Somatoform Disorders

1. Somatoform Disorders

2. Somatoform and somatization • Somatoform disorders • Somatization • Somatization disorder

3. defining feature • physical symptoms suggesting a physical disorder for which there are no demonstrable organic findings or known physiological mechanisms, and for which there is strong evidence, or a strong presumption, that the symptoms are linked to psychological factors or conflicts.

4. Some features • Somatoform disorders are mental illnesses • not faking their symptoms • Doctors need to perform many tests to rule out other possible causes

5. Including： • somatization disorder (involving multisystem physical symptoms), • undifferentiated somatoform disorder (fewer symptoms than somatization disorder), • conversion disorder (voluntary motor or sensory function symptoms), • pain disorder (pain with strong psychological involvement), • hypochondriasis (fear of having a life-threatening illness or condition), • body dysmorphic disorder (preoccupation with a real or imagined physical defect), • somatoform disorder not otherwise specified (used when criteria are not clearly met for one of the other somatoform disorders).

6. Somatization Disorder Historical perspective • In the medical/clinical nomenclature since the mid-1600’s • Known as “Hysteria,” “hypochondriasis,” and “melancholia” until 1800’s when mental disorders were differentiated • Briquet’s syndrome, named for the French physician who initially defined it in 1859 • Term “somatization disorder” was first used in DSM-III (1980)

7. Somatization Disorder • The symptoms involve several different organs and body systems. The patient may report a combination of: pain neurologic problems gastrointestinal complaints sexual symptoms

8. Somatization disorder：Additional descriptive information • Report of symptoms usually colorful or exaggerated; factual info usually lacking • Lab findings do not support somatic complaints • Treatment sought from several doctors at once

9. Diagnostic convention • DSM –IV • ICD-10

10. A 36-year-old divorced woman who worked as a salesclerk entered the hospital emergency room at 2:00 AM complaining loudly that something was wrong with her stomach. She was tearful and agitated, with arms held tightly across her abdomen. She stated that shortly after her evening meal she began to feel nausea and “bloated” and that she vomited some undigested food. Within minutes of vomiting she began to feel a dull pain in her periumbilical area that gradually became sharper and spread throughout her entire abdomen; when the pain became “unbearable,” she decided to come to the emergency room. • As the patient calmed down and became more comfortable, she stated that she had had many similar episodes of abdominal discomfort over the past 15 years but that no doctor had been able to determine the cause. • At the age of 18 she had had severe salpingitis requiring removel of the left oviduct, and 2 years later, because of persistent abdominal pain, the right ovary was removed.

11. When she was 22, she underwent cholecystectomy, and over the next 10 years she had 3 abdominal surgical procedures to correct “adhesions” causing abdominal pain. She said, physicians had told her that she had “an ulcer” or “colitis,” but despite a variety of medical treatments her symptoms had persisted. • On further questioning, she also admitted to sporadic episodes of dizziness, chest pain that awakened her from sleep, chronic dysuria, occasional urinary retention requiring catheterization, and chronic low back pain. • She commented that only someone with a poor constitution could be sick for this long. She admitted taking diazepam (10 mg) 4 times a day for ”nerves,” phenobarbital (30 mg) 4 times a day for her gastric symptoms, and “some pain pills when I need them” – each medication prescribed by a different physician. • Except for voluntary guarding on palpation of the abdomen and the old abdominal surgical scars, physical examination was normal.

12. Somatization disorder:Statistics and course Statistics and course • Lifetime prevalence: • 0.2 – 2% in women • less than 0.2% in men • Rates affected by rater, method of assessment, and demographic variables: • Non-physicians diagnose it less frequently • In primary medical care settings, rate is 4.4 – 20% • Typical demographic is lower SES unmarried woman

13. Somatization disorder:Statistics and course (cont.) • Onset is usually before 25 (must have symptoms before 30) • Course is chronic and rarely remits completely

14. Somatization disorder：Treatment • No treatment shown to be effective • Behavioral approach  limit doctor visits • Use a gatekeeper physician • Train patient to relate to others without using physical complaints

15. Hypochondriasis • People with this type are preoccupied with concern they have a serious disease. They may believe that minor complaints are signs of very serious medical problems. For example, they may believe that a common headache is a sign of a brain tumor.

16. Body dysmorphic disorder • People with this disorder are obsessed with -- or may exaggerate -- a physical flaw. Patients may also imagine a flaw they don't have.

17. Pain disorder • People who have pain disorder typically experience pain that started with a psychological stress or trauma.

18. Conversion Disorder • Sensory Symptoms: These include anesthesia, excessive sensitivity to strong stimulation (hyperanesthesia), loss of sense of pain (analgesia, and unusual symptoms such as tingling or crawling sensations.Motor Symptoms: In motor symptoms, any of the body‘s muscle groups may be involved: arms, legs, vocal chords. Included are tremors, tics, and disorganized mobility or paralysis.Visceral Symptoms: Examples are trouble swallowing, frequent belching, or vomiting, all carried to an uncommon extreme.

19. A 36-year-old divorced woman who worked as a salesclerk entered the hospital emergency room at 2:00 AM complaining loudly that something was wrong with her stomach. She was tearful and agitated, with arms held tightly across her abdomen. She stated that shortly after her evening meal she began to feel nausea and “bloated” and that she vomited some undigested food. Within minutes of vomiting she began to feel a dull pain in her periumbilical area that gradually became sharper and spread throughout her entire abdomen; when the pain became “unbearable,” she decided to come to the emergency room. • As the patient calmed down and became more comfortable, she stated that she had had many similar episodes of abdominal discomfort over the past 15 years but that no doctor had been able to determine the cause. • At the age of 18 she had had severe salpingitis requiring removel of the left oviduct, and 2 years later, because of persistent abdominal pain, the right ovary was removed.

20. When she was 22, she underwent cholecystectomy, and over the next 10 years she had 3 abdominal surgical procedures to correct “adhesions” causing abdominal pain. She said, physicians had told her that she had “an ulcer” or “colitis,” but despite a variety of medical treatments her symptoms had persisted. • On further questioning, she also admitted to sporadic episodes of dizziness, chest pain that awakened her from sleep, chronic dysuria, occasional urinary retention requiring catheterization, and chronic low back pain. • She commented that only someone with a poor constitution could be sick for this long. She admitted taking diazepam (10 mg) 4 times a day for ”nerves,” phenobarbital (30 mg) 4 times a day for her gastric symptoms, and “some pain pills when I need them” – each medication prescribed by a different physician. • Except for voluntary guarding on palpation of the abdomen and the old abdominal surgical scars, physical examination was normal.

21. Dissociative Disorders

22. Overview • Disorders are marked by disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. • dissociative amnesia, • dissociative fugue, • dissociative identity disorder, depersonalization disorder • dissociative disorder not otherwise specified.

23. dissociative amnesia an inability to recall information about one‘s life that cannot be accounted for by other diseases.

24. dissociative fugue • is an unexpected and unexplained migration from one's home characterized by an inability to recall any of one's past.

25. dissociative identity disorder fracturing of the self into two or more distinct personalities.

26. depersonalization disorder a recurring feeling that one is detached from one's self or one's body.

27. Summary • Somatoform disorders involve a focus on physical symptoms that are either not real or are exaggerated • Dissociative disorders involve a disturbance in normally integrated functions (memory, identity, etc.) • Course is usually chronic • Causes for most are unknown

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