somatoform disorders

Karen Abinsay Psychiatry Feb. 10, 2015IV-BSOT

SOMATOFORM DISORDERS

1. Somatization Disorder: characterized by many physical complaints affecting many organ systems.

2. Conversion Disorder: characterized by one or two neurological complaints.3. Hypochondriasis: characterized less by a focus on symptoms than by patients’ beliefs that they

have a specific disease.4. Body dysmorphic Disorder: characterized by a false belief or exaggerated perception that a

body part is defective.5. Pain Disorder: characterized by symptoms of pain that are either solely related to, or

significantly exacerbated by, psycho-logical factors.6. Undifferentiated somatoform disorder: includes somatoform disorders not otherwise described

that have been present for 6 months of longer.7. Somatoform disorder not otherwise specified: the category for somatoform symptoms that do

not meet any of the somatoform disorder diagnoses mentioned above.

SOMATIZATION

An illness of multiple somatic com-plaints in multiple organ systems that occurs over a period of several years and results in significant impairment or treatment seeking, or both.

Is chronic and is associated with significant psychological distress, impaired social and occupational functioning, and excessive medical-help-seeking behavior.

Clinical Features:

Patients with somatization disorder have many somatic com-plaints and long, complicated medical histories.

Nausea and vomiting (other than during pregnancy), difficulty swallowing, pain in the arms and legs, shortness of breath unrelated to exertion, amnesia, and complications of pregnancy and menstruation are among the most common symptoms.

Patients frequently believe that they have been sickly most of their lives. Psychological distress and interpersonal problems are prominent; anxiety and depression are

the most prevalent psychiatric conditions. Suicide threats are common, but actual suicide is rare. If suicide does occur, it is often associated

with substance abuse. Somatization disorder is commonly associated with other mental disorders, including major

depressive disorder, personality disorders, substance-related disorders, generalized anxiety disorder, and phobias.

Epidemiology/Etiology

Common d/o W>M

5:1 female-male ratio


Beginning before age 30, usually during teenage years.

Possible Factors: Psychosocial, Biological (Genetics & cytokines)

DX

Requires onset of symptoms before age 30. During the course of the disorder, patients must have complained of at least four pain

symptoms, two gastrointestinal symptoms, one sexual symptom, and one pseudo neurological symptom, none of which is completely explained by physical or laboratory examinations.

REFER TO TABLE 17-2

Differential DX

3 features that most suggest a diagnosis of somatization disorder instead of another medical disorder are:

o (1) the involvement of multiple organ systems, o (2) early onset and chronic course without development of physical signs or structural

abnormalities, and o (3) Absence of laboratory abnormalities that are characteristic of the suggested medical

condition. In the process of diagnosis, the astute clinician considers other medical disorders that are

characterized by vague, multiple, and confusing somatic symptoms, such as thyroid disease, hyperparathyroidism, intermittent porphyria, multiple sclerosis(MS), and systemic lupus erythematosus.

REFER TO TABLE 17-3

Course and Prognosis

Is a chronic, undulating, and relapsing disorder that rarely remits completely. It is unusual for the individual with somatization disorder to be free of symptoms for greater

than 1year, during which time they may see a doctor several times. Research has indicated that a person diagnosed with somatization disorder has approximately

an 80 percent chance of being diagnosed with this disorder 5 years later.

TX

Best treated when the patient has a single identified physician as primary caretaker. The visits should be relatively brief, although a partial physical examination should be conducted

to respond to each new somatic complaint. Additional laboratory and diagnostic procedures should generally be avoided. Once somatization disorder has been diagnosed, the treating physician should listen to the

somatic complaints as emotional expressions rather than as medical complaints. Psychotherapy & Psychopharmacological tx


CONVERSION DISORDER

Is an illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors because the illness is preceded by conflicts or other stressors.

The symptoms or deficits of conversion disorder are not intentionally produced, are not caused by substance use, are not limited to pain or sexual symptoms, and the gain is primarily psychological and not social, monetary, or legal.

Clinical Features:

Paralysis, blindness, and mutism are the most common conversion disorder symptoms. Depressive and anxiety dis-order symptoms often accompany the symptoms of conversion

disorder, and affected patients are at risk for suicide.


W>M Among children, an even higher predominance is seen in girls. Symptoms are more common on the left than on the right side of the body in women. The onset is general from late childhood to early adulthood and is rare before 10 years of age or

after 35 years of age. Possible factors: Psychoanalytic, Learning theory, biological

DX

Limits the diagnosis of conversion disorder to those symptoms that affect a voluntary motor or sensory function, that is, neurological symptoms.

REFER TO TABLE 17-5

Differential DX

REFER TO TABLE 17-6 Since diagnosing the disorder is difficult in and must rule out a medical a disorder, a thorough

medical and neurological work is essential in all cases.


Acute; Symptoms or deficits are usually of short duration One episode is a predictor for future episodes. Good prognosis=acute onset, presence of clearly identifiable stressors at the time of onset, a

short interval between onset and the institution of treatment, and above average intelligence; Paralysis, aphonia, and blindness.

Poor= tremor and seizures

TX


Psychotherapy (Behavior Thx, hypnosis, psychodynamic approaches s/a psychoanalysis and insight-oriented psychotherapy)


HYPOCHONDRIASIS

Is characterized by 6 months or more of a general and no delusional preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms.

Reflects the common abdominal complaints of many patients with the disorder, but they may occur in any part of the body.

Clinical Features:

Believe that they have a serious disease that has not yet been detected, and they cannot be persuaded to the contrary.

