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SOMATOFORM DISORDERS Maria L.A. Tiamson, MD Asst. Professor, Psychiatry New York Medical College SOMATIZATION, the concept Poorly understood…”crocks”..”turkeys”.. “hysterics”..”worried well” the tendency to express and communicate psychological distress in the form of somatic symptoms for which they seek medical help “one of medicine’s blind spots” Psychosomatic Illnesses Asthma Ulcerative colitis Rheumatoid arthritis Eczematous disorders Irritable bowel syndrome Forms of Somatization Medically unexplained symptoms Hypochondriacal somatization Somatic presentation of psychiatric disorders (ie., depressive equivalents) Most common presenting symptoms Abdominal pain chest pain dyspnea headache fatigue Cough back pain nervousness dizziness Infectious Diseases Lyme disease AIDS Infectious mononucleosis Syphilis Chronic Fatigue Syndrome Post-infection syndromes SOMATIZATION, the cost 10% of total direct healthcare costs with the potential to bankrupt the healthcare financing system Somatizers have 9x more total charges, 6x more hospital charges, 14x more MD services Somatizers are sick in bed an average of 7 days a month vs. 0.48 days for the general population SOMATIC COMPLAINTS Patients who experience their symptoms but do not deliberately produce them (SOMATOFORM DISORDERS) Patients who knowingly create symptoms in themselves, either for material gain (MALINGERING), or for more subtle benefits, such as gratification of the patient role (FACTITIOUS DISORDERS) Pathophysiological Mechanisms Physiological Mechanisms • • • • • • • autonomic arousal muscle tension hyperventilation vascular changes cerebral information processing physiological effects of inactivity sleep disturbance Pathophysiological Mechanisms Psychological Mechanisms • • • • perceptual factors beliefs mood personality factors Interpersonal Mechanisms • reinforcing actions of relatives and friends • health care system • disability system DSM-IV Somatoform Disorders A group of disorders that include medical symptoms and complaints FOR WHICH AN ADEQUATE MEDICAL EXPLANATION CANNOT BE FOUND. Not intentionally produced Onset, severity and duration of symptoms are strongly linked to psychological factors DSM-IV Somatoform Disorders Somatization Disorder Conversion Disorder Hypochondriasis Body Dysmorphic Disorder Somatoform Pain Disorder Undifferentiated Somatoform Disorder Somatoform Disorder, NOS Somatization Disorder “hysteria”, Briquet’s Syndrome multiplicity of somatic complaints involving multiple organ systems female predominance before age 30 chronic excessive medical help-seeking behavior Somatization Disorder Cannot be fully explained by any known GMC or substance use if GMC is present, physical complaints or impairment are in excess of what could be expected significant impairment in functioning Somatization Disorder Four pain symptoms One sexual symptom One pseudoneurological symptom Two GI symptoms Somatization Disorder Complaints described in colorfiul, exaggerated terms but lack specific factual information prominent anxiety and depressive symptoms 10-20% female 1st degree relatives of SD women, increased ASPD and SUD in male rrelatives Conversion Disorder Monosymptomatic (one or more neurological symptoms) Most common in • • • • • adolescents, young adults rural populations low education and low IQ low socioeconomic group military personnel exposed to combat Conversion Disorder Symptom has a symbolic relation to the unconscious conflict “la belle indifference” Conversion Disorder Impaired coordination, balance paralysis, weakness aphonia, difficulty swallowing, lump in the throat urinary retention loss of touch/pain, double vision, blindness deafness, seizures Conversion Disorder Symptoms do not conform to known anatomical pathways and physiological mechanisms often inconsistent DDX: multiple sclerosis, myasthenia gravis, dystonias Conversion Disorder Dramatic or histrionic suggestible sx are self-limited and do not lead to physical changes/disability associated with dissociative disorders, MDD, histrionic, antisocial and dependent personality disorders Hypochondriasis Preoccupation with the fear of contracting, or the belief of having, a serious disease Usually with co-morbid depression, anxiety Misinterpretation of physical symptoms and sensations Request for admission to the “sick role”, which offers an escape Hypochondriasis Preoccupation is with any of the ff: bodily functions, minor physical abnormalities, vague and ambiguous physical sensations medical history is presented in great detail and length “doctor shopping” associated with serious illness in childhood, past experience with disease in a family member Body Dysmorphic Disorder Preoccupation with an imagined defect or an exaggerated distortion of a minimal or minor defect in physical appearance dysmorphophobia Comorbid with major depression (90%), anxiety disorder (70%), psychotic disorder (30%) Body Dysmorphic Disorder Marked distress over supposed deformity frequent mirror checking and checking in other reflecting surfaces excessive grooming behavior use of special lighting or magnifying glasses avoidance of usual activities Somatoform Pain Disorder Presence of pain that is the “predominant focus of clinical attention” Not fully accounted by a nonpsychiatric medical or neurological condition The symbolic meaning of body disturbances relate to atonement for perceived sin, to expiation of guilt, or to suppressed aggression Nonspecific Somatoform Disorders Undifferentiated somatoform disorder • unexplained physical effects that last for at least six months Somatoform Disorder, NOS • residual category Relation of Depression and Somatization Patients with SD have a high prevalence of depression (48-94%) Patients with MDD have substantial levels of somatization (63-84%) Depression can be treated successfully when it coexists with SD Smith, 1992 Relation of Depression and Pain Patients with chronic pain have a significant current prevalence of depressive disorders More than half of patients with MDD complain of pain Pain is reduced with the treatment of depression Smith, 1992 Baron Karl Friedrich Hieronymus von Munchausen Factitious Disorders Psychological symptoms Physical symptoms Munchausen’s syndrome, pseudologica fantastica, peregrination usually co-morbid with psychiatric conditions intentional production of symptoms but goal is intangible and psychologically complex ALERT…ALERT…ALERT... Numerous surgical scars, usually in the abdominal area Patient is truculent and evasive Personal and medical history were fraught with acute and harrowing adventures History of many hospitalizations, malpractice claims, insurance claims Involved in the healthcare profession Symptom Types Total fabrications Exaggerations Simulations of the disease Self-induced disease A Physical Diagnosis is more likely if…. Symptoms do not meet DSM-IV criteria. Premorbid social history is unremarkable. There is an ABRUPT change in personality, mood, or ability to function. There are RAPID fluctuations in mental status. There is lack of response to usual biologic or psychologic interventions. Principles of Management Emphasize explanation Arrange for regular follow-up Treat mood/anxiety disorder Minimize polypharmacy and multiple diagnostic tests Provide specific treatment when indicated Remember…. Reassurance that “nothing is wrong” does NOT help. The patient does not want symptom relief but rather a RELATIONSHIP and understanding. Little is to be gained by saying that “it’s all in your head”. Remember... You should acknowledge the patient’s plight, avoid challenging the patient. A positive organic diagnosis will not cure the patient. SOMATIZATION MAY CO-EXIST WITH ANY PHYSICAL ILLNESS AND MAY INITIALLY MASK THE ILLNESS. Malingering Intentional fabrication of symptoms to achieve a secondary gain, usually material benefits