Professional Documents
Culture Documents
Somatoform Disorders
Somatoform Disorders
Behavioral Science II
"For each ailment that doctors cure with medications (as I am told
they do occasionally succeed in doing) they produce 10 others in
healthy individuals by inoculating them with that pathogenic agent
1000 times more virulent than all the microbes--the idea that they are
ill."
---Marcel Proust
Objectives
Review diagnostic criteria for Somatoform
Disorders
Identify symptom presentation of
somatoform and somatization
Review patient management and treatment
strategies for somatoform and somatization
symptoms
Case example #1
A 46 year old divorced female with no history of chronic medical illness
presents to the ER with right side upper and lower extremity weakness,
shortness of breath, unsteady gait, fainting spells, and difficulty speaking.
Neurological insult is ruled out and medical tests are unremarkable. Her
normal personality style is shy and soft spoken. She reports a recent
traumatic, severely emotional experience at work. You should explore which
of the following?
A. Malingering
B.
Conversion
C. Hypochondriasis
D. Factitious disorder
E. Panic disorder
Case example #2
Harold is a 30-year-old male. For the past 5 years he has become more
and more worried about the shape and size of his nose. He feels it is too
big for his face and is asymmetrical, this results in feelings of
embarrassment. He has recently refused to go to several work parties
because of the way his nose looks. He has started growing a mustache
which he hopes will help to hide the problem. What is his most likely
diagnosis?
A. Hypochondriasis
B . Body Dysmorphic Disorder
C. Somatization Disorder
D. Conversion Disorder
E. Undifferenitated Somatoform Disorder
Somatoform Disorders
The blind spot of medicine
Physical symptoms without identified
pathology or beyond expected medical
findings
NOT factitious and NOT malingering
NOT intentionally produced.
{keep in mind that many conditions are misdiagnosed and
symptoms can be progressive}
DSM IV TR
Conversion Disorder unexplained symptoms or
deficits affecting voluntary motor or sensory functions
that suggest neurological or general medical condition.
Psychological issues are thought to play a key role.
DSM IV TR
Hypochondriasis preoccupation with fear of
having, or the idea that one has a serious disease.
Based on misinterpretation of bodily symptoms or
functions.
Somatization
Somatization is the primary characteristic of
somatoform disorders and is characterized by:
1. In the absence of identified organic etiology, to
experience somatic distress in response to
psychological stress
2. To attribute this distress to physical illness or
physical disorder
3. To seek medical attention for these symptoms
(Stern & Herman, Massachusetts General Hospital, 2004)
Medically Unexplained
Symptoms
Medically unexplained symptoms, also known as functional
somatic symptoms, are extremely common in patients in
both community and clinic settings.
In a study of 14 common symptoms in 1,000 patients in an
ambulatory medical clinic, 74% were medically unexplained
(Kroenke and Mangelsdorff 1989).
Kroenke K, Mangelsdorff
D. Common symptoms in
ambulatory care:
incidence, evaluation,
therapy and outcome. Am J
Med, 1989:86: 2626.
Diagnosis of Somatoform
Symptoms
We can only estimate symptoms severity based on samples
and experience and must be careful when judging
exaggeration or behavioral style.
Tremendous variability in medical symptoms and pain
experience can be so pervasive that we can only try to
understand this individual, with this history, under these
conditions.
Observation over time has best diagnostic validity.
Adaptive element in somatic behavior seeking the patient
role, defenses not working, limited coping skills,
emotionally overwhelmed, etc.
Large percentage of cases misdiagnosed medical conditions.
Diagnostic Processes
Collaborate with Referral Sources
TAKE A COMPLETE HISTORY how does this make sense?
Review the Medical Records carefully
Collaborate with the patients family and friends if possible
Build an Alliance With the Patient
- Use of empathic comments such as:
The symptoms sound very difficult or
How has this illness or symptom affected your life?
How has your life affected this illness?
