Somatoform Disorder

Body Dysmorphic Disorder Case 1 Sarah is a 23-year-old woman who believes she has had BDD for the past eight years. When she was 15-years old she began obsessing over the shape of her nose. She had plastic surgery at 18. Two other reconstructive nose surgeries followed because she was unhappy with the results. Although many men her age feel she is attractive and often express interest in her, Sarah has stopped dating, and now rarely even goes out with her girlfriends. Obsessions over her skin and her cheekbones have also surfaced, and she has also sought consultation to have those perceived "flaws" corrected with surgery. She continues to use multiple skin care products to cover minor acne scaring, and is exploring the possibility of a cheek implant to correct what she believes to be an asymmetric appearance of her cheekbones. She has had several bouts of major depression, and has admitted herself on two occasions to a psychiatric hospital because she was seriously considering committing suicide, and she suffered one overdose of her anti-depressant medications. Case 2 Jane, a 32-year-old single Hispanic female, had been obsessed since high school with her huge nose and pock-marked skin. She reported being absolutely convinced that she looked deformed and atrocious. She could not be talked out of her beliefs. Additionally, she was convinced that people on the street took special notice of her hideous nose and skin and that they talked about her and snickered behind her back because she was so ugly. Due to these beliefs, Jane became severely depresed. She was unable to work or even leave her home. She attempted suicide twice and was hospitalized psychiatrically after both attempts. Although advised against it, Jane received two rhinoplasties for a nose that outwardly appeared normal. She also received a course of isotreninoin (Accutane). These treatments left Jane even more obsessed with her appearance and feeling more depressed because her last hopes hadnt cured her perceived ugliness. Jane underwent psychodynamic psychotherapy without any benefit. In addition, she had trials of several medications (several antipsychotics and low doses of antidepressants), which failed to improve her symptoms. Only after a trial of escitalopram (30mg/d) did Jane report improvement in her BDD symptoms. In fact, while Jane continued the medication, her improvement was sustained. After stopping the medication, however, Janes symptoms recurred. Hypochondriasis Case 1 Robert, a 38-year-old radiologist, has just returned from a 10-day stay at a famous diagnostic center where he has undergone extensive testing of his entire gastrointestinal tract. The evaluation proved negative for any significant physical illness, but rather than feel relieved, the radiologist appeared resentful and disappointed with the findings. The radiologist has been bothered for several months with various physical symptoms, which he describes as symptoms of mild abdominal pain, feelings of fullness, bowel rumblings, and a feeling of a firm abdominal mass. He has become convinced that his symptoms are due to colon cancer and has become accustomed to testing his stool for blood on a weekly basis and carefully palpating his

abdomen for masses while lying in bed every several days. He has also secretly performed Xray studies on himself. There is a history of a heart murmur that was detected when he was 13, and his younger brother died of congenital heart disease in early childhood.When the evaluation of his murmur proved it to be benign, he nonetheless began to worry that something might have been overlooked. He developed a fear that something was actually wrong with his heart, and while the fear eventually subsided, it has never entirely left him. In medical school he worried about the diseases that he learned about in pathology. Since graduating, he has repeatedly experienced concerns about his health that follow a typical pattern: noticing certain symptoms, becoming preoccupied with what the symptoms might mean, and undergoing physical evaluations that proved negative. His decision to seek a psychiatric consultation was prompted by an incident with his 9-year-old son. His son accidentally walked in on him while he was palpating his abdomen and asked, What do you think it is this time, Dad? He becomes tearful as he relates this incident, describing his feelings of shame and angermostly at himself. Case 2 A 43-year-old attorney was referred to a psychiatric physician from his gastroenterologist after repeated evaluations for abdominal cramping and alternating bowel habits. The patient continued to believe he had a serious gastrointestinal disorder, either an occult malignancy or ulcerative colitis that had not been discovered. He reported that he tended to worry about everything and had sought evaluations at a number of major diagnostic centers. Each of these evaluations ended in the similar conclusion that he suffered from irritable bowel syndrome. He admitted that this seemed reasonable, but shortly after each medical encounter, he began to worry that the physicians might have missed something or a negative laboratory result was in error. He openly admitted to a depressed mood, difficulty sleeping since he worried about having a serious illness, and other symptoms suggestive of a major mood disorder. His wife reported that being married to him was like having another child because he was constantly identifying new maladies and staying home from work. His law partners were always joking about his many complaints, and his children viewed their father as the world's greatest hypochondriac. He complained that his internist did not believe him and thus sent him to a psychiatrist as a punishment. Conversion Disorder Case 1 A young womans family brings her to the hospital and she presents with a chief complaint of spells. It seems that over the past several weeks, the patient has suffered from attacks of bilateral arm jerking, followed by bilateral leg jerking after she lowers herself to the floor. Often, her head shakes violently side to side and her eyes are seen to "roll back in her head" followed by forced eye closure. These incidents follow episodes of emotional outbursts, and the patient is fortunately able to warn others that Im about to have a seizure! After hearing this, her family grabs the patient and places her in a chair or on the ground until the spell is over, which sometimes can wax and wane for 20-30 minutes with varying intensity. These spells are not accompanied by loss of bladder or bowel continence, but often the patient bites the tip of her tongue and kicks over tables or strikes family members during an episode. This most recent spell occurred while the patient was driving her car, in which she warned of an impending seizure and pulled the car to the shoulder just before losing consciousness; her spell was much more intense than she has had in the past. She has no significant past medical history and takes no medications. She reports a past history of childhood sexual abuse from a paternal uncle several years ago. On exam, her vital signs are

normal and her neurologic evaluation is without significant findings. She is not orthostatic. Laboratory work-up, including urine toxin screen, is negative. Case 2 A 15-year-old pregnant Hispanic girl presented in the emergency room with her right elbow held in a flexion position and her left toe pointed downward in plantar extension. When asked about her symptoms, she stated with little affect that, I'll get used to it. Her presentation could not be explained by any known medical condition and she was then diagnosed with conversion disorder. Additionally, her symptoms tended to disappear with distraction. She subsequently reported that her boyfriend, who was the father of the baby, had recently started seeing another girl. She noted she was so angry with her ex-boyfriend that she wanted to hit and kick him. Yet, with her current symptoms, she could not do so.

Somatization Disorder Case 1 Ms. J is a 37-year-old woman who presents to the emergency department with abdominal pain. She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple abdominal surgeries, the most recent was for pain felt due to adhesions. These operations have failed to reduce her complaints of pain. Her physical examination, vital signs, and laboratory examination, including CBC, urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician. Ms. J's primary care physician has followed her for many years and has made the diagnosis of somatization disorder. The treatment plan includes regular frequent visits to monitor her chronic pain complaints. Use of medication with addictive potential is restricted. Physical symptoms are monitored with limited use of invasive diagnostic procedures. Outpatient visits focus on identifying sources of stress and encouraging healthy coping mechanisms. Case 2 Mr X, a 68-year-old married Chinese man who is a retired cook, reportssleep disturbances with irritability and loss of appetile for the past 6months. He has frequent headaches, dizziness, and a sensation of tightness inthe chest. Three weeks before this visit, he had several episodes of chest pain andwent to the local hospital, where he was admitted for a medical evaluation.Results of all investigations, including tests for ischemic heart disease,were normal. He was referred for psychiatric consultation. Despite sensitive probing by the psychiatrist, Mr X denies symptoms ofanxiety and depression. He has no history of psychiatric or physicalillness.