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SOMATOFORM DISORDERS

SOMATOFORM 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. 5 Specific somatoform disorders: Somatization DO

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SOMATOFORM DISORDERS

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  1. SOMATOFORM DISORDERS

  2. 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

  3. 5 Specific somatoform disorders: • Somatization DO • Conversion DO • Hypochondriasis • Body Dysmorphic DO • Pain DO

  4. SOMATIZATION DISORDER • Hysteria, Briquet’s Syndrome • Many somatic symptoms • Multiple complaints and organ systems affected • Chronic

  5. Epidemiology • Lifetime prevalence = 0.1-0.2% • F > M (5-20X) = 5:1

  6. Etiology • Psychosocial factors - social communication • Biological factors - attention and cognitive impairments

  7. Diagnosis • Onset before the age of 30 years • Complain of at least 4 pain sxs, 2 GI sxs, 1 sexual sx, 1 pseudoneurological sx • No physical or laboratory explanation

  8. Clinical Features • Many somatic complaints; long complicated medical history • Psychological distress: anxiety, depression • Common suicidal threats • Medical history is circumstantial, vague, imprecise, inconsistent, disorganized

  9. Patients are dependent, self-centered, hungry for admiration or praise • Common associated mental DO - MDD, PD, SRD, GAD, phobias

  10. Differential Diagnosis • Non-psychiatric medical condition • Mental DO - MDD, GAD, schizophrenia • Other somatization DO

  11. Course and Prognosis • Chronic, debilitating • Onset before age 30 years

  12. Treatment • Single identified MD • Visits: regular, avoid additional lab/diagnostic procedures • Somatic symptoms - emotional expressions • Psychotherapy: individual, group

  13. CONVERSION DISORDER • One or more neurological symptoms (paralysis, blindness, paresthesias) • Psychological factors --> onset, exacerbation

  14. Epidemiology • F:M = 2:1 - 5:1 • Onset is any age (common during adolescence and young adults) • Rural population, little educated, low IQ, low SE group, military personel • Comorbid with MDD, anxiety, schizophrenia

  15. Etiology • Psychoanalytic - repression of unconscious conflict/anxiety --> physical sx Nonverbal means of controlling and manipulating • Biological factors - hypomentabolism of dominant hemisphere impaired hemispheric communication

  16. Diagnosis • Symptoms or deficits affecting neurological functions • Psychological factors --> onset, exacerbations • Not intentionally feigned or produced

  17. Clinical Features • Most common symptoms: paralysis, blindness, mutism • Most commonly associated with passive-aggressive, dependent, antisocial and histrionic PDs

  18. 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

  19. 2. Motor Sxs: abnormal movements, gait disturbance, weakness, paralysis generally worsen by attention 3. Seizure Sxs: pseudoseizure 4. Mixed presentation

  20. 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

  21. Differential Diagnosis • Rule out medical disorder: thorough medical and neuro work-up • 25-50% diagnosed with conversion DO --> neuro or non-psychiatric medical DO • Neuro DO - dementia, brain tumors, degenerative dse, basal ganglia dse • Psychiatric DO - schiz, deprssive DO, other somatoform, malingering, factitious DO

  22. Course 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

  23. Treatment • Spontaneously resolve • Insight-oriented supportive or behavioral therapy

  24. HYPOCHONDRIASIS • Unrealistic or inaccurate interpretations of physical symptoms or sensations --> preoccupation and fear that they have serious disease • Significant distress; impaired function

  25. Epidemiology • F = M • Onset at any age

  26. Etiology • Misinterpretation of bodily symptoms • Social learning model • Variant form of other mental disorder - depression and anxiety DO (80%) • Aggressive and hostile wishes

  27. Diagnosis • Preoccupied with false belief based misinterpretation of physical s/sxs • At least 6 months • Not a delusion or restricted to distress of appearance

  28. Clinical 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

  29. Differential Diagnosis • Non-psychiatric medical condition • Other somatoform disorders • MDD, anxiety DO, schiz, other psychotic DO

  30. Course and Prognosis • Episodic, months to years • Good prognosis: high SE class, treatment-responsive anxiety or depression, sudden onset, (-) PD, (-) related non-psychiatric medical condition

  31. Treatment • Usually resistant to psychiatric treatment • Focus on stress reduction and education in coping with chronic illness • Group psychotherapy • Regular scheduled PE

  32. BODY DYSMORPHIC DO • Preoccupation with an imagined bodily defect or an exaggerated distortion of a minimal or minor defect • Causes significant distress; impaired function

  33. Epidemiology • Rare; poorly studied • Most common age of onset: 15-30 yo • F > M, unmarried • Commonly coexists with other mental DO (MDD, anxiety, psychotic DOs)

  34. Etiology • Serotonin • Cultural and social effects • Psychodynamic models

  35. Diagnosis • Preoccupied with an imagined defect in appearance or an overemphasis of a slight defect • Significant emotional distress; impaired functioning

  36. Clinical Features • Most common concerns: facial flaws • Common associated symptoms: ideas of reference, attempts to hide deformity, excessive mirror checking or avoidance • Avoid social or occupational exposure • Housebound; attempt suicide • Traits: O-C, schizoid, narcissistic PD • Comorbid: depression, anxiety DO

  37. Differential Diagnosis • Anorexia nervosa, gender identity DO, brain damage • Delusional DO, somatic type • Narcissistic PD, depressive DO, OCD, schizophrenia

  38. Course and Prognosis • Gradual onset • Usually chronic

  39. Treatment • Serotonin-specific drugs - clomipramine, fluoxetine • Treat coexisting mental DO

  40. PAIN DISORDER • Psychogenic pain DO • Pain in one or more sites --> no non-psychiatric medical or neurological condition • Emotional distress; functional impairment

  41. Epidemiology • F > M • Peak onset on 4th to 5th decades • Blue-collar occupation, 1st degree relatives

  42. Etiology • Psychodynamic: expression of intrapsychic conflict defense mechanism-displacement, substitution, repression • Behavioral: reinforced with reward and inhibited when ignored/punished • Interpersonal: manipulation and gaining advantages • Biological: 5HT and endorphins

  43. Diagnosis • Significant complaints of pain • Emotional distress and functional impairment

  44. Clinical 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%

  45. Differential Diagnosis • Physical pain VS Psychogenic pain • Physical Pain: fluctuates in intensity, highly sensitive to emotional, cognitive, attentional and situational influence • Psychogenic Pain: does not vary, insensitive to any of above factors, does not wax or wane, not temporarily relieved by distraction • Other somatoform DO

  46. Course and Prognosis • Abrupt onset and increases in severity

  47. Treatment • Address rehabilitation • PAIN IS REAL • Pharmacotherapy - antidepressant • Behavioral therapy • Psychotherapy • Pain control program

  48. 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 months • Significant emotional distress and impaired functioning

  49. 2 types of somatoform pattern: • Involving ANS: CV, GI, urogenital, derma sxs • Involving sensations of fatigue or weakness (neurasthenia): mental or physical fatigue, physical weakness and exhaustion

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