Post on 17-Dec-2015
SOMATOFORM DISORDERSSOMATOFORM DISORDERS
Group of disorders that includes physical symptoms for which an adequate medical explanation cannot be found
Psychological factors --> symptom’s onset, severity, duration
Not malingering or factitious disorder
Group of disorders that includes physical symptoms for which an adequate medical explanation cannot be found
Psychological factors --> symptom’s onset, severity, duration
Not malingering or factitious disorder
5 Specific somatoform disorders:1. Somatization DO2. Conversion DO3. Hypochondriasis4. Body Dysmorphic DO5. Pain DO
5 Specific somatoform disorders:1. Somatization DO2. Conversion DO3. Hypochondriasis4. Body Dysmorphic DO5. Pain DO
SOMATIZATION DISORDERSOMATIZATION DISORDER
Hysteria, Briquet’s SyndromeMany somatic symptomsMultiple complaints and organ systems
affectedChronic
Hysteria, Briquet’s SyndromeMany somatic symptomsMultiple complaints and organ systems
affectedChronic
Epidemiology Epidemiology
Lifetime prevalence = 0.1-0.2%F > M (5-20X) = 5:1
Lifetime prevalence = 0.1-0.2%F > M (5-20X) = 5:1
EtiologyEtiology
1. Psychosocial factors - social communication
2. Biological factors - attention and cognitive impairments
1. Psychosocial factors - social communication
2. Biological factors - attention and cognitive impairments
DiagnosisDiagnosis
Onset before the age of 30 yearsComplain of at least 4 pain sxs, 2 GI
sxs, 1 sexual sx, 1 pseudoneurological sx
No physical or laboratory explanation
Onset before the age of 30 yearsComplain of at least 4 pain sxs, 2 GI
sxs, 1 sexual sx, 1 pseudoneurological sx
No physical or laboratory explanation
Clinical FeaturesClinical Features
Many somatic complaints; long complicated medical history
Psychological distress: anxiety, depression
Common suicidal threatsMedical history is circumstantial, vague,
imprecise, inconsistent, disorganized
Many somatic complaints; long complicated medical history
Psychological distress: anxiety, depression
Common suicidal threatsMedical history is circumstantial, vague,
imprecise, inconsistent, disorganized
Patients are dependent, self-centered, hungry for admiration or praise
Common associated mental DO - MDD, PD, SRD, GAD, phobias
Patients are dependent, self-centered, hungry for admiration or praise
Common associated mental DO - MDD, PD, SRD, GAD, phobias
Differential DiagnosisDifferential Diagnosis
1. Non-psychiatric medical condition2. Mental DO - MDD, GAD,
schizophrenia3. Other somatization DO
1. Non-psychiatric medical condition2. Mental DO - MDD, GAD,
schizophrenia3. Other somatization DO
Course and PrognosisCourse and Prognosis
Chronic, debilitatingOnset before age 30 years
Chronic, debilitatingOnset before age 30 years
Treatment Treatment
Single identified MDVisits: regular, avoid additional
lab/diagnostic proceduresSomatic symptoms - emotional
expressionsPsychotherapy: individual, group
Single identified MDVisits: regular, avoid additional
lab/diagnostic proceduresSomatic symptoms - emotional
expressionsPsychotherapy: individual, group
CONVERSION DISORDERCONVERSION DISORDER
One or more neurological symptoms (paralysis, blindness, paresthesias)
Psychological factors --> onset, exacerbation
One or more neurological symptoms (paralysis, blindness, paresthesias)
Psychological factors --> onset, exacerbation
Epidemiology Epidemiology
F:M = 2:1 - 5:1Onset is any age (common during
adolescence and young adults)Rural population, little educated, low IQ,
low SE group, military personelComorbid with MDD, anxiety,
schizophrenia
F:M = 2:1 - 5:1Onset is any age (common during
adolescence and young adults)Rural population, little educated, low IQ,
low SE group, military personelComorbid with MDD, anxiety,
schizophrenia
Etiology Etiology
1. Psychoanalytic - repression of unconscious conflict/anxiety --> physical sx
Nonverbal means of controlling and manipulating
1. Biological factors - hypomentabolism of dominant hemisphere
impaired hemispheric communication
1. Psychoanalytic - repression of unconscious conflict/anxiety --> physical sx
Nonverbal means of controlling and manipulating
1. Biological factors - hypomentabolism of dominant hemisphere
impaired hemispheric communication
Diagnosis Diagnosis
Symptoms or deficits affecting neurological functions
Psychological factors --> onset, exacerbations
Not intentionally feigned or produced
Symptoms or deficits affecting neurological functions
Psychological factors --> onset, exacerbations
Not intentionally feigned or produced
Clinical FeaturesClinical Features
Most common symptoms: paralysis, blindness, mutism
Most commonly associated with passive-aggressive, dependent, antisocial and histrionic PDs
Most common symptoms: paralysis, blindness, mutism
Most commonly associated with passive-aggressive, dependent, antisocial and histrionic PDs
1. Sensory Sxs: anesthesia and paresthesia, esp extremities
distribution usually inconsistent with central or peripheral neuro dse
characteristic stocking and glove anesthesia or hemianesthesia (along the midline)
organs of special senses - deafness, blindness, tunnel vision --> N neuro exam
1. Sensory Sxs: anesthesia and paresthesia, esp extremities
distribution usually inconsistent with central or peripheral neuro dse
characteristic stocking and glove anesthesia or hemianesthesia (along the midline)
organs of special senses - deafness, blindness, tunnel vision --> N neuro exam
2. Motor Sxs: abnormal movements, gait disturbance, weakness, paralysis
generally worsen by attention3. Seizure Sxs: pseudoseizure4. Mixed presentation
2. Motor Sxs: abnormal movements, gait disturbance, weakness, paralysis
generally worsen by attention3. Seizure Sxs: pseudoseizure4. Mixed presentation
Other associated features: Primary gain: represent an unconscious
psychological conflict Secondary gain: accrue tangible
advantages & benefits Le belle indifference: unconcerned about
what appears to be a major impairment Identification: unconsciously model their
sxs on those someone important to them
Other associated features: Primary gain: represent an unconscious
psychological conflict Secondary gain: accrue tangible
advantages & benefits Le belle indifference: unconcerned about
what appears to be a major impairment Identification: unconsciously model their
sxs on those someone important to them
Differential DiagnosisDifferential Diagnosis
Rule out medical disorder: thorough medical and neuro work-up
25-50% diagnosed with conversion DO --> neuro or non-psychiatric medical DO
1. Neuro DO - dementia, brain tumors, degenerative dse, basal ganglia dse
2. Psychiatric DO - schiz, deprssive DO, other somatoform, malingering, factitious DO
Rule out medical disorder: thorough medical and neuro work-up
25-50% diagnosed with conversion DO --> neuro or non-psychiatric medical DO
1. Neuro DO - dementia, brain tumors, degenerative dse, basal ganglia dse
2. Psychiatric DO - schiz, deprssive DO, other somatoform, malingering, factitious DO
Course and PrognosisCourse and Prognosis
90-100% resolve in few days to less than a month
Good prognosis: sudden onset, easily identifiable stressor, good premorbid adjustment, no comorbid psychiatric or medical DO
25-50% --> neuro or non-psychiatric DO
90-100% resolve in few days to less than a month
Good prognosis: sudden onset, easily identifiable stressor, good premorbid adjustment, no comorbid psychiatric or medical DO
25-50% --> neuro or non-psychiatric DO
Treatment Treatment
Spontaneously resolveInsight-oriented supportive or behavioral
therapy
Spontaneously resolveInsight-oriented supportive or behavioral
therapy
HYPOCHONDRIASISHYPOCHONDRIASIS
Unrealistic or inaccurate interpretations of physical symptoms or sensations --> preoccupation and fear that they have serious disease
Significant distress; impaired function
Unrealistic or inaccurate interpretations of physical symptoms or sensations --> preoccupation and fear that they have serious disease
Significant distress; impaired function
Epidemiology Epidemiology
F = MOnset at any age
F = MOnset at any age
Etiology Etiology
