TG 7 Somatoform Des 2013 (DR - Lucky)

Neurobehavior & special sense system
TUTOR’S GUIDE SOMATOFORM DISORDERS
Case
SOMATOFORM DISORDERS
Date :
15 & 19 Desember 2014
Faculty of Medicine
Universitas Padjadjaran Bandung
2014 – 2015
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TUTORIAL
NEUROBEHAVIOR AND SPECIAL SENSE SYSTEM
(NBSS)
Title of Case : Case of Mrs. Sani
Week Theme : Somatoform disorders
Basic : Psychodynamic and Neurotransmitters related to Psychiatric disorder
Trigger case: Somatization disorder
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Case Description
In all areas of medicine, one of the most challenging classes of disorders to
diagnose and treat are somatoform disorders. Somatoform disorders comprise a
spectrum of illnesses in which psychological problems manifest as physical
symptoms and complaints. Patients with these conditions are most commonly
present to a primary care physician or an emergency room; psychiatry usually
only becomes involved late in the medical history. Somatization disorder,
conversion disorder, hypochondriasis, body dysmorphic disorder, and pain
disorder all belong to this diagnostic class.
It is important for all physicians to be aware of these conditions; early
diagnosis can save the patient from unneeded procedures and save the physician
from frustration. Somatoform disorders are seldom ”cured” and should be
approached as a chronic disease. A patient-centered approach and specific
treatments may help alleviate symptoms and distress. Most patient with
unexplained symptoms do not have somatoform disorders, but where somatoform
disorders are present, symptoms persist much longer and the cost of ambulatory
care is 9-14 times greater. With appropriate recognition and treatment, costs of
care may be reduced by 50%. Somatoform disorders are frequent among primary
care patients.
Learning objectives
After completing the topic, the learner should be able to explain:
1. Classification and diagnosis of somatoform disorder
2. Differential diagnosis of Somatoform disorders
3. Biopsychosocial model for somatoform disorder
4. Course, prognosis, and complications of somatoform disorder
5. Management of somatoform disorders
6. Indication for referral
7. Technique of stress management and time management
8. Problem solving skills
9. Complementary and alternative medicine
Duration
The duration for this topic is 3 sessions, 150 minutes each session.
Methods
Mode of delivery for this topic is tutorial
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Case Synopsis
Mrs Sani is a 32-year-old woman came to a clinic with complains of severe back
pain that is not being relieved by analgesics, aches in her upper extremities and
pain in her knee joints. She already seen many doctors but the complaint is still
persist. Mrs Sani has been sick since 3 years ago, she experienced severe
headache and difficulty with her balance, unexplained bloating and frequent
diarrhoea ‘due to certain food intolerance’, excessive menstrual bleeding and pain
during menstruation.
Mrs Sani lives with her busy husband, 2 children, and her mother. Mrs Sani has a
very busy job that makes her often comes home late almost every day and feels
very tired. At home she still has to do the house work. Her mother is very fussy
and anxious. She takes care the children and often complaint that she feels very
tired. Mrs Sani physical examination is within normal limits. She is diagnosed as
Somatization disorder. Mrs Sani follows-up regularly to her primary physician
who counsels her on the links between the mind and physical complaints and
teaches her a technique for stress management. Mrs Sani agrees to see a
psychiatrist.
References
1. Elder W. Somatoform Disorders, Factitious Disorders and Malingering. In
South-Paul, JE. Matheny, SC and Lewis, EL. Current Diagnosis and
Treatment Family Medicine. Second edition. New York. McGraw Hill. 2008.
pp 606 - 14.
2. Coulehan JL. Somatization. In Mengel MB, Schwiebert LP. Family Medicine
Ambulatory Care and Prevention. Fourth edition. Boston McGraw Hill. 2005.
pp 655-60.
3. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical
Psychiatry, 10th Edition, 2007, Lippincott Williams & Wilkins
4. WHO, mhGAP (Mental Health Gap Action Programme) Intervention Guide
for mental, neurological and substance use disorders in non-specialized health
settings, 2010
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Tutorial 1 Page 1
Mrs Sani is a 32-year-old woman, graduated from law faculty,works as staff in a

Bank, come to your clinic with complains of severe back pain that is not being
relieved by analgesics. She reports aches in her upper extremities and pain in her
knee joints. Mrs Sani already seen many doctors but the complaint is still persist.
Question:
1. Identify the problems!
2. What is your hypothesis for this patient?
3. What further information do you need?
Problems:
1. A 32-year-old woman
2. Severe back pain that is not being relieved by analgesics
3. Aches in her upper extremities
4. Pain in her knee joints
5. She already seen many other doctors but the complaint still persist.
Hypotheses:
1. Multiple pain
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Tutorial 1 Page 2
Physical Examination
Physical Exam reveals:
Vitals : BP 110/70 mmHg, HR 80x/m, RR 20x/m, temp 36,5’C
General : Mrs Sani is appeared to be in discomfort.
Head : normal
ENT : normal
Cardiovascular: normal
Respiratory : normal
Abdominal : normal
Back : normal
Neurological : normal
Laboratory Results: within normal limits

X Ray of vertebrae : normal
Question:
1. Does your hypothesis changes?
Problems:
Normal result of physical examination
Hypotheses:
1. Somatoform disorders:
- Pain disorder
- Somatization disorder
2. Factitious disorder
3. Malingering
Learning objectives
1. Different diagnosis of unexplained medical symptoms
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Tutorial 1 Page 3
The patient states that she has been sick ‘most of her life’ since 3 years ago until now.
She experienced severe headache and difficulty with her balance. She had unexplained
bloating and frequent diarrhoea ‘due to certain food intolerance’. She also had a history
of excessive menstrual bleeding and pain during menstruation.She had laparoscopic
diagnostic to confirm gynaecology problems but the doctor did not find anything.
When Mrs Sani begun to work in a Bank 4 years ago,Mrs Sani sometimes has
temporary back pain that is slight and didn’t interfere with her daily activities.
Because of these problems the patient often do not comes to her office for works and
recently she got a warning letter from her office. The patient had no certain problems
with the law or any other parties.
Mental Status Examination

