SOMATOFORM DISORDERS

Group of disorders that includes physical symptoms for which an adequate medical explanation cannot be found Psychological factors --> symptom’s onset, severity, duration Not malingering or factitious disorder Group of disorders that includes physical symptoms for which an adequate medical explanation cannot be found Psychological factors --> symptom’s onset, severity, duration Not malingering or factitious disorder

5 Specific somatoform disorders: 1. Somatization DO 2. Conversion DO 3. Hypochondriasis 4. Body Dysmorphic DO 5. Pain DO 5 Specific somatoform disorders: 1. Somatization DO 2. Conversion DO 3. Hypochondriasis 4. Body Dysmorphic DO 5. Pain DO

SOMATIZATION DISORDER Hysteria, Briquet’s Syndrome Many somatic symptoms Multiple complaints and organ systems affected Chronic Hysteria, Briquet’s Syndrome Many somatic symptoms Multiple complaints and organ systems affected Chronic

Epidemiology Lifetime prevalence = % F > M (5-20X) = 5:1 Lifetime prevalence = % F > M (5-20X) = 5:1

Etiology 1. Psychosocial factors - social communication 2. Biological factors - attention and cognitive impairments 1. Psychosocial factors - social communication 2. Biological factors - attention and cognitive impairments

Diagnosis Onset before the age of 30 years Complain of at least 4 pain sxs, 2 GI sxs, 1 sexual sx, 1 pseudoneurological sx No physical or laboratory explanation Onset before the age of 30 years Complain of at least 4 pain sxs, 2 GI sxs, 1 sexual sx, 1 pseudoneurological sx No physical or laboratory explanation

Clinical Features Many somatic complaints; long complicated medical history Psychological distress: anxiety, depression Common suicidal threats Medical history is circumstantial, vague, imprecise, inconsistent, disorganized Many somatic complaints; long complicated medical history Psychological distress: anxiety, depression Common suicidal threats Medical history is circumstantial, vague, imprecise, inconsistent, disorganized

Patients are dependent, self-centered, hungry for admiration or praise Common associated mental DO - MDD, PD, SRD, GAD, phobias Patients are dependent, self-centered, hungry for admiration or praise Common associated mental DO - MDD, PD, SRD, GAD, phobias

Differential Diagnosis 1. Non-psychiatric medical condition 2. Mental DO - MDD, GAD, schizophrenia 3. Other somatization DO 1. Non-psychiatric medical condition 2. Mental DO - MDD, GAD, schizophrenia 3. Other somatization DO

Course and Prognosis Chronic, debilitating Onset before age 30 years Chronic, debilitating Onset before age 30 years

Treatment Single identified MD Visits: regular, avoid additional lab/diagnostic procedures Somatic symptoms - emotional expressions Psychotherapy: individual, group Single identified MD Visits: regular, avoid additional lab/diagnostic procedures Somatic symptoms - emotional expressions Psychotherapy: individual, group

CONVERSION DISORDER One or more neurological symptoms (paralysis, blindness, paresthesias) Psychological factors --> onset, exacerbation One or more neurological symptoms (paralysis, blindness, paresthesias) Psychological factors --> onset, exacerbation

Epidemiology F:M = 2:1 - 5:1 Onset is any age (common during adolescence and young adults) Rural population, little educated, low IQ, low SE group, military personel Comorbid with MDD, anxiety, schizophrenia F:M = 2:1 - 5:1 Onset is any age (common during adolescence and young adults) Rural population, little educated, low IQ, low SE group, military personel Comorbid with MDD, anxiety, schizophrenia

Etiology 1. Psychoanalytic - repression of unconscious conflict/anxiety --> physical sx Nonverbal means of controlling and manipulating 1. Biological factors - hypomentabolism of dominant hemisphere impaired hemispheric communication 1. Psychoanalytic - repression of unconscious conflict/anxiety --> physical sx Nonverbal means of controlling and manipulating 1. Biological factors - hypomentabolism of dominant hemisphere impaired hemispheric communication

Diagnosis Symptoms or deficits affecting neurological functions Psychological factors --> onset, exacerbations Not intentionally feigned or produced Symptoms or deficits affecting neurological functions Psychological factors --> onset, exacerbations Not intentionally feigned or produced

Clinical Features Most common symptoms: paralysis, blindness, mutism Most commonly associated with passive-aggressive, dependent, antisocial and histrionic PDs Most common symptoms: paralysis, blindness, mutism Most commonly associated with passive-aggressive, dependent, antisocial and histrionic PDs

1. Sensory Sxs: