Understanding Psychosomatic Medicine in Psychiatry: A Comprehensive Overview

1. Psychosomatic Medicine Psychosomatic Medicine Presented by : B.Oji, Assistant Professor of Psychiatry, Fellowship of Psychosomatic Medicine

2. Psychosomatic medicine has been a specific area of concern within the field of psychiatry for more than 50 years. The term psychosomatic derived from the Greek words psyche (soul) and soma (body). The term literally refers to how the mind affects the body. psychosomatic is

3. Introduction  Psychosomatic medicine is rooted in consultation-liaison psychiatry, having expanded from a handful of general medical wards in the 1930s to specialized medical units throughout various parts of the health care delivery system. 3

4. Introduction In the medical setting, prompt recognition and evaluation of psychiatric problems are essential because psychiatric comorbidity 1 Prolongs hospital length of stay, and increases Prolongs hospital length of stay, and increases costs of care costs of care 2 Commonly exacerbates the course of medical illness, 3 Significant distress Significant distress 4

5. Introduction Practitioners in this psychiatric subspecialty assist with the care of a variety of patients, especially those with complex conditions such as  Cancer  Organ failure  HIV infection, dementia, delirium  Agitation, psychosis  Substance use disorder or withdrawal  Somatic symptom disorder, personality disorders, and mood and anxiety disorders, as well as suicidal ideation  Treatment nonadherence, and aggression and other behavioral problems 5

6. CATEGORIES OF PSYCHIATRIC DIFFERENTIAL DIAGNOSES IN THE GENERAL HOSPITAL  Psychiatric presentations of medical conditions  Psychiatric complications of medical conditions or treatments  Psychological reactions to medical conditions or treatments  Medical presentations of psychiatric conditions  Medical complications of psychiatric conditions or treatments  Comorbid medical and psychiatric conditions 6

7. Introduction  Everyone experiences somatic symptoms, and most can cope with them effectively  However, some people’s lives are overwhelmed by their somatic concerns.  Sometimes the somatic concerns stem from well-established major medical illnesses; What is common in both situations are the pervasive and sometimes, the origins of the concerns are never quite clear. overwhelming thoughts and behaviors centered on these sensations.

8. Other Specified Somatic Symptom and Related Disorder Somatic Symptom Disorder Functional Neurologic Symptom Disorder(Conversion Disorder) Somatic Symptom and related Disorder Illness Anxiety Disorder Psychological Factors Affecting Other Medical Conditions Factitious Disorder

9. THE CLINICAL PRESENTATION THE CLINICAL PRESENTATION Persons suffering from one of these disorders have one or more somatic symptoms that become all-consuming or lead to notable impairment in their day-to-day lives.

10. HISTORY hysteria,” “hypochondria,” “spleen,” “English malady,” “surmenage,” “humoral disorders,” “neurovegetative dysfunction,” “neurasthenia,” “neurovegetative dystonias,” “psychosomatic disorders In the DSM-5, the term, “somatization,” is no longer used diagnostically

11. Somatic Symptom and Related Disorders Somatic Symptom and Related Disorders  Somatic Symptom Disorder – One syndrome or many?  Internal Medicine • Chronic fatigue  Gynecology • Chronic pelvic pain  ENT • Idiopathic tinnitus  Dentistry • Temporomandibular dysfunction  Rheumatology • Fibromyalgia  GI • Irritable bowel syndrome  Neurology • Nonepileptic seizures

12. DSM IV DSM IV   DSM 5 DSM 5  Somatization disorder  Somatic Symptom Disorder  Conversion disorder  Conversion Disorder  Same but shift in focus to positive signs and neuro exam  Pain disorder  Somatic Symptom Disorder with predominant pain  also consider: Psychological Factors affecting Other Medical Conditions VS Adjustment Disorder  Hypochondriasis  Illness Anxiety Disorder  Body Dysmorphic disorder  moved to Obsessive-Compulsive and Related disorders  Undifferentiated somatoform disorder  Other Specified Somatic Symptom and Related Disorder  Somatoform disorder NOS  Unspecified Somatic Symptom and Related Disorder 12

14. رس تشپ رد دردرس میلاع اب هک تسا هلاس سا هدش عورش لبق لاس کی زا میلاع نیا دیوگ یم یو ت دهد یم ناشن رس قرف ار دردرس لحم . تدم مامت دیوگ یم دنوش یمن هنابش یرادیب ثعاب اما . نچ لاس کی یط و راب د ساسحا یتدم زین هتشذگ لاس دنک یم رکذ کی زا دعب تیاهن رد و هدرک یم تیذا ار وا هام نیدنچ هک تسا هتشاد هدعم ینیگنس تسا هدش بوخ ترفاسم . رس شزوس ساسحا و مناخ کی عجارم 65 تسا هدرک هعجارم امش هب لد دراد درد رس زور ره و . دنتسه اهدردرس زور هنابش . تسا هدرک هعجارم کشزپ هب اهنا رطاخب  . .