General appearance: Her hygiene is fair but she looks tired. She appears to be in
discomfort.
Attitude : She answers most questions but she answer in short sentences
when psychological themes are asked.
Speech : Normal tone, volume, rate, and rhythm.
Thought process: Logical and goal-directed.
Thought content: Mrs Sani denies suicidal or homicidal ideation. There is no
evidence of delusional systems. Preoccupation about her illness
Perception : Denies auditory or visual hallucinations
Cognition : Alert and well oriented
Mood :Dysphoric
Attention and concentration: Normal
Insight : Unaware that this condition based on her psychological distress
1. What is your diagnosis?
2. How do you explain Mrs Sani’s slight and temporary back pain 4 years ago?
Problems
1. The patient has been sick ‘most of her life’ since 3 years ago until now
2. Severe headache (pain symptom)
3. Difficulty with her balance (neurological symptom)
4. Unexplained bloating and frequent diarrhoea ‘due to certain food
intolerance’ (gastrointestinal symptoms)
5. History of excessive menstrual bleeding and pain during menstruation, and
had laparoscopic diagnostic to confirm gynaecology problems but the doctor
did not find anything (sexual symptoms)
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6. Because of these problems the patient often do not comes to her office for
works and recently she got a warning letter from her office (occupational
problems due to her illness)
7. In the past Mrs Sani sometimes has temporary pain on her back that is slight
and didn’t interfere with her daily activities (somatization symptom)
8. Dysphoric mood
Hypotheses:
Somatoform disorders: Somatization disorder
Learning objectives
1. Diagnosis of Somatization disorder
2. Somatization symptoms
Tutorial 2 Page 1
Mrs Sani lives with her husband, their daughter (5 years old), their son (3 years
old), and Mrs Sani’s mother (62 years old). Her husband is a busy businessman
who goes for works early in the morning and comes home late at night. Mrs Sani
also has a very busy job that makes her often comes home late almost every day
and feels very tired. While Mrs Sani is in the office, her mother takes care for the
children. After Mrs Sani comes home, her mother will take a rest and Mrs Sani
has to do all of the house works. Her mother is very fussy and anxious, and she
often complaints that she is too old for taking cares the children and feels very
tired. Once Mrs Sani hired a housemaid but it didn’t last long because Mrs Sani’s
mother does not like her. Thesesituation makes Mrs Sanivery stressed.
Question:
1. Identify the problems!
2. What do you think about Mrs Sani family?
3. What is your management plan for this patient?
Problems:
1. Mrs Sani lives with her husband, daughter, son, and Mrs Sani’s mother
2. Her husband is a busy businessman
3. Mrs Sani has a very busy job feels very tired.
4. Mrs Sani’s mother is very fussy and anxious.
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5. Mrs Sani’s mother takes care for the children and often complaint that she
feels very tired.
6. At home Mrs Sani has to do all of the house works
7. Once Mrs Sani hired a housemaid, but her mother does not like her.
8. Mrs Sani feels very stressed.
Learning objectives
1. Psychosocial risk factor for somatization disorder
2. Management of somatization disorder (Pharmacotherapy and non
pharmacotherapy)
3. Stress management, problem solving skills, time management
Tutorial 2 Page 2
The doctor diagnoses Mrs Sani as Somatization disorder. The doctor informed
her about the links between mind and her physical complaints and teaches her a
technique for stress management and problems solving.
Questions:
1. Describe the diagnosis of somatization disorder and other somatoform
disorder!
2. Explain the biopsychosocial model for somatoform disorder!
3. Explain the complication of somatoform disorder!
4. Describe the technique of stress management!
5. Could you give Mrs Sani complementary and alternative treatment? Please
explain!
6. What is the indication for referral?
Learning Objectives:
1. Classification and diagnosis of somatoform disorder
2. Biopsychosocial model for somatoform disorder
3. Course, prognosis and complication of somatoform disorder
4. Technique of stress management
5. Indication for referral
6. Complementary and alternative medicine
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Tutorial 3
Epilogue
Mrs Sani came regularly to her primary physician. After several discussions
with her doctor, Mrs Sani agrees to be referred to a psychiatrist.
-Case ended-
BIOPSYCHOSOCIAL APPROACH
Health is traditionally equated to the absence of disease. A lack of a fundamental

pathology was thought to define one's health as good, whereas biologically driven
pathogens and conditions would render an individual with poor health and the
label "diseased". However, such a narrow scope on health limited our
understanding of wellbeing, thwarted our treatments efforts, and perhaps more
importantly, suppressed prevention measures.
Every discipline needs to delineate its area of knowledge and its basic
methodology, and then must struggle within the limits of this paradigm. Modern
medicine has opted for molecular biology as its knowledge base, with the result
that other crucial aspects of health care are often overlooked or totally ignored.
Thus a biopsychosocial model that emphasizes the unity of body, mind and social
context is warranted.
The biopsychosocial model is a scientific model constructed to take into account

the missing dimensions of the biomedical model.
In 1977, American Psychiatrist George Engel introduced the major theory in

medicine, the BPS Model. The model accounted for biological, psychological, and
sociological interconnected spectrums, each as systems of the body. In fact, the
model accompanied a dramatic shift in focus from disease to health, recognizing
that psychosocial factors (e.g. beliefs, relationships, stress) greatly impact
recovery the progression of and recuperation from illness and disease.
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Engel eloquently states:

"To provide a basis for understanding the determinants of disease and arriving at
a rational treatments and patterns of health care, a medical model must also take
into account the patient, the social context in which he lives and the
complementary system devised by society to deal with the disruptive effects of
illness, that is, the physician role and the health care system. This requires a
biopsychosocial model."
BioPsychoSocial Model of Health and Illness Venn Diagram

1. Biological, psychological, and social factors exist along a continuum of natural
systems
2. Systematic consideration of psychological and social factors requires

application of relevant social sciences, just as consideration of biological
factors requires application of relevant natural sciences. Therefore, both the
natural and social sciences are ‘basic’ to medical practice. In other words,
psychological and social factors are not merely epiphenomena: they can be
understood in scientific ways at their own levels as well as in regard to their
biological correlates.
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3. Humanistic qualities are highly valued complements to the biopsychosocial

approach, which involves the application of the scientific method to diverse
biological, psychological, and social phenomena as related to human health.
4. While the biomedical approach takes the reductionistic view that all phenomena
are best understood at the lowest level of natural systems (e.g., cellular or
molecular), the biopsychosocial approach recognizes that different clinical
scenarios may be most usefully understood scientifically at several levels of the
natural systems continuum.
To apply the biopsychosocial approach to clinical practice, the clinician should:

1. Recognize that relationships are central to providing health care
2. Use self-awareness as a diagnostic and therapeutic tool
3. Elicit the patient’s history in the context of life circumstances
4. Decide which aspects of biological, psychological, and social domains are
most important to understanding and promoting the patient’s health
5. Provide multidimensional treatment
Somatic symptoms are a prominent part of affective disorders and may be the first
indication of a major or minor affective disorder that may benefit from
psychotropic and/or psychotherapeutic treatment; however, a depression or
“stressed” explanation is likely to be met first with denial. Patients are instead
attached to some biomedical explanation, the need for tests, and for biomedical
intervention. It is a longer process to negotiate the connection between mind and
body, and may benefit from the inclusion of a psychotherapist on the treatment
team.
Twelve Principles for a Biopsychosocial Approach to Somatic Fixation
1. Use a biopsychosocial approach from the beginning. a. Begin by

interspersing biomedical and psychosocial questions in the interview. b.
Do a balanced, reasonable work-up, neither overusing tests nor avoiding
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the biological aspects of the symptoms.

