Somatoform Disorders

Dr Nemache Mawere
Psychiatrist
MBBS: Part 4-March 2021
 Contents
• Common Mental Disorders
• Definition-Somatoform disorders
• Classification
• Detailed Discussion of Conditions
(Definition, epidemiology, aetiology, clinical
features, Differential diagnosis, Investigations,
treatment, prognosis)
 Common Mental Disorders
• Depression
• Anxiety
• Somatization.
 Somatoform Disorders
• Definition-
• Body sensations or functions being influenced
by disorder of the mind. (mind-body
intereaction)
 Core symptoms
• Presence of a physical/somatic complaint of
major severity
• Lack of any demonstrable organic findings
• No known physiologic mechanisms to explain
the syndrome.
• Associated psychological factors or
unconscious conflicts which initiate, worsen or
maintain the symptoms.
 Classification
• Somatization Disorder
• Somatoform Pain Disorder
• Hypochondriasis
• Conversion Disorder
• Undifferentiated Somatoform Disorder
• [Other Related conditions-Malingering,
Factitious Disorder]
 Somatization
• Definition-Somatic complaints not limited to
one organ system and not caused by known
medical disorder.
• “Hysteria”- uterus wanders around the body
causing symptoms all over.(Disease of women)
• Syndenham 17th century- described it in men.
• Briquet’s Disease(1851)- 25 symptoms. from
10 symptom groups.
 Epidemiology
• Female: Male-20:1
• 1-2% of all women
• 10- 20% of admissions
• 0,13 of general population.
• Associated with other mental illness-
depression, substance abuse, antisocial and
histrionic personality disorders.
 Aetiology
• Social communication: Use of body symptoms to
manipulate or control relationships.
• Emotional communication: patient uses somatic
symptoms and complaints to verbalize their emotions
and also to symbolically communicate an emotion.
• Coping Device: Somatic complaints to deal with
stress ( Defense mechanism -repression)
• Solving intrapsychic conflict: As solution to the
conflict- (conversion- monosymptomatic vs.
somatization - polysymptomatic)
 Aetiology
• Psychoanalytic theory: substitution of
repressed impulse(instincts) by somatic
symptoms.
• Genetics-10-20 %- 1st degree relatives
-Twins-29% monozygotes
-10% dizygotes
• First degree male relatives-Substance abuse
and antisocial personality disorder or trait.
 Clinical Features
• Multiple somatic complaints. (4:2:1:1)
• Pain Symptoms- 4 pain in extremities , back pain, joint
pains, dysuria, abdomen, dysmenorrhea, dyspareunia
(Not headaches).
• GIS- 2- (Not pain)N,V,D,, flatulence (gassy), food
fads/intolerance, boborygmi.
• Sexual symptoms-1-(Not pain) burning sensation in
sexual organs, irregular or excessive menses, vomiting
throughout pregnancy, impotence(erectile or
ejaculatory problems).
 Clinical Features
• Conversion/ Pseudoneurologic - 1-Amnesia,
dysphagia, Aphonia, deafness, vision (double or
blurred or none- blind), fainting/ blackouts,
seizure/convulsions, muscle weakness or paralysis
(isolated groups), urine retention, lump in throat,
loss of balance, numbness(glove and stocking)
• CVS-(Not included in DSM V)-sob (Not on exertion),
palpitations, chest pain, dizziness.
**CVS Symptoms sometimes referred to as Da Costa
Syndrome
 Co Morbidity
• Major Depression - 50% of patients
• Anxiety Disorders
• Personality disorders-histrionic, ASPD
• Suicide-threats-common
-Acts-near lethal or non lethal(DSH)
 Investigations
• Physical exam, lab and radiology- all negative
or if present there is gross exaggeration of
symptoms from what is expected.
• Screening Instruments-SSQ/SRQ-8; SSQ 14/20.
 Differential Diagnosis
• Organic cause (Rule out)
• Chronic Fatigue Syndrome (EBV)
• Somatic delusions
• Panic attacks-intermittent
• Conversion disorder-fewer symptoms with
clearer symbolic meaning.
• Factitious Disorder.
• Somatoform pain disorder-c/o pain only.
 Treatment
• Antidepressants-TCA, SSRI.