Convictions persist despite negative laboratory results, the benign course of the alleged disease over time, and appropriate reassurances from physicians.

Often accompanied by symptoms of depression and anxiety and commonly coexists with a depressive or anxiety disorder.

Although DSM-IV-TR specifies that the symptoms must be present for at least 6 months, transient hypochondrical states can occur after major stresses.

Such states that last fewer than 6 months should be diagnosed as somatoform disorder not otherwise specified.


Epidemiology

M=F Onset 20-30 y/o More common in blacks than whites plus medical students

DX

REFER TO TABLE 17-7

Differential DX

Must be differentiated from nonpsychiatric medical cx, especially disorder that show sx that are not necessarily easily dx (AIDS, MG, MS, degenerative d/s of NS, etc.)

Must also be differentiated from other somatization d/s by emphasis on fear of having a disease and not by concerns about many sx.

Less specific age of onset Also occurs in px’s with depressive and anxiety d/o’s plus schizophrenia.


Episodic Lasts from months to years Good prognosis= associated with high socioeconomic status, treatment-responsive anxiety or

depression, sudden onset of symptoms, the absence of a personality disorder, and the absence of a related nonpsychiatric medical cx.

TX

Group psychotherapy Frequent, regular physical exams Pharmacotherapy


BODY DYSMORPHIC DISORDER

Characterized by a preoccupation with an imagined defect in appearance that causes clinically significant distress or impairment in important areas of functioning.

Clinical Features:

Most common concern involves facials flaws. Other body parts of concerns are hair, breasts, and genitalia.

FEFER TO TABLE 17-9


Cause unknown. W>M Common age of onset between 15-30 y/o. High comorbidity with depressive d/o, a higher-than-expected family history of mood d/o’s and

OCD, plus serotonin pathophysiology.

DX

REFER TO TABLE 17-8

Differential DX

Although individuals with body dysmorphic disorder have obsessional pre-occupations about their appearance and may have associated compulsive behaviors (e.g., mirror checking), a separate or additional diagnosis of OCD is made only when the obsessions or compulsions are not restricted to concerns about appearance and are ego dystonic.

An additional diagnosis of delusional disorder, somatic type, can be made in people with body dysmorphic dis-order only if their preoccupation with the imagined defect in appearance is held with a delusional intensity.

Restricted to concerns in anorexia nervosa and major depressive episode.


Usually begins adolescence and can be gradual or abrupt.

TX

Surgical, dermatological, dental, and other med. Procedures Pharmacotherapy: Prozac and Anafranil


PAIN DISORDER

Characterized by the presence of, and focus on, pain in one or more body sites and is sufficiently severe to come to clinical attention.

Psychological factors are necessary in the genesis, severity, or maintenance of the pain, which causes significant distress or impairment, or both.

Clinical Features:

Patients with pain disorder are not a uniform group, but a heterogeneous collection of persons with low back pain, headache, atypical facial pain, chronic pelvic pain, and other kinds of pain.

A patient’s pain may be posttraumatic, neuropathic, neurological, iatrogenic, or musculoskeletal.

To meet a diagnosis of pain disorder, however, the disorder must have a psychological factor judged to be significantly involved in the pain symptoms and their complications.


Can begin at any age. Common; 10-15% adult workers in USA; LBP Pain disorder is associated with other psychiatric disorders, especially affective and anxiety

disorders. Chronic pain appears to be most frequently associated with depressive disorders, and acute pain

appears to be more commonly associated with anxiety disorders.


Individuals whose pain is associated with severe depression and those whose pain is related to a terminal illness, such as cancer, are at increased risk for suicide.

Possible factors: Psychodynamic, Behavioral, Interpersonal, Biological

DX

REFER TO TABLE 17-10

Differential DX

Must be distinguished from other somatoform d/o’s and if purely psychogenic. Physical pain fluctuates in intensity and is highly sensitive to emotional, cognitive, attentional,

and situational influences. Px with this d/o are not pretending to be in pain.


Generally begins abruptly and increases in severity for a few weeks or months. The prognosis varies, although pain disorder can often be chronic, distressful, and completely

disabling. Acute pain disorders have a more favorable prognosis than chronic pain disorders. A wide range of variability is seen in the onset and course of chronic pain disorder. People with pain disorder who resume participation irregularly scheduled activities, despite the

pain, have a more favorable prognosis than people who allow the pain to become the determining factor in their lifestyle.

TX

Pharmacotherapy (Antidepressants & amphetamines) Psychotherapy Pain control Programs Others: Biofeedback, hypnosis, nerve blocks and surgical ablative procedures, etc…


UNDIFFERENTIATED SOMATOFORM DISORDER

Characterized by one or more unexplained physical symptoms of at least 6 months ‘duration, which are below the threshold for a diagnosis of somatization disorder.

Two types of symptom patterns may be seen in patients with undifferentiated somatoform disorder: those involving the autonomic nervous system and those involving sensations of fatigue or weakness.

Such patients have complaints involving the cardiovascular, respiratory, gastrointestinal, urogenital, and dermatological systems. Other patients complain of mental and physical fatigue, physical weakness and exhaustion, and inability to perform many everyday activities because of their symptoms.


SOMATOFORM DISORDER NOT OTHERWISE SPECIFIED

Is a residual category for patients who have symptoms suggesting a somatoform disorder, but do not meet the specific diagnostic criteria for other somatoform disorders.

Such patients may have a symptom not covered in the other somatoform disorders or may not have met the 6-month criterion of the other somatoform disorders.

somatoform disorders

Documents