1. Misinterpretation of bodily symptoms2. Social learning model3. Variant form of other mental disorder -
depression and anxiety DO (80%)4. Aggressive and hostile wishes
1. Misinterpretation of bodily symptoms2. Social learning model3. Variant form of other mental disorder -
depression and anxiety DO (80%)4. Aggressive and hostile wishes
Diagnosis Diagnosis
Preoccupied with false belief based misinterpretation of physical s/sxs
At least 6 monthsNot a delusion or restricted to distress
of appearance
Preoccupied with false belief based misinterpretation of physical s/sxs
At least 6 monthsNot a delusion or restricted to distress
of appearance
Clinical FeaturesClinical Features
Believe that they have a serious disease not yet detected
Conviction persist despite negative lab results, benign course, reassurances
Usually with depression and anxiety
Believe that they have a serious disease not yet detected
Conviction persist despite negative lab results, benign course, reassurances
Usually with depression and anxiety
Differential Diagnosis Differential Diagnosis
1. Non-psychiatric medical condition2. Other somatoform disorders3. MDD, anxiety DO, schiz, other
psychotic DO
1. Non-psychiatric medical condition2. Other somatoform disorders3. MDD, anxiety DO, schiz, other
psychotic DO
Course and PrognosisCourse and Prognosis
Episodic, months to yearsGood prognosis: high SE class,
treatment-responsive anxiety or depression, sudden onset, (-) PD, (-) related non-psychiatric medical condition
Episodic, months to yearsGood prognosis: high SE class,
treatment-responsive anxiety or depression, sudden onset, (-) PD, (-) related non-psychiatric medical condition
Treatment Treatment
Usually resistant to psychiatric treatment Focus on stress reduction and education in
coping with chronic illnessGroup psychotherapyRegular scheduled PE
Usually resistant to psychiatric treatment Focus on stress reduction and education in
coping with chronic illnessGroup psychotherapyRegular scheduled PE
BODY DYSMORPHIC DOBODY DYSMORPHIC DO
Preoccupation with an imagined bodily defect or an exaggerated distortion of a minimal or minor defect
Causes significant distress; impaired function
Preoccupation with an imagined bodily defect or an exaggerated distortion of a minimal or minor defect
Causes significant distress; impaired function
Epidemiology Epidemiology
Rare; poorly studiedMost common age of onset: 15-30 yoF > M, unmarriedCommonly coexists with other mental
DO (MDD, anxiety, psychotic DOs)
Rare; poorly studiedMost common age of onset: 15-30 yoF > M, unmarriedCommonly coexists with other mental
DO (MDD, anxiety, psychotic DOs)
Etiology Etiology
SerotoninCultural and social effectsPsychodynamic models
SerotoninCultural and social effectsPsychodynamic models
Diagnosis Diagnosis
Preoccupied with an imagined defect in appearance or an overemphasis of a slight defect
Significant emotional distress; impaired functioning
Preoccupied with an imagined defect in appearance or an overemphasis of a slight defect
Significant emotional distress; impaired functioning
Clinical FeaturesClinical Features
Most common concerns: facial flawsCommon associated symptoms: ideas
of reference, attempts to hide deformity, excessive mirror checking or avoidance
Avoid social or occupational exposureHousebound; attempt suicideTraits: O-C, schizoid, narcissistic PDComorbid: depression, anxiety DO
Most common concerns: facial flawsCommon associated symptoms: ideas
of reference, attempts to hide deformity, excessive mirror checking or avoidance
Avoid social or occupational exposureHousebound; attempt suicideTraits: O-C, schizoid, narcissistic PDComorbid: depression, anxiety DO
Differential DiagnosisDifferential Diagnosis
Anorexia nervosa, gender identity DO, brain damage
Delusional DO, somatic typeNarcissistic PD, depressive DO, OCD,
schizophrenia
Anorexia nervosa, gender identity DO, brain damage
Delusional DO, somatic typeNarcissistic PD, depressive DO, OCD,
schizophrenia
Course and PrognosisCourse and Prognosis
Gradual onsetUsually chronic
Gradual onsetUsually chronic