Perform a Mental Status Examination screen for neurological
conditions
Principles of Management
(Abbey, 1996)
Somatization Disorder
Epidemiology
women have a 0.2-2% lifetime prevalence of somatoform
disorders.
In men the overall prevalence is 0.2%
Psychiatric Co-Morbidity
Axis I: 50% of patients are likely to have comorbid mood
disorders. Anxiety disorders, substance abuse, and posttraumatic stress disorder are also common.
Axis II: 72% of patients with somatization disorder have
personality disorders, most commonly histrionic, borderline, and
antisocial personality disorders.
The co-morbidity of a history of childhood sexual abuse and
neglect
DSM-IV-TR,
2000. and somatoform disorder is high (30-70%).
Somatization Disorder:
Treatment
The best treatment occurs in the context of a long-term
relationship with an empathetic primary care provider
(PCP). The PCP should be encouraged to:
Somatization Disorder:
Treatment cont.
Psychiatric referral is useful to treat and manage co-morbid psychiatric
disorders.
Psychiatric consultation decreases health care costs and unnecessary
utilization of services.
The goal of psychiatric consultation is to provide a framework for
treatment. It should not be viewed as the end of the relationship
with the PCP.
Co-morbid psychiatric disorders should be treated and managed by
the PCP or psychiatric consultant.
Individual or group psychotherapy can be useful
Stress reduction
A small number of studies report symptom improvement with
antidepressant use (independent of depression).
Epidemiology
Its lifetime prevalence is 4-11%. (DSM-IVTR, 2000.)
Treatment
Treatment is similar to that of Somatization
Disorder.
Conversion Disorder
Conversion disorder involves the presence of
symptoms or deficits that affect voluntary motor or
sensory function in a fashion that suggests a
neurological condition but which is not explained
by the medical findings.
Clinical Features
Conversion-disordered patients are more likely
to have had prior conversion symptoms or
symptoms of dissociation.
One-third of patients with Conversion Disorder
have concurrent neurological illness.
Conversion Disorder
Etiology
A dynamic hypothesis suggests that the conversion
symptom is a solution to an unconscious conflict. For
example, a woman whose husband had an affair may
become paralyzed rather than walk away from the marriage.
Epidemiology
Conversion disorder is the most common somatoform
disorder. Approximately 33% of female psychiatric
outpatients report an episode of conversion.
A gender bias exists, with a ratio of 2-10:1, women to men.
Left-handed women have a higher incidence.
Conversion Disorder
Psychiatric Co-Morbidity
Conversion disorders can be a precursor to depression,
somatization, and/or dissociative disorders.
Symptoms
As opposed to the patient with somatization disorder or the
patient with hypochondriasis who believes they are gravely
ill, the patient with conversion disorder often presents with la
belle indifference conversion provides relief.
Symptoms are more likely to occur following extreme stress.
Symptoms are inconsistent with the physical examination.
The symptoms rarely cause longer term physical disability.
The symptoms tend to recur.
Conversion Disorder
DSM-IV Criteria
One or more symptoms or deficits affecting voluntary motor or
sensory function that suggest a neurological or other general
medical condition
Psychological factors are judged to be associated with the
symptom or deficit because the initiation or exacerbation of the
symptom or deficit is preceded by conflicts or other stressors
The symptom or deficit is not intentionally produced or feigned
The symptom or deficit cannot, after appropriate investigation be
fully explained by a general medical condition or by the effects
of a substance or as a culturally sanctioned behavior or
experience.
Conversion Disorder
DSM-IV Criteria cont.
Conversion Disorder
Course
Conversion disorder is rarely reported in patients
younger than 10 years, or older than 35 years of age;
however, cases have been seen in people of all ages,
including 90-year olds.
Conversion Disorder:
Treatment
A good prognosis is associated with an acute onset of disease, a
clear stressor, a short interval between the onset of symptoms
and initiation of treatment, rapid improvement in the hospital, an
above-average intelligence, and a presenting symptom of
paralysis, aphonia, or blindness.