2. Solicit the patient’s symptoms, but do not let the symptoms run the
interview. a. Reflect or ask a question after each sentence or two by the
patient. b. Interrupt if necessary. c. Assume a curious or perplexed posture
rather than a frustrated, intimidated, or weary posture. d. With unusual
symptoms, use unusual diagnostic procedures that allow you to remain
active (e.g., measuring the length or intensity of symptoms). e. Keep the
patient active in the diagnostic process (e.g., request a symptom diary
including both biomedical and psychosocial information about symptoms).
3. Develop a relationship with the patient and family that is collaborative.
 Avoid taking a traditional, authoritarian position or promising any

easy answers to the patient’s symptoms.
 Consider framing the patient’s symptoms as mysterious and scien-

tifically baffling, requiring the patient, family, and clinician to work
together to manage the problem.
4. See the patient at regular intervals and discourage visits to other health
providers, except on specific referral.
 Schedule regular appointments, not dictated by symptom occurrence

or intensification.
 Route all acute and chronic patient complaints through the primary
care clinician.
 Have patients avoid Emergency Department visits, medical

specialists, and inpatient treatment, unless specifically recommended
by the primary care clinician.
 When referral is indicated, be sure to talk with the consultant before-

hand and be specific about the referral question(s).
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5. Negotiate a mutually acceptable diagnosis
 Elicit the patient and family’s diagnoses of the problem.

 Explore the meaning of the symptom to the patient and family.
 Work toward mutually acceptable diagnoses or explanations for the
symptoms.
 Given their diagnoses, what treatment do they expect will be useful?
 Develop a plan that addresses both biomedical and psychosocial
aspects of the problem.
 When appropriate, collaborate with any nontraditional healers.
6. Elicit any recent stressful life events, life cycle challenges, or unresolved
family problems—ask especially about: a. A history of early abuse or
deprivation. b. Unresolved grief. c. Alcohol or drug abuse, workaholism,
and other forms of overfunctioning.
7. Invite the family to participate in the process early in treatment.a. Request

each person’s observations, diagnoses, and opinions about the illness and
the treatment. b. Listen for how the illness may have changed the typical
roles or balance of power in the family.c. Try to understand any marital
and/or transgenerational meaning for the symptom by asking: “Has anyone
else in the family had an illness that in any way resembles this one?”d.
Ask what each person is doing to help the patient with the illness. e. Ask
how family life would be different if the patient was asymptomatic.
Develop a treatment plan that the group can accept and request each
person’s help in its implementation.
8. Solicit and constantly return to the patient and family’s strengths and areas
of competence.
9. Avoid psychosocial fixation; continue with an integrated approach. a. Use
interventions that combine the biomedical and the psychosocial. b. Use
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biomedical explanations that also have psychosocial meanings (e.g., stress,

scarring, or depressed immune system).
10. Find a way to enjoy somatically fixated patients. a. Listen to the patient’s
symptoms as metaphors for their larger problems. b. Monitor both the
patient’s and your own discomfort with uncertainty. c. Discuss the case
with a clinician colleague or invite that person to consult. d. Refer or
collaborate closely with a family therapist or other mental health
consultant.
11. Judge progress in these patients by monitoring changes in their level of
functioning rather than in their symptoms.
12. Terminate the intense phase of treatment slowly.
 Caution patients from too-rapid improvement.

 Keep your own expectations low; set realistic goals.
 With some improvement, ask what problems might emerge if the
patient were to recover completely?
 Predict relapses.
 Slowly lengthen the time between office visits when the patient
experiences an increase in general level of functioning and a decrease
in the incapacitating nature of the symptoms.
 Remain available to the patient.
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SOMATOFORM DISORDERS
Current Diagnosis & Treatment in Family Medicine, 2 nd Edition, 2008
A. GENERAL CONSIDERATIONS
Somatoform disorders involve unexplained physical symptoms that bring
significant distress and functional impairment. They present one of the more
common and most difficult problems in primary care. They are seldom “cured”
and should be approached as a chronic
disease. Recognition, a patient-centered approach, and specific treatments may
help alleviate symptoms and distress.
Essential features of somatoform disorders include the following:
 Physical symptoms or irrational anxiety about illness or appearance, for
which biomedical findings are not consistent with a general medical
condition.
 Symptoms develop with or are worsened by psychologicalstress and are not
intentional.
 Symptoms that vary along a spectrum of seriousness.Somatic expression of
psychological distress is normal.Comorbid or primary mental disorders are
commonwith somatoform symptoms.
 Extensive utilization of medical care. Paradoxically,treatment and attempts to
reassure patients can becounterproductive.
 Feelings of frustration on the part of the physician.Patients are often seen as
“difficult patients.”Ten percent of all medical services are provided topatients
with no organic disease. Twenty-six percent ofprimary care patients meet
criteria for somatic “preoccupation”:19% of patients have medically
unexplainablesymptoms and 25–50% of visits involve symptomsthat have no
serious cause. Most patients with medically unexplained symptoms do not
have somatoform disorders, but where somatoform disorders are
present,symptoms persists much longer and the cost of ambulatorycare is 9–
14 times greater than in controls. Withappropriate recognition and treatment,
costs of caremay be reduced by 50%. Individuals with somatoformdisorders
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undergo numerous medical examinations,diagnostic procedures, surgeries,