15. Somatic Symptom Disorder Excessive thoughts, feelings, and behaviors related to the symptoms Typically more than 6 months Somatic symptoms

17. EPIDEMIOLOGY  In general, somatic presentations are very common in all countries and cultures.  A WHO study done in nine countries of the world, showed that only one-third of patients presenting to primary care had a documentable physical illness.  At least one additional third had a mental disorder.

19. Is the absence of non Is the absence of non- -psychiatric disorder necessary for somatic symptom disorder necessary for somatic symptom disorder diagnosis? diagnosis? psychiatric disorder

20. کناب دنمراک هدرک هعجارم هاگنامرد هب شرسمه اب تسا هداد ماجنا انورک تست راب تسه هلاس ییاقا رامیب تسه انورک هب لاتبا نارگن میاد دیوگ یم شرسمه هتشذگ هام یط هتشادن ار انورک یرامیب میلاع تقو چیه دیوگ یم امش لاوس خساپ رد رامیب دوخ دهد یم ماجنا تست شدوخ شمارا یارب تسا نارگن زور کی دودح ات شیامزا زا دعب دوش یم نارگن هرابود دعب یلو تدم نیا یط لحم زا ررکم ،هام نو چ اما تسا تحار شلایخ دریگ یم یصخرم راک

21. Illness Anxiety Disorder

22. Illness Anxiety Disorder  In DSM-5, key features of health anxiety are preoccupation with physical symptoms and the belief that they may be due to a serious physical illness that persists despite medical reassurance or objective evidence on the contrary.  A belief that they have a particular disease or, as time progresses, they may transfer their belief to another disease

24. Illness Anxiety Disorder Some experts subscribe to a dimensional concept of health anxiety, according to which, these symptoms exist on a continuum from heightened awareness of bodily function to extreme delusional bodily preoccupation Delusional bodily preoccupation Health anxiety

25. دناوت یمن ، شگرزبردام توف لابندب لبق زور رب ذغاک یور طقف و دنک یمن زاب ار شناهد رامیب ، هبحاصم تدم مامت رد یا ار شنابز و دنک زاب ار شناهد دناوت یم هنیاعم رد ند هب زین هتشذگ لاس دنیوگ یم هداوناخ توف لاب دهد ناکت هتسناوت یمن ار شپچ تسد زور دنچ ، شیومع زا هک تسا هلاس رتخد کی عجارم دنک تبحص دنز یمن فرح لاصا و دسیون یم امش دنک یم هفرس، دیهاوخ یم یتقو و دهد ناکت

26. Functional Neurological Symptom Disorder A. One or more symptoms of altered voluntary motor or sensory function. B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. C. The symptom or deficit is not better explained by another medical or mental disorder. D. The symptom of deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

27. Functional Neurological Symptom Disorder Specify symptom type: With weakness or paralysis With abnormal movement ( tremor, dystonic movement, myoclonus, gait disorder) With swallowing symptoms With speech symptom (i.e., dysphonia, slurred speech) With attacks or seizures With anesthesia or sensory loss With special sensory symptom (i.e., visual, olfactory, or hearing disturbance) With mixed symptoms

28. Epidemiology  Less than 1 percent in the general population, 5 to 14 percent among general hospital medical/surgical referrals to psychiatry consultation services, and 5 to 25 percent in treated psychiatric outpatients.  The disorder appears to be more frequent in females and can be seen in children as young as 7 or 8 years old.  It is rare after the age of 35 years.

31. Psychological Factors Affecting Other Medical Conditions The A criterion for this condition is the presence of a medical symptom or condition while the B criterion, the essential feature, is the presence of one or more clinically significant psychological or behavioral factors that adversely affect a medical condition by increasing the risk for suffering, death, or disability. Severity ranges from “mild” to “extreme.”

32. Psychological Factors Affecting Other Medical Conditions Conditions Psychological Factors Affecting Other Medical A criterion • Presence of a medical symptom or condition • Presence of one or more clinically significant psychological or behavioral factors that adversely affect a medical condition by increasing the risk for suffering, death, or disability B criterion

33. Psychological Factors Affecting Other Medical Conditions Psychological distress Patterns of interpersonal interaction Coping styles, and Maladaptive health behaviors such as : Denial of symptoms Poor adherence to medical recommendations

34. Factitious Disorder These patients feign, misrepresent, simulate or cause signs or symptoms or physical illness on themselves. • Falsification of physical or psychological signs or symptoms • Induction of injury or disease • Presents self as ill, impaired, or injured • Deceptive behavior in the absence of external rewards