A poor prognosis is associated with a presenting symptom of
tremor and/or seizure, an increased interval between symptom
onset and treatment, and a reduced intelligence level.
Confrontation of the patient is not helpful, as it results in a loss
of face.
Indirect examination of stressors can lead to relief
Behavioral techniques should be instituted; referral to family
therapy is often indicated.
Pain Disorder
DSM-IV Criteria
Pain Disorder
DSM-IV Criteria cont.
Specifiers
Pain Disorder
Clinical Features
Pain Disorder
Epidemiology
Pain Disorder
Treatment Pain is what the patient says it is!!!!
Emphasize living with pain and not removal of pain. Teach
skills of functional movement, weight loss, sleep hygiene.
The physician should also explain how brain regions involved with
emotion (i.e., the limbic system) may influence sensory pain
pathways.
The three gross categories of pain which are not mutually exclusive.
Neurogenic pain results from damage to the CNS can be unrelenting and
not exacerbated by movement. Physical in origin.
Structural (mechanical) pain fluctuates in intensity and movement. Is highly
sensitive to emotional, cognitive, attentional, and situational influences.
Physical in origin.
Psychogenic pain does not vary and is insensitive to any of these cognitive
and behavioral factors.
When pain does not wax and wane and is not even temporarily relieved by
distraction or analgesics, clinicians can suspect that there is a major
psychogenic component to the pain.
Hypochondriasis
DSM-IV Criteria
Hypochondriasis
Clinical Course
The preoccupation with bodily functions (e.g., heartbeat, sweating,); with minor physical
abnormalities (e.g., a small sore or an occasional cough); or vague and ambiguous
physical sensations (e.g., feeling worn out, aching veins).
Hypochondriasis
Treatment
A good prognosis for hypochondriasis is associated with an
acute onset and high levels of general medical co-morbidity.
They may be more accepting of psychiatric treatment if it takes
place in a medical setting and is focused on stress reduction and
education regarding coping with a chronic illness.
Regular contact with a caring medical physician should be
maintained with palliation, and not cure, as the goal.
Work-ups should be based only on objective findings.
Cognitive-educational group treatments work for some.
Use of selective serotonin reuptake inhibitors (SSRIs) may have
some benefit in these patients.
Somatoform Disorder
Not Otherwise Specified
Definition
These disorders are residual categories for disorders where
physical symptoms are the focus of treatment but which do
not meet criteria for another somatoform disorder.
Examples
Pseudocyesis, or the belief that one is pregnant.
Couvade Syndrome in males: sympathy symptoms
Hypochondriasis lasting less than 6 months
Unexplained physical complaints lasting less than 6 months.
Fibromyalgia
Fibromyalgia is a controversial polysymptomatic syndrome of unknown
etiology characterized by chronic widespread musculoskeletal pain,
multiple tender points, abnormal pain sensitivity, and additional
symptoms such as:
fatigue
irritable bowel (e.g., diarrhea, constipation, etc.)
sleep disorder (or sleep that is unrefreshing)
chronic headaches (tension-type or migraines)
jaw pain (including TMJ dysfunction)
cognitive or memory impairment
post-exertional malaise and muscle pain
morning stiffness (waking up stiff and achy)
menstrual cramping
numbness and tingling sensations
dizziness or lightheadedness
skin and chemical sensitivities
Case example #1
A 46 year old divorced female with no history of chronic medical illness
presents to the ER with right side upper and lower extremity weakness,
shortness of breath, unsteady gait, fainting spells, and difficulty speaking.
Neurological insult is ruled out and medical tests are unremarkable. Her
normal personality style is shy and soft spoken. She reports a recent
traumatic, severely emotional experience at work. You should explore which
of the following?
A. Malingering
B.
Conversion
C. Hypochondriasis
D. Factitious disorder
E. Panic disorder
Case example #2