and hospitalizations.They risk increased morbidity from these
procedures.Eighty-two percent stop working at some point becauseof their
difficulties.
B. PATHOGENESIS
 To some degree, somatoform symptoms should be considered normal. Bodily
experiences of emotions are common. Examples include anger in the jaw,
tension in the shoulders, loss in the chest, disappointment in the gut, shame in
the reddening face, fear in the bowels,and so on.
 Regarding somatoform disorders, some individuals are susceptible to
overexperiencing sensations, apparentlythrough a difference in gating, which
is worsened by anxiety or psychological stress. Other individuals demonstrate
obsessive tendencies. Fears of disease may form. A viciousprocess of
symptom amplification has been demonstratedin hypochondriasis whereby
obsession about the bodyfocuses attention on sensations, which when
misinterpretedcause anxiety, increasing sensations and furtherworsening
obsessiveness. Perceptual disturbances andbodily concerns apparent in body
dysmorphic disorderare similar to obsessive-compulsive disorders but
whenextreme may suggest a mild thought disorder.
 Because families differ in how they respond to symptomsand illnesses,
individual differences in health beliefsand illness-related behaviors are to be
expected. Families also shape the tendency to experience, display, and
magnify somatic symptoms; thus, somatoform disorders ormalingering may
be modeled or reinforced by adults.Social factors include single parenthood,
living alone,unemployment, and marital and job difficulties.
 Western medicine’s dominant conceptualization ofthe mechanism of
somatoform symptoms is that of somatization,a process in which mental
phenomena such as emotions manifest as physical symptoms. As a
concept,somatization assumes psychopathology. It originated in
psychoanalytic theory, where it was considered a primitive, psychological
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defense against unconscious conflicts,needs, and desires that the individual

was too weak toexpress. The notion of somatization as a defense has some
clinical utility and constitutes an improvement overbeliefs that some feminine
physical complaints reflect a uterus loose in the body, hence the term
hysterical, derived from the Greek word for uterus. However, thenotion of
somatization as pathologic ignores the normalcy of physical expression of
emotions and the social construction of illness behaviors, including the belief
thatconventional medical treatments such as medication andsurgery can solve
most problems.
C. CLINICAL FINDINGS
a. Symptoms And Signs
Somatoform symptoms can suggest a large number of general medical
conditions. However, in addition toruling out general medical conditions,
diagnosis mayalso be made by nclusion. The following featuresshould increase
suspicion of a somatoform presentation:
 Unexplained symptoms that are chronic or constantly change.
 Multiple symptoms. Four symptoms in men and sixin women suggest
somatic preoccupation. Fainting,menstrual problems, headache, chest pain,
dizziness,and palpitations are the symptoms most likely to besomatoform.
 Vague or highly personalized, idiosyncratic complaints.
 Inability of more than three physicians to make a diagnosis.
 Presence of another mental disorder, especially depressive,anxiety, or
substance use disorders.
 Distrust toward the physician.
 Physician experience of frustration.
 Paradoxic worsening of symptoms with treatment.
 High utilization, including repeated visits, frequenttelephone calls,
multiple medications, and repeatedsubspecialty referrals.
 Disproportionate disability and role impairment.
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b. Diagnostic Criteria
Somatoform disorders are mental disorders that involvephysical symptoms or
irrational anxiety about illness orappearance, and for which biomedical
findings are notconsistent with a general medical condition. Diagnosisrequires
a finding that the symptoms have broughtunneeded medical treatment or that
there is significantimpairment in social, occupational, or other importantareas
of functioning. Somatoform disorders cannot becaused by another mental
condition or by direct effectsof substances. If the disorder occurs in the
presence of ageneral medical condition, complaints or impairmentmust be in
excess of what would be expected from thephysical findings and history.
1. Somatization disorder
This persistent pattern ofrecurring, multiple somatic complaints begins
beforeage 30. Patients view themselves as “sickly.” Current diagnostic
criteria are more extensive, requiring ahistory of pain related to at least four
different sites or functions, two gastrointestinal symptoms other thanpain,
one sexual symptom other than pain, and onepseudoneurologic symptom
other than pain.
 Commonsites of pain include the head, abdomen, back,
joints,extremities, chest, and rectum and common functionsinclude
pain during menstruation, during sexual intercourse,or during
urination.
 Common gastrointestinal symptoms include nausea, bloating,
diarrhea, or multiplefood intolerances.
 Sexual symptoms include sexualindifference, sexual dysfunction, and
menstrual problems.
 Pseudoneurologic symptoms can be motor related(eg, impaired
coordination or balance, paralysis or localized weakness, difficulty
swallowing including“lump in throat,” aphonia, and urinary retention)
orsensory-perceptual (eg, minor hallucinations, loss oftouch or pain
sensation, double vision, blindness, anddeafness). Seizures, amnesia,
and loss of consciousnessare also possible.
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2. Undifferentiated somatoform disorder

This is aresidual diagnosis for clinically significant, somatoformcomplaints
persisting for more than 6 months. Examplesinclude chronic fatigue,
weakness, and anorexia as well asthe symptoms described with regard to
somatization disorder,when insufficient in number to meet
diagnosticcriteria for somatization disorder.
3. Conversion disorder (formerly hysterical conversiondisorder)

This consists solely of pseudoneurologicsymptoms such as those described
with somatizationdisorder (ie, deficits affecting the central nervous
system,voluntary motor or sensory functions). Psychological factorsin the
form of stressors or emotional conflicts areexpected and precede the
symptoms. Depending on themedical naivete of the patient, symptoms are
often quiteimplausible, not conforming to anatomic pathways orphysiologic
mechanisms. Symptoms may symbolically representemotional conflicts,
such as arm immobility, as anexpression of anger and impotence. Other
clues indicatingthat the symptoms are pseudoneurologic include
worseningin the presence of others; noninjuries despite dramaticfalls;
normal reflexes, muscle tone, and pupillary reactions;and striking
inconsistencies on repeated examinations.Symptoms may be experienced
with a relative lack of concern(so-called la belle indifference) but dramatic
or histrionicpresentations are more common. Course is an
importantconsideration. Conversion disorder is rare before age10 or after
age 35 years. Symptoms are transient, rarelylasting beyond 2 weeks, and
respond to reassurance, suggestion,and psychological support. Secondary
gain, seenin malingering, may be apparent but is not primary inconversion
disorders.
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4. Pain disorder associated with psychological factors