• Benzodiazepines-only for acute anxiety (Risk of
dependence-long term therapy)
• Psychological-Supportive psychotherapy and in
the long term-resolve the psychological conflicts.
• One doctor concept and advice vs. doctor
shopping.
 Prognosis
• Chronic course with few remissions.
• Substance abuse and drug dependence
• Doctor Shopping
• Unnecessary procedures-Repeated
investigations and operations
• Side effects of prescription drugs (multiple
symptom treatment)
• Depression.
 Somatoform Pain Disorder
• Definition-
• Preoccupation with pain for at least 6 months.
• Absence of physical disease to account for its
intensity.
• The pain does not follow a neuroanatomic
distribution.
• Close correlation between stress and conflict
and onset or worsening of pain.
 Epidemiology
• Age- any, usually 30-40
• Female > Male
 Aetiology
• Psychological
-Defense mechanism-regression, repression
-Intrapersonal factors- how we react to pain (low pain
threshold)
-Interpersonal factors- lavish attention /secondary gain
• Genetics- First degree relatives have higher incidence
of low pain threshold , depression and alcoholism.
 Clinical Features
• Localized sensorimotor symptoms-
anesthesia, parasthesia- “chiveve/inkantsho.”
• Pain does not follow neuroanatomic
distribution. (e.g. glove and stocking)
• Associated symptoms of depression
• If some organic pathology present the
intensity of pain or degree of physical
impairment is grossly in excess of what is
expected from physical exam.
 Investigations
• Repeated physical exam TRO organic cause.
• SRQ 8
• SSQ14/20
 Differential Diagnosis
• Organic cause (exclude)
• Somatization
• Depression
• Malingering (usually drug seeking behavior).
• Histrionic personality disorder.(Attention
seeking/drama queen)
 Treatment
• Analgesia-simple types, avoid narcotics
• Antidepressants-TCA, SSRI
• Anticonvulsants- Carbamazepine
• Psychological- change focus from pain to
regaining of function.
• Pain Clinic- multidisciplinary
• Chronic Pain- personality, family dynamics,
environment
 Hypochondriasis
• Definition-
Morbid fear or belief
that one has a serious
disease even though it
is not present.
• Present for at least 6 months
 Epidemiology

• 10% of medical patients

• Men= Women
• All ages-peak 30s-men; 40s-women
 Aetiology
• Psychodynamics- Ego defense vs. guilt/low self
esteem (aggression to others turned against self
through a particular body part-
repression/displacement)
• Amplification: Hypersensitivity to normal bodily
functions and sensations-e.g peristalsis perceived as
boborygmi
• Low threshold for pain/physical discomfort
• Affected organ may have symbolic meaning.
 Clinical Features
• Any organ affected
• Common-GIS, CVS
• Belief that there is disease or malfunction
(when not present).
• Physical exam and medical tests reassures
patient only for a short time.
• Belief is not of delusional intensity.
 Investigations
• Repeated physical exam TRO organic cause
• Psychological tests
• Amytal interview-100 to 500mg slow infusion
of amytal reverses symptoms temporarily.
 Differential Diagnosis
• Depression
• Anxiety disorder
• Somatization disorder
• Psychogenic pain disorder
• Malingering
• Factitious disorder.
 Treatment
• Antidepressants- TCA, SSRI
• Psychotherapy -Do not say “its all in the
head.”-
• Vital long term relationship to reassure
• Hypnosis and behavioural therapy induce
relaxation
 Prognosis
• Chronic course with remissions
• Exacerbations associated with identifiable life
stress.
• Good outcome with stable premorbid
personality.
• Poor outcome- preexisting physical disorder.
 Conversion Disorder
• Hysterical Neurosis-conversion type.
• Definition-
• Involuntary alteration or limitation of
physical /bodily function
• Due to psychologic conflict or need, not
physical disorder.
 Epidemiology
• 10% of inpatients
• 0.15% of all psychiatric out patients
• Age- Early adulthood-common
• Male : Female- 1:2.
• Common in lower social classes and less
educated.
 Aetiology
• Genetic- Higher in family members
• Biological
- activation of inhibitory brain mechanisms
-Excess cortical arousal (in non dominant
hemisphere) triggers inhibitory CNS mechanisms.
-Common in patients with frontal lobe trauma
and related neurological deficits.
