
underlying emotions
• Help to develop alternative
strategies for expressing
their feelings
• Psychopharmacological
intervention difficult
Conversion disorder
Neurological complaint
• With motor symptom or
deficit
• With sensory symptom or
deficit
• With seizure or
convulsions
• With mixed presentations
Conversion disorder
A- one or more symptoms of deficit affecting voluntary motor or sensory
function that suggest a neurological or other general medical
condition
B-Psychological factors are judged to be associated with the symptom
deficit because the initiation or exacerbation of the symptoms or
deficit is preceded by conflicts or other stressors
C-The symptom or deficit is not intentionally produced or feigned
D-The symptom or deficit cannot, after appropriate investigation, be fully
explained by a general medical condition or by the direct effects of a
substance, or as a culturally sanctioned behaviour or experience
E-Causes clinically significant distress or impairment in social,
occupational or other important areas of functioning or warrants
medical evaluation
F-The symptoms or deficit is not limited to pain or sexual dysfunction,
does not exclusively occur during the course of a somatisation
disorder and is not better accounted for by another mental disorder
Conversion disorder
Common amongst:
-F>M
-rural population
-little education
-low SES
-military personnel exposed to combat situations
Co-morbidities include-MDD, Anxiety,
schizophrenia, somatisation, histrionic pd,
passive-dependent pd
Conversion disorder-clinical
features
Motor symptoms
• Involuntary movements
• Tics
• Blepharospasm
• Torticollis
• Opisthotonus
• Seizures
• Abnormal gait
• Falling
• Astasia-Abasia
• Paralysis
• Weakness
• aphonia
Sensory deficits
• Anaesthesia of extremities
• Midline anaesthesia
• Blindness
• Tunnel vision
• Deafness
Visceral symptoms
• Psychogenic vomiting
• Pseudocyesis
• Globus hystericus
• Swooning or syncope
• Urinary retention
• diarrhoea
Conversion disorder-aetiology
Psychodynamic factors- intrapsychic conflict, repression, sublimation,
projection
Learning theory/ social factors –
nonverbal means of controlling and
managing others
Biological factors- impaired
hemispheric function
Genetic factors- women probands more
prone to somatisation, depression and
anxiety, male probands more prone to
ASPD and substance abuse
Psychological Concepts in
Somatoform disorders
• Primary Gain- distracts from primary intrapsychic conflict
• Secondary Gain-receives tangible benefits
to sick role
• La Belle indifference-indifference to what
should normally be anxiety provoking
symptoms
• Identification-assumption of symptoms of a
significant other
Conversion disorder-course and
prognosis
• Usually acute onset
• 95% remit spontaneously within 2 weeks of
hospital admission
• If symptoms present for more than 6 months
less than 50% remit spontaneously
• Good prognostic factors- clearly identifiable
stressor, acute onset, above average
intelligence and quick institution of treatment
Conversion disorder- treatment
• Relationship with a caring and confident
psychotherapist
• Insight-oriented supportive or behaviour
therapy
• Telling patients their symptoms are
imaginary makes them worse
• Hypnosis, anxiolytics and behavioural
relaxation exercises
• Psychodynamic psychotherapy
Hypochondriasis
• Generalised and nondelusional preoccupation with
fears of having a specific
illness
• Preoccupation persists
despite appropriate medical
evaluation and reassurance
• Based on misinterpretation of
bodily symptoms
• Lasting 6 months or more
• Preoccupation causes
significant impairment or
distress in a person’s life
Hypochondriasis-aetiology
Psychodynamic factorsintra-psychic conflict, projection,
deserving of punishment
Learning theory/ social
factors –symptoms often
learnt from past experiences,
often have related medical
illnesses
Biological factors- low
threshold for and low tolerance
of physical discomfort
Hypochondriasis-Treatment
• Psychiatric treatment in a medical setting
• Focus on stress reduction and education in coping with a
chronic illness
• Appear to do well in group therapy because it provides
them with the social support and interaction that they
need
• Long term regular follow up with physical exams and
investigations as necessary reassures the patients that
their physicians are not abandoning them and their
complaints are being taken seriously.
• Pharmacotherapy useful only when hypochondriacs
have an underlying drug responsive condition.
Body Dysmorphic disorder (BDD)
• Preoccupation with an imagined defect in
appearance that causes clinically significant
distress or impairment in important areas of
functioning.
• If a slight physical anomaly is actually present,
the person’s concern is excessive and
bothersome.
• Emil Kraeplin-dysmorphophobia
• Pierre Janet- obsession de la hontu du corps
BDD
• More likely to present to dermatologists, plastic
surgeons, internists
• Study of college students-50% preoccupied with
at least one body feature, 25% reporting it had
some impact on their feeling and functioning
• F>M, onset at ages 15-30
• More likely to be single
• Depression, anxiety, psychotic comorbidity
common
BDD-commonest feature affected
1.
2.
3.
4.
5.
6.
Hair
Nose
Skin
Eyes
Head/face
Overall body build/ bone
structure
7. Lips
8. Chin
9. Stomach, waist
10. teeth
Body Dysmorphic Disorder-etiology
• Serotonin pathways?
• Psychodynamic
explanations- repression,
dissociation, distortion,
symbolization and
projection, displacement
• Familial and cultural
concepts/ values around
beauty
• DD-OCD, delusional
disorder, Psychosis,
depression, anxiety
BDD-clinical symptoms
• Ideas or delusions of
reference
• Avoidance of social and
even occupational
exposure
• Excessive mirror checking
or avoidance of reflective
surfaces
• House bound
• Suicide in response to
distress
BDD-course, prognosis and
management
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Begins in adolescence
Gradual or abrupt onset
Long and undulating course
TCAs, MAOIs, SSRIs
Augmentation of antidepressant
Psychotherapy
Surgical intervention largely unsuccessful
Pain disorder
• Pain in one or more anatomical
sites is the main focus
• Of sufficient severity to warrant
clinical attention
• Causes significant distress and
dysfunction
• Psychological factors identified as
having an important contributory
role
• Not intentionally produced or better
accounted for by another medical
condition
Pain disorder
Aetiology
• Psychodynamic factors
• Behavioural factors
• Interpersonal factors
• Biological factors
Clinical factors
• Heterogeneous group
• Long medical and
surgical histories
• Lead pain-centric lives
• At risk for substance
abuse/dependence
• Co-morbidity with
depression (up to 50%)
Pain disorder
Treatment
• Pharmacotherapy-avoid analgesics and consider antidepressants
• Psychotherapy-therapeutic alliance, identify source of psychological
pain, cognitive strategies
• Other therapies-biofeedback, hypnosis, transcutaneous nerve
stimulation, dorsal column stimulation
• Pain Control Program
Course and Prognosis
• Abrupt onset often
• Increase in severity over weeks or months
• Acute pain prognosis better than chronic pain
The End