This disorder is the psychiatric equivalent ofchronic nonmalignant pain
syndrome, except that nominimum duration of symptoms is required.
Psychologicalfactors play a significant role in the pain picture,including its
onset, severity, exacerbation, and maintenance.Physical pathologies are
possible and frequentbut organic findings are insufficient to explain
theseverity of the pain. Common sites for pain include thelower back,
neck, pelvis, and head. Patients with thisdisorder may follow a downward
spiral of poor functioning,especially if they lack adequate skills to
adaptivelycope with their losses of physical functioning andsituational
changes. The experience of pain will severelydisrupt patients’ lives; thus
functional deficits are common,including disability, increased use of the
healthcare system, abuse of medications, and relational andvocational
disruptions. Depression or anxiety may besecondary or may also be
primary or comorbid, predisposingthe patient to an increased experience of
pain aswell as a deficient ability to cope with the illness situation.Patients
with severe depression or with terminalconditions are at increased risk of
suicide. Insomnia isfrequently associated with pain complaints.
5. Hypochondriasis
The individual with hypochondriasisis preoccupied with fears of having a
serious disease.The preoccupation may originate in an overfocuson and
misinterpretation of normal physiologic sensations(eg, orthostatic
dizziness), erroneous attributionsabout the body (eg, “aching veins”), or
obsession aboutminor physical abnormalities. Patients are easily
alarmedwhen hearing of new diseases or knowing someone whois sick.
Fears persist despite medical reassurance. Hypochondriacalconcerns (ie,
attention to symptoms and fearof death) are common in panic disorders. In
the case ofconcerns about physical abnormalities, the individualmust
believe that the abnormality indicates the presenceof a disease; otherwise a
diagnosis of body dysmorphicdisorder is more appropriate.
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6. Body dysmorphic disorder

This disorder involvesexcessive preoccupation with a minor or imagined
defect ofone or more body parts. Concern may not focus exclusivelyon a
false belief one is obese, which would indicatean eating disorder. Although
many people are concernedabout their appearance, the concerns and
behaviors associatedwith this disorder are extreme, distressing, time
consuming,and debilitating. Self-consciousness is significant,and avoidance
of public exposure, hiding of defects, andnondisclosure to the physician are
common. Medical, dental,and surgical treatments are sought but may
onlyworsen preoccupations. Concerns about appropriateness ofsexual
characteristics may be better represented in a diagnosisof gender identity
disorder. Concerns about appearanceare common during major depressive
episodes. Patientswho insist that an imagined defect is real and hideous
willmeet the criteria for delusional disorder, somatic type.
7. Malingering, factitious disorder, and factitious disorder by proxy

These are not somatoform disorders;symptoms are voluntary and deceptive.
Deception isobtained by feigning or self-inducing symptoms or by
falsifyinghistories or laboratory findings. Common symptomsinclude fever,
self-mutilation, hemorrhage, and seizures.Malingering and factitious
disorder differ bywhether symptom gain is primary or secondary.
Inmalingering, symptoms are produced to gain rewards oravoid
punishments (secondary gains). Factitious disorderinvolves production of
symptoms in order to assume thesick role (primary gain). Unlike
malingering, factitious disorderis considered a mental disorder principally
becausethe need to be in the sick role is abnormal. Factitious disorderby
proxy occurs when illness is caused by a caregiver,typically to meet a need
for drama and to be a rescuer ofthe patient. Direct evidence, such as
inconsistent laboratoryor physical findings or observations (eg, injection
ofbacteria), may be the first sign that symptoms are intentional.Earlier signs
of factitious disorder include patientswho are migratory or have no visitors,
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are comfortablewith more aggressive treatments including extended

hospitalization,are connected in some manner with the healthprofessions, or
whose presentation is exaggerated and quitedramatic (Munchausen
syndrome).
C. SCREENING AND DIAGNOSTIC MEASURES

Valid diagnostic and screening questionnaires exist, butoften lack clinical
utility in comparison to an interview.Where doubts remain, a referral for
evaluation is probablyin order. Asking questions about depressed mood
andhopelessness or loss of interest has great sensitivity fordepressive disorder,
if the depression is not occult. Questionsshould address cognitive symptoms,
such as guiltand lowered self-esteem, endorsement of which may
suggestdepression even in the absence of sad mood. Questionsshould also
evaluate patients suspected of havingbody dysmorphic disorder
D. DIFFERENTIAL DIAGNOSIS
Diagnosis should be considered tentative and provisionaluntil there is
considerable external support. General medical conditions characterized by
multiple andconfusing somatic symptoms (eg, hyperparathyroidism,porphyria,
multiple sclerosis, and systemic lupuserythematosus) should be considered.
Conversion disorder,in particular, is often misdiagnosed, with medical diagnoses
eventually replacing up to 50% of conversion diagnoses. Shaibani and Sabbagh
have described several clinical tests that may reveal whether conversion
symptoms are pseudoneurologic. Onset of multiple physicalsymptoms in early
adulthood suggests somatization disorderbut in the elderly suggests a general
medical condition. Primary or secondary depression should be considered in any
patient suspected of having somatoformdisorder. Other mental disorders,
including anxiety disordersand substance-related disorders, are frequentlyseen
with somatoform disorders and in some cases maybetter explain symptoms and
thus constitute the betterdiagnosis. Personality disorders (eg, histrionic,
23
borderline,or antisocial personality disorder) are also frequently associated with

somatoform disorders.
E. COMPLICATIONS
Failure to recognize and properly treat somatoform complaints can lead to
excessive diagnostic procedures and treatments, which perpetuate patient
preoccupations and place the patient at risk for iatrogenic disorders. Use of
unidentified, unconventional, or alternativetreatments by patients with
somatoform disorders may interact negatively with prescribed medications.
Dependencies on sedative, analgesic, or narcotic agents are common iatrogenic
complications.
F. TREATMENT
Characterizing medically unexplained symptoms as pathologic may lead
physicians to misconstrue patients as solely suffering from a psychiatric disorder.
In reality, primary care patients are usually quite different from those seen
inspecialty psychiatric care. The notion and usefulness of discrete disease entities
are problematic to begin with. Primary care patients present with undifferentiated
symptoms that are best addressed with a comprehensive approach that includes
continuity of care and attention to the physician–patient relationship.
“Pathologizing” makes patients feel illegitimate, in itself a major source of
distress, and produces stereotypes of patients as “crocks, whiners, or difficult.”If
this happens, the relevance of the patient’s experience and the potential of
partnership between patient and physician are both obviated. A patient-centered
method, so important to family practice, becomes impossible. Patients who
consider their physicians as patient centered are more satisfied with care, are
referred less, and receive fewer diagnostic tests. Even without attributions of a
mental disorder, somatoform symptoms present one of the most
difficultchallenges in primary care. Patient characteristics considered as difficult
include extensive or exaggerated complaints, nonadherence with treatment
recommendations, and behaviors that raise suspicion of seeking drugs.
24
Uncertainties associated with the diagnosis, the sense that the focus is not medical
and therefore the interaction is inappropriate, patient symptom amplification, and
the sense that services are being overused inappropriately contribute to the
perception that the patient is difficult. Furthermore, most physicians sought their
career in order to cure people; treatment of people with these chronic conditions
conflicts with that goal.
1. GENERAL RECOMMENDATIONS
Somatoform symptoms exist on a continuum and shouldrarely indicate that the
patient’s difficulties are to beattributed solely to a mental disorder.
Comprehensive,continuous, patient-centered care appropriately addressesmost
primary care patient presentations. The followinggeneral recommendations
apply to such an approach.
a. First visits—A therapeutic alliance should be built by a thorough history
and physical examination and by areview of the patient’s records. The
physician should show curiosity and interest in the patient’s complaints
and validatethe patient’s suffering. Psychogenic attributionsshould be
avoided. To appear puzzled initially is a goodstrategy. Delivery of a
diagnosis is a key treatment stepwith somatoform disorders. Different
disorders require different types of information.
b. Management—The disorder should be treated as achronic illness, with
the focus on functioning rather thansymptom cure. Gradual change should
be expected, withperiods of improvement and relapse. Physicians
shouldpractice secondary prevention, especially of iatrogenic harm.When
new symptoms arise, at least a limited physical examinationshould be
performed. However, invasive diagnosticand therapeutic procedures
should be permitted only on thebasis of objective evidence, not subjective
complaints. Theneed for unnecessary tests and procedures can be avoided
byhaving the patient feel “known” by the physician.
c. Patient-centered care—Feelings of illegitimacy by patients and common
physician attitudes towardmpatients contribute to power differentials and
25
struggles.These can be avoided by practicing the relational behaviors

