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Somatoform Disorders Objectives By the end of lecture, students would be able to, Identify the diagnostic features of the most common somatoform disorders List characteristics differentiating somatoform disorders from malingering and factitious disorders List some of the common causes of somatoform disorder Outline management strategies for patients with somatoform disorders. Ahmed 35 years old came to hospital complaining of dizziness, backache and indigestion. His file show: for the last 7 month, he presented with the following: abdominal pain, nausea, intolerance to 13 different foods, backache, shortness of breath at rest, chest pain, dizziness, difficulty swallowing, palpitation. Investigation: Blood test 5 times chest x-ray 3 times, ECG ( 6 times), ultrasound abdomen (2 times), CT scan abdomen( 2 times), upper GI endoscopy (2 times), colonoscopy once ALL investigations were NORMAL HOW YOU WILL MANAGE AHMED ? No explanatory organic cause can be found in 20-84% of patients presenting with bodily symptoms. Bodily or physical symptoms (hence the term somatoform) without any organic, physical cause (general medical condition or effect of substance) Increased bodily sensitivity Physical symptoms perceived are normal for most individuals Need to be sick Becoming physically sick is less stressfull than being unsuccessfull Central features of Somatoform Disorders Physical complaints without organic basis Psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the symptoms Symptoms or magnified health concerns are not under conscious control(Guggenheim2000) Symptoms must cause clinically significant distress or impairment in social, occupational or other important areas of functioning Classification Somatization disorder Undifferentiated somatoform disorder Conversion disorder Pain disorder Hypochondriasis Body dysmorphic disorder Somatoform disorder not otherwise specified Somatization Disorder multiple recurrent physical complaints over many years 4 pain symptoms 2 gastrointestinal symptoms 1 sexual symptom 1 pseudoneurologic symptom No organic etiology for these complaints Begins by age 30 Undifferentiated Somatoform Disorder One or more physical complaints (e.g. fatigue, loss of appetite, GI or urinary complaints) Present for 6 months or longer Conversion Disorder Unexplained symptoms or deficits affecting voluntary motor or sensory function suggesting neurological or other general medical condition Types: With motor symptoms or deficits With sensory symptoms or deficits With seizures or convulsions With mixed presentation Pain Disorder symptoms of pain that are either solely related to or significantly initiated, exacerbated or maintained by psychological factors. Hypochondriasis Preoccupation with fear of having or idea that one has a serious disease based on person’s misinterpretation of bodily symptoms or functions despite medical evaluations and reassurance Body Dysmorphic Disorder Preoccupation with imagined or exaggerated defects in physical appearance somatoform Disorder Not Otherwise Specified somatoform symptoms that do not meet any of the previously mentioned somatoform disorder diagnoses. Differential Diagnosis Factitious disorder and malingering Factitious disorder and malingering are different names for the same condition. Factitious disorder attempts to achieve psychological benefit, malingering attempts to achieve external benefit. Factitious disorder is conscious, malingering is primarily unconscious. Malingering is a much more chronic condition than factitious disorder. Malingering patients complain of a wider variety of symptoms. Etiology Psychosocial Factors interpretations of the symptoms as social communication avoid obligations express emotions symbolize a feeling or a belief the symptoms substitute for repressed instinctual impulses Biological Factors decreased metabolism in the frontal lobes and in the nondominant hemisphere genetic components Management – Discuss the diagnosis We counldn’t find anything serious after the exam or investigations. But htere is something bothering you. Although the reason is not clear, this is a situation we face frequently…” Management – Discuss the diagnosis Better we should discuss how we can help you instead of the name. However, although there are a lot of names given, we frequently call this situation as “Somatoform disorder” Primary physician should see patients usually at monthly interval. Additional laboratory and diagnostic procedures should generally be avoided. Long- range strategy for patient with somatoform disorder is to increase the patient's awareness of the possibility that psychological factors are involved in the symptoms until the patient is willing to see a mental health clinician. Management - Pharmacological No specific medicine Treat concomittant psychiatric problem Deal with domiant symptom Pain Amitriptilline Fatigue Bupropion Anxiety, sleep dist SSRI, TCA Medication must be monitored, because patients with somatoform disorder tend to use drugs erratically and unreliably Management - Psychotherapy In psychotherapy, patients are helped; to cope with their symptoms to express underlying emotions to develop alternative strategies for expressing their feelings. In psychotherapy stress-somatic symptom relationship is explained Focus is on anxiety, not physical symptoms Minimize secondary gain (I.e. increased attention and decreased responsibilities) Management – Life style changes Exercise Yoga, meditation, walks Socialization Thank you