 Aetiology
Psychological-
-Primary Gain-Defense mechanism-repression (reduced
anxiety) e.g. arm paralysis prevents expression of
aggression. Also denial, displacement, reaction
formation.
-Secondary gain-benefits of illness e.g. compensation,
avoiding work, dependence on others, lack of insight.
-Identification with family member with similar
symptoms of real disease.
-Disguise of id impulses e.g. sex/aggression and
expressed as symptom.
 Clinical Features
• Motor-paralysis, ataxia, vomiting, aphonia
• Sensory-blindness, deafness, anosmia, paraesthesia, diplopia,
neuropathy-does not follow known sensory pathways.
• Consciousness- pseudoseizures, unconsciousness/”fainting”
• Close temporal relation of symptom and stress or intense
emotion.
• Left sided symptoms common.
• Not culturally acceptable and cannot be explained by a known
physical disorder.
• La belle (Beautiful ) indifference-lack of concern about illness.
 Investigations
• Evoked potentials-diminished or absent on
side of defect.
• Psychological tests
• Thorough physical examination and relevant
tests to rule out physical cause.
• Amytal interview- Reduces/eliminates
conversion symptoms.
 Differential Diagnosis
• Paralysis-(No pathologic reflexes (Babinski),
inconsistent with motor pathways, cogwheel rigidity,
clonus & spasticity- all absent)
• Ataxia-(Bizarre e.g. leg is dragged, Astasia abasia
-does not fall or injure self)
• Blindness-(pupillary reaction to light, No tracking
movements, monocular symptoms, vision tests
-bizarre results)
• Deafness-(loud noise awakens sleeping conversion
patient and audiometry -variable report)
 Differential Diagnosis
• Sensory loss-Does not follow dermatomes, hemisensory loss
(one sided), glove and stocking paraesthesia.
• Hysterical pain-head , face, back, abdomen (no obvious
pathology seen)
• Epilepsy (true seizures) vs. Pseudoseizures
-Absent: incontinence, loss of motor control, tongue biting,
aura; EEG normal.
• Malingering and factitious disorder- patients aware they are
faking.
• Schizophrenia-thought disorder
• BAD-depression, mania.
 Treatment
• Anxiolytics-BZ-reduces anxiety and muscle tension
• Antidepressants-TCA, SSRI
• Psychologic- insight oriented to explore conflicts and
manage them appropriately.
• Behaviour therapy- Relaxation reduces anxiety levels
and so symptoms reduced.
• Hypnosis/ re education
• Don’t tell patient off :“wasting my time, attention
seeking etc”
 Prognosis
• Recurrent course
• If early signs missed will develop into worse
condition of loss of function and disability.
Undifferentiated Somatoform Disorder
• Partial picture of somatization disorder
• Multiple somatic complaints
• Vague and mild symptoms
• General fatigue-common syndrome.
 Factitious Disorder
• Deliberate and conscious simulation of
symptoms.
• 5-10% of admissions esp. fevers
• Early real life illness coupled by parental abuse
or rejection. In adult life patient recreates
illness to get loving attention from doctors.
• Desire to be hurt-masochistic gratification.
 Factitious Disorder
Physical Symptoms-(Munchausen’s syndrome)-intentional
production of physical symptoms-nausea, vomiting, pain
,seizures. Intentionally put blood in faeces or urine; artificially
raise body temp; take insulin to lower blood sugar. “Gridiron
abdomen.”
Psychological symptoms-Intentional production of psychiatric
symptoms- hallucinations, delusions, bizarre behaviour &
depression. Story of a major life stressor is made up to justify
symptoms.
Pseudologia fantastica-make up exaggerated lies which
patient believes
Factitious disorder by proxy-one person produces symptoms
in another e.g. parent to child.
 Malingering
• Voluntary production of physical or
psychological symptoms to accomplish a
specific goal e.g. insurance claims, avoid jail/
punishment.
• Vague or poorly localized symptoms
presented in great detail.
• Easily irritated if doctor skeptical.
• Secondary gain (defined goal) evident on
further interrogation/ collateral history.
 Conclusion
• Somatoform disorders-common in medical
practice (In and out patients)
• Major cost driver of health care.
• Ability to recognize and treat early, benefits all-
patient, doctor, state.
• Screening at primary level can help identify and
treat CMD
• **Friendship Bench concept.-dealing with
somatoform disorders in the community.