patients prefer from their providers. Physicians should speak with patients
as equals, listen well, ask lots of questions, answer lots of questions,
explain things understandably, and allow patients to make decisions about
their care. A collaborative relationshipshould be developed in which the
physician workstogether with the patient to understand and managepatient
problems. The “common ground” shared by thephysician and the patient
should be monitored and differencesdiscussed.
d. Office visits—Regular, brief appointments shouldbe scheduled, thus
avoiding “as-needed” medicationsand office visits that make medical
attention contingenton symptoms. Practical time-related strategies
includenegotiating and setting the agenda early in the visit,paying attention
to the emotional agenda, listeningactively rather than in a controlling
manner, solicitingthe patient’s attributions for the problems, and
communicatingempathetically.
e. Psychosocial issues—Reassurance should be provided to the patient, but
not too soon. Psychosocial questions should be interspersed with
biomedical ones to explore all issues: physiologic, anatomic, social,
family, and psychological. The physician should inquire about trauma and
abuse. As trust builds, the patient should be encouraged to explore
psychological issuesthat may be related to symptoms. In this way,
symptomscan be linked to the patient’s life and feelings. The term stress
should not be overused. Eventually and subtly,patients are likely to reveal
their personal side andconcerns.
f. Family involvement—Family members should be invited to participate in
patients’ visits. An occasionalfamily conference can be valuable. Each
person’s opinionabout the illness and treatment can be solicited, and
familymembers can be asked how family life would be differentif the
patient were without symptoms. Physicians should solicit and constantly
return to the patient’s andfamily’s strengths and areas of competence.
26
2. PHARMACOTHERAPY
Because these patients may be extremely sensitive to sideeffects,
psychopharmacologic agents generally should not be used unless the patient
has a demonstrated pharmacologicallyresponsive mental disorder such as major
depression, generalized anxiety disorder, panic disorder,or obsessive-
compulsive disorder.
Selective serotoninreuptake inhibitors (SSRIs), other nontricyclic
antidepressants,and benzodiazepines are the medications most frequently used
for coexisting psychiatric conditions. Treatment should be initiated at
subtherapeutic doses and increased very gradually, as described elsewhere.
Hypochondriasis and body dysmorphic disorders are similar to obsessive-
compulsive disorder and patients with these disorders may benefit directly
from higher doses of SSRIs, if side effects are tolerated. Those with transitorily
extreme dysmorphic concerns may benefit from temporary treatment with an
atypical antipsychotic medication
.
3. CONSULTATION OR REFERRAL
Involvement of a mental health clinician may be helpful to diagnose comorbid
mental conditions, offer suggestions for psychotropic medications, and engage
some unlikely to see the value of consultation or may experiencereferral as an
accusation that their symptoms arenot authentic. Pressuring the patient to
accept a consultationis unlikely to be effective and may render theconsultant
encounter unproductive. Trust must first beestablished and psychological
issues must be made alegitimate subject for discussion. The idea of referralcan
be reintroduced later. When possible, it can bemore effective to see the patient
along with the mentalhealth clinician so that a comprehensive approach
continuesto be emphasized, the patient does not feel abandoned,and doubts that
the patient’s concerns are nottaken seriously are alleviated. Extreme distress or
preoccupationsworsening to delusional levels may requireinpatient
hospitalization.
27
4. PSYCHOTHERAPEUTIC INTERVENTIONS
Standardized group or individual cognitive-behavioraltherapies can be an
effective treatment for chronicsomatoform disorders, reducing somatic
symptoms,distress, impairment, and medical care utilization andcosts.
Cognitive interventions train the patient to identifyand restructure
dysfunctional beliefs and assumptionsabout health. Behaviorally, the patient is
encouragedto experiment with activities that are counter tousual practices, such
as avoidance, “doctor shopping,”or excess seeking of reassurance. In addition,
patientslearn relaxation and meditation techniques to managesymptoms of
anxiety. Patients with high emotional distressrespond more rapidly to
psychotherapy andpatients able to at least partially attribute symptoms
topsychological factors show better therapeutic outcomesthan patients who
firmly believe that their physicalsymptoms have a physical cause.
5. COMPLEMENTARY AND ALTERNATIVE THERAPIES

It is to be expected that patients with somatoformsymptoms often try
alternative treatments such asherbal remedies, mind–body interventions, and
othernonwestern medical approaches. In these patients, conventionaltreatments
appear to have failed, distrust ofphysicians may be high, and distress is great.
Federalregulations require that label claims and instructions onherbal products
and supplements address symptomsonly; therefore, there are no specific herbal
agents forsomatoform disorders, per se. Given the plethora ofsymptoms that
can exist in patients with somatoformdisorders, it is not surprising that there
are numerousalternative medications that patients may try.Patients with pain
disorder or primary or comorbidanxiety may benefit from body and mind–body
interventionssuch as massage, movement therapies, manipulations,relaxation,
guided imagery, and hypnosis. Theplacebo effect of various remedies may be
helpful, particularlyif the agents are largely inert, as bothersomeside effects
seen in conventional medicines will befavorably avoided. Alternative therapies
often include“nonspecific therapeutic effects” that go beyond theplacebo effect
and can be beneficial. Nonspecific effectsinclude warmth and listening skills of
28
the practitioner,empowerment that comes from legitimization of thepatient’s