35. Factitious Disorder imposed on another (previously known as Factitious Disorder by proxy).

37. Clues That Should Trigger Suspicion of Factitious Disorder  The patient has sought treatment at various different hospitals or clinics  The patient is an inconsistent, selective, or misleading informant; he or she resists allowing the treatment team access to outside sources of information  The course of the illness is atypical and does not follow the natural history of the presumed disease  A remarkable number of tests, consultations, and medical and surgical treatments have been done to little or no avail  The magnitude of symptoms consistently exceeds objective pathology or symptoms have proved to be exaggerated by the patient  Some findings are discovered to have been self-induced or at least worsened through self-manipulation  The patient might eagerly agree to or request invasive medical procedures or surgery  Physical evidence of a factitious cause might be discovered during the course of treatment  The patient predicts deteriorations or there are exacerbations shortly before their scheduled discharge

38. Clues That Should Trigger Suspicion of Factitious Disorder  A diagnosis of factitious disorder has been explicitly considered by at least one healthcare professional  The patient is noncompliant with diagnostic or treatment recommendations or is disruptive on the unit  Evidence from laboratory or other tests disputes information provided by the patient  The patient has a history of work in the healthcare field  The patient engages in gratuitous, self-aggrandizing lying  The patient has been prescribed (or obtained) opiate drugs when not indicated  While seeking medical or surgical intervention, the patient opposes psychiatric assessment

39. Clues Triggering Suspicion for Factitious Disorder Imposed on Another Person  Diagnosis does not match the objective findings  Signs or symptoms are bizarre  Caregiver or suspected offender does not express relief or pleasure when told that dependent is improving or that dependent does not have a particular illness  Inconsistent histories of symptoms from different observers Caregiver insists on invasive or painful procedures or hospitalizations  Caregiver’s behavior does not match expressed distress or report of symptoms (e.g., unusually calm)

40. Clues Triggering Suspicion for Factitious Disorder Imposed on Another Person  Signs and symptoms begin only in the presence of one caregiver  Sibling or another dependent has or had an unusual or unexplained illness or death  Sensitivity to multiple environmental substances or medicines 10. Failure of the dependent’s illness to respond to its normal treatments or unusual intolerance to those treatments  Caregiver publicly solicits sympathy or donations or benefits because of the dependent’s rare illness  Extensive unusual illness history in the caregiver or caregiver’s family; caregiver’s history of somatization disorders  Caregiver seeks other medical opinions when told the dependent does not have illness  Caregiver perseverates about borderline abnormal results of no clinical relevance despite repeated reassurance, or refutes the validity of normal results

41. Other Specified Somatic Symptom and Related Disorders  Below threshold somatic syndromes  Brief somatic symptom disorder,  brief illness anxiety disorder (both with less than 6 months duration of symptoms),  Illness anxiety disorder without excessive health-related behaviors (criterion D not met)  Pseudocyesis

42. Unspecified Somatic Symptom and Related Disorders and Other BelowThreshold Somatic Symptom Syndromes Several investigators responding to the expressed need of clinicians and researchers, particularly in primary care, have proposed below- threshold subtypes that may capture many of the patients often seen in primary care who do not meet the full criteria for somatization disorder and fall into the nonspecific categories of undifferentiated somatoform disorder or somatoform disorder not otherwise specified.

43. Must establish the intentional and conscious production of symptoms

44. The following recommendations are aimed at primary care physicians and somatic specialists; they also form a basis for interventions by mental health Consider the possibility of SSD in a patient with persistent physical symptoms as early as possible; do not equate such symptoms with malingering Avoid repetitive, especially risky investigations undertaken solely to reassure and calm the patient or yourself; bear in mind that negative findings rarely provide lasting reassurance, and excessive evaluation introduces risk of additional complications and “incidentalomas” Be attentive to patient clues indicating bodily or emotional distress beyond the current main symptom and outside your specialist field. Screen for other physical symptoms, anxiety, and depression. Do not miss potential medication or alcohol misuse, or suicidal ideation

45. The following recommendations are aimed at primary care physicians and somatic specialists; they also form a basis for interventions by mental health Assess the patient’s experiences, expectations, functioning, beliefs, and illness behavior, especially in regard to catastrophizing, body checking, avoidance, and dysfunctional health care utilization If psychobehavioral criteria of SSD/IAD are present, decide whether the patient has SSD or IAD—depending on actual presence, or absence, of distressing bodily symptoms

49. Body Dysmorphic Disorder Persistent preoccupations about one or more perceived defects or flaws in one’s appearance The defects or flaws appear slight or are not observable to others. Their concerns about their appearance result in a range of mental acts or behaviors, including comparing themselves with others, checking in the mirror, or camouflaging their perceived flaws.

50. “The sole meaning of life is to serve humanity,” -Leo Tolstoy