Treatment Treatment
Serotonin-specific drugs - clomipramine, fluoxetine
Treat coexisting mental DO
Serotonin-specific drugs - clomipramine, fluoxetine
Treat coexisting mental DO
PAIN DISORDERPAIN DISORDER
Psychogenic pain DOPain in one or more sites --> no non-
psychiatric medical or neurological condition
Emotional distress; functional impairment
Psychogenic pain DOPain in one or more sites --> no non-
psychiatric medical or neurological condition
Emotional distress; functional impairment
Epidemiology Epidemiology
F > MPeak onset on 4th to 5th decadesBlue-collar occupation, 1st degree
relatives
F > MPeak onset on 4th to 5th decadesBlue-collar occupation, 1st degree
relatives
Etiology Etiology
1. Psychodynamic: expression of intrapsychic conflict
defense mechanism-displacement, substitution, repression
2. Behavioral: reinforced with reward and inhibited when ignored/punished
3. Interpersonal: manipulation and gaining advantages
4. Biological: 5HT and endorphins
1. Psychodynamic: expression of intrapsychic conflict
defense mechanism-displacement, substitution, repression
2. Behavioral: reinforced with reward and inhibited when ignored/punished
3. Interpersonal: manipulation and gaining advantages
4. Biological: 5HT and endorphins
Diagnosis Diagnosis
Significant complaints of painEmotional distress and functional
impairment
Significant complaints of painEmotional distress and functional
impairment
Clinical FeaturesClinical Features
Collection of different histories of various pains
Pain maybe post-traumatic, neuropathic, neurological, iatrogenic, musculoskeletal
(+) psychological factor Long history of medical and surgical care,
visits many MDs, requests many meds Complicated by SRD MDD: 25-50% of patients
Dysthymic or depressive DO sxs - 60-100%
Collection of different histories of various pains
Pain maybe post-traumatic, neuropathic, neurological, iatrogenic, musculoskeletal
(+) psychological factor Long history of medical and surgical care,
visits many MDs, requests many meds Complicated by SRD MDD: 25-50% of patients
Dysthymic or depressive DO sxs - 60-100%
Differential DiagnosisDifferential Diagnosis
1. Physical pain VS Psychogenic pain1. Physical Pain: fluctuates in intensity,
highly sensitive to emotional, cognitive, attentional and situational influence
2. Psychogenic Pain: does not vary, insensitive to any of above factors, does not wax or wane, not temporarily relieved by distraction
2. Other somatoform DO
1. Physical pain VS Psychogenic pain1. Physical Pain: fluctuates in intensity,
highly sensitive to emotional, cognitive, attentional and situational influence
2. Psychogenic Pain: does not vary, insensitive to any of above factors, does not wax or wane, not temporarily relieved by distraction
2. Other somatoform DO
Course and PrognosisCourse and Prognosis
Abrupt onset and increases in severityAbrupt onset and increases in severity
Treatment Treatment
Address rehabilitationPAIN IS REAL
Pharmacotherapy - antidepressant Behavioral therapy Psychotherapy Pain control program
Address rehabilitationPAIN IS REAL
Pharmacotherapy - antidepressant Behavioral therapy Psychotherapy Pain control program
UNDIFFERENTIATED SOMATOFORM DO
UNDIFFERENTIATED SOMATOFORM DO
One or more physical complaints that can’t be explained by known medical condition
Doesn’t meet the diagnostic criteria for any somatoform DO
At least 6 monthsSignificant emotional distress and
impaired functioning
One or more physical complaints that can’t be explained by known medical condition
Doesn’t meet the diagnostic criteria for any somatoform DO
At least 6 monthsSignificant emotional distress and
impaired functioning
2 types of somatoform pattern:1. Involving ANS: CV, GI, urogenital, derma
sxs2. Involving sensations of fatigue or
weakness (neurasthenia): mental or physical fatigue, physical weakness and exhaustion
2 types of somatoform pattern:1. Involving ANS: CV, GI, urogenital, derma
sxs2. Involving sensations of fatigue or
weakness (neurasthenia): mental or physical fatigue, physical weakness and exhaustion