problem, and an egalitarian approach to care.These may be recognized as
important constituents ofthe patient-centered approach. Physicians may wish
torecommend alternative treatments and collaborate withalternative
practitioners but should also be prepared toprotect the patient by cautioning
against treatmentsthat are potentially harmful, excessively expensive, orthat
circumvent conventional treatments that areneeded for demonstrated medical
conditions.
6. STRESS MANAGEMENT
The causes of stress are multiple and varied but they can be classified in two
general groups: external and internal. External stressors can include relatives
getting sick or dying, jobs being lost or people criticizing or becoming angry.
However, most of the stress that most of us have is self-generated (internal).
There are many ways to relieve stress, from going for a walk to quitting your job.
What follows is a list of 10 practical and down-to-earth strategies, which helpful
over the years. Some are simple and can be implemented quickly; others are a bit
more involved. All are feasible and beneficial.
1. Decrease or Discontinue Caffeine
In terms of "bang for the buck," it is hard to beat this simple intervention. Most
patients do not realize that caffeine (coffee, tea, chocolate and cola) is a drug, a
strong stimulant that actually generates a stress reaction in the body. The best way
to observe the effect of caffeine is to get it out of the system long enough to see if
there is a difference in how they feel.
29
2. Regular Exercise
As a way of draining off stress energy, nothing beats aerobic exercise. To

understand why, we need to review what stress is. People often think of stress as
pressure at work, a demanding boss, a sick child or rush-hour traffic. All these
may be triggers but stress is actually the body's reaction to factors such as these.
Stress is the fight-or-flight response in the body, mediated by adrenaline and other
stress hormones, and comprised of such physiologic changes as increased heart
rate and blood pressure, faster breathing, muscle tension, dilated pupils, dry
mouth and increased blood sugar. In other words, stress is the state of increased
arousal necessary for an organism to defend itself at a time of danger.
The stress reaction is in us, not "out there." It provides us with the strength and
energy to either fight or run away from danger and is therefore self-protective.
There is only one problem: unlike a caveman being attacked by a wild animal or
warring tribesman, fighting and running away are rarely appropriate responses to
stressful situations in the modern world. The result is that our bodies go into a
state of high energy but there is usually no place for that energy to go; therefore,
our bodies can stay in a state of arousal for hours at a time.
Exercise is the most logical way to dissipate this excess energy. It is what our
bodies are trying to do when we pace around or tap our legs and fingers. It is
much better to channel it into a more complete form of exercise like a brisk walk,
a run, a bike ride or a game of squash. During times of high stress, we could
benefit from an immediate physical outlet - but this often is not possible.
However, regular exercise can drain off ongoing stress and keep things under
control. I recommend physical activity every day or two. At the very least, it is
important to exercise three times per week for a minimum of 30 minutes each
time. Aerobic activities like walking, jogging, swimming, bicycling, racquet
sports, skiing, aerobics classes and dancing are suitable. Choose things you like or
they will feel like a chore and you will begin to avoid them. It is also beneficial to
30
have a variety of exercise outlets. I have never met a patient who did not feel
better with some form of regular exercise - and I know I could not exist without it.
For chronic or acute stress, exercise is an essential ingredient in any stress
reduction program.
3. Relaxation/Meditation
Another way to reduce stress in the body is through certain disciplines which fall
under the heading of relaxation techniques.
Where the stress reaction is automatic, however, the relaxation response needs to
be brought forth by intention. Fortunately, there are many ways of doing this.
Sitting quietly by a lake or fireplace, gently petting the family cat, lying on a
hammock and other restful activities can generate this state. There also are
specific skills that can be learned which are efficient and beneficial. A state of
deep relaxation achieved through meditation or self-hypnosis is actually more
physiologically restful than sleep. These techniques are best learned through
formal training courses which are taught in a variety of places. Books and
relaxation tapes can be used when courses are not available or are beyond the
patient's budget.
4. Sleep
As mundane as it sounds, sleep is an important way of reducing stress.

Chronically stressed patients almost all suffer from fatigue (in some cases
resulting from stress-induced insomnia), and people who are tired do not cope
well with stressful situations. These dynamics can create a vicious cycle. When
distressed patients get more sleep, they feel better and are more resilient and
adaptable in dealing with day-to-day events. Most people know what their usual
sleep requirement is (the range is five to 10 hours per night; the average being
seven to eight), but a surprisingly large percentage of the population is chronically
31
sleep deprived. The three criteria of success are waking refreshed, good daytime
energy and waking naturally before the alarm goes off in the morning.
Sleeping-in is fine but if you sleep too long, it throws off your body rhythms
during the following day. It is better to go to bed earlier. Daytime naps are an
interesting phenomenon. They can be valuable if they are short and timed
properly (i.e., not in the evening). The "power nap" or catnap is a short sleep (five
to 20 minutes) that can be rejuvenating. A nap lasting more than 30 minutes can
make you feel groggy. Patients with insomnia should be discouraged from
daytime naps. Beyond these cautionary notes, sleep can be key in reducing stress
and helping patients cope and function better.
5. Time-outs and Leisure
No one would expect a hockey player to play an entire game without taking
breaks. Surprisingly though, many otherwise rational people think nothing of
working from dawn to dusk without taking intermissions, and then wonder why
they become distressed. The two major issues are pacing and work/leisure
balance.
Pacing has two components: monitoring your stress and energy level, and then
pacing yourself accordingly. It is about awareness and vigilance; knowing when
to extend yourself and when to ease up. It is also about acting on the information
your body gives you.
6. Realistic Expectations
A common source of stress is unrealistic expectations. People often become upset

about something, not because it is innately stressful, but because it does not
concur with what they expected. Take, for example, the experience of driving in
slow-moving traffic. If it happens at rush hour, you may not like it but it will not
surprise or upset you. However, if it occurs on a Sunday afternoon, especially if it
32
makes you late for something, you are more likely to be stressed by it.
When expectations are realistic, life feels more predictable and therefore more
manageable. There is an increased feeling of control because you can plan and
prepare yourself (physically and psychologically). For example, if you know in
advance when you have to work overtime or stay late, you will take it more in
stride than when it is dropped on you at the last minute.
There is much we can do to help patients by letting them know when their
expectations (of themselves and others) are unrealistic.
7. Reframing
Reframing is a technique used to change the way you look at things in order to
feel better about them.
The key to reframing is to recognize that there are many ways to interpret the
same situation. One of the things we can do with patients is help them reframe
stressful situations. This most often involves helping them see positives in a
negative situation and assisting them in understanding the behavior of other
people. It is best to get the patient to provide the input first (to which you can add
later) by asking certain questions. The information is more meaningful when it
comes from them.
Notice that reframing does not change the external reality but simply helps people
view things differently (and less stressfully). It should be done with a bit of
preamble to explain the premise (e.g., using the glass half empty as an illustration)
and only after you have acknowledged the validity of the patient's initial
(stressful) interpretation. You are not trying to disrespect their point of view but
only to suggest there are other, less stressful ways of looking at the same thing.
33
8. Belief Systems
A lot of stress results from our beliefs. Beliefs cause stress in two ways. The first
is the behavior that results from them. For example, if you believe that work
should come before pleasure, you are likely to work harder and have less leisure
time than you would otherwise. If you believe that people should meet the needs
of others before they meet their own, you are likely to neglect yourself to some
extent. Several patients tell me, "If you want something done right, you have to do
it yourself." They do not delegate well and tend to get overloaded.
In the above three cases, the beliefs are expressions of people's philosophy or
value system, but all lead to increased effort and decreased relaxation - a formula
for stress. There is no objective truth to begin with. These are really just opinions
but they lead to stressful behavior. Helping patients uncover the unconscious
assumptions behind their actions can be helpful in getting them to change.
The second way beliefs cause stress is when they are in conflict with those of
other people.
We can do much for patients by getting them to articulate their beliefs and then to
label them as such. Next, we need to help them acknowledge that their
assumptions are not truth but rather opinions and, therefore, they can be
challenged. Lastly, we can help patients revise their beliefs or at least admit that
the beliefs held by the other person may be just as valid as their own. This is a
mind-opening exercise and usually diminishes the upset the patient was
experiencing.
9. Ventilation/Support System
We have all had patients who come into the office upset, talking incessantly about
a problem, and feeling better when they are finished. They have told their story,
cried or made some admission, and the act of doing so in the presence of a trusted
34
and empathic listener has been therapeutic. We often do not have to say much. We
just have to be there, listen attentively and show our concern and caring. On other
occasions we might offer validation, encouragement or advice. But the
combination of the patient being able to ventilate and our support can be
profoundly beneficial.
Another form of ventilation that many patients find helpful is writing, for example
in a private journal at home. Former tennis star Guillermo Vilas once said: "When
my life is going well, I live it. When it's not going well, I write it." When patients
are angry, I often suggest they write a letter to the person at whom they are vexed.
These letters are not for sending; they should be destroyed once they are written -
unread. The value is in expressing the feelings and getting them out. Rereading
the letter just reinforces the upset and fans the flames of anger all over again.
10. Humor
Humor is a wonderful stress reducer, an antidote to upsets. Laughter relieves

tension. In fact, we often laugh hardest when we have been feeling most tense.
Humor is an individual thing - what is funny to one individual may be hurtful to

another. It is wonderful when patients can poke fun at themselves. We can also do
this with patients, but we have to be careful and respectful in what we say. If you
think of something funny that may help the patient, say it if you feel it will ease
their tension and not be offensive.
35

TG 7 Somatoform Des 2013 (DR - Lucky)

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Neurobehavior & special sense system

TUTOR’S GUIDE SOMATOFORM DISORDERS

15 & 19 Desember 2014

TUTOR’S GUIDE SOMATOFORM DISORDERS

NEUROBEHAVIOR AND SPECIAL SENSE SYSTEM

Title of Case : Case of Mrs. Sani

Week Theme : Somatoform disorders

Basic : Psychodynamic and Neurotransmitters related to Psychiatric disorder

Trigger case: Somatization disorder

TUTOR’S GUIDE SOMATOFORM DISORDERS

TUTOR’S GUIDE SOMATOFORM DISORDERS

TUTOR’S GUIDE SOMATOFORM DISORDERS

Mrs Sani is a 32-year-old woman, graduated from law faculty,works as staff in a

TUTOR’S GUIDE SOMATOFORM DISORDERS

Laboratory Results: within normal limits

1. Different diagnosis of unexplained medical symptoms

TUTOR’S GUIDE SOMATOFORM DISORDERS

Mental Status Examination

TUTOR’S GUIDE SOMATOFORM DISORDERS

TUTOR’S GUIDE SOMATOFORM DISORDERS

TUTOR’S GUIDE SOMATOFORM DISORDERS

Health is traditionally equated to the absence of disease. A lack of a fundamental

The biopsychosocial model is a scientific model constructed to take into account

In 1977, American Psychiatrist George Engel introduced the major theory in

TUTOR’S GUIDE SOMATOFORM DISORDERS

Engel eloquently states:

BioPsychoSocial Model of Health and Illness Venn Diagram

2. Systematic consideration of psychological and social factors requires

TUTOR’S GUIDE SOMATOFORM DISORDERS

3. Humanistic qualities are highly valued complements to the biopsychosocial

To apply the biopsychosocial approach to clinical practice, the clinician should:

Twelve Principles for a Biopsychosocial Approach to Somatic Fixation

1. Use a biopsychosocial approach from the beginning. a. Begin by

TUTOR’S GUIDE SOMATOFORM DISORDERS

the biological aspects of the symptoms.

 Avoid taking a traditional, authoritarian position or promising any

 Consider framing the patient’s symptoms as mysterious and scien-

 Schedule regular appointments, not dictated by symptom occurrence

 Have patients avoid Emergency Department visits, medical

 When referral is indicated, be sure to talk with the consultant before-

TUTOR’S GUIDE SOMATOFORM DISORDERS

5. Negotiate a mutually acceptable diagnosis

 Elicit the patient and family’s diagnoses of the problem.

7. Invite the family to participate in the process early in treatment.a. Request

TUTOR’S GUIDE SOMATOFORM DISORDERS

biomedical explanations that also have psychosocial meanings (e.g., stress,

12. Terminate the intense phase of treatment slowly.

 Caution patients from too-rapid improvement.

TUTOR’S GUIDE SOMATOFORM DISORDERS

TUTOR’S GUIDE SOMATOFORM DISORDERS

undergo numerous medical examinations,diagnostic procedures, surgeries,

TUTOR’S GUIDE SOMATOFORM DISORDERS

defense against unconscious conflicts,needs, and desires that the individual

TUTOR’S GUIDE SOMATOFORM DISORDERS

TUTOR’S GUIDE SOMATOFORM DISORDERS

2. Undifferentiated somatoform disorder

3. Conversion disorder (formerly hysterical conversiondisorder)

TUTOR’S GUIDE SOMATOFORM DISORDERS

4. Pain disorder associated with psychological factors

TUTOR’S GUIDE SOMATOFORM DISORDERS

6. Body dysmorphic disorder

7. Malingering, factitious disorder, and factitious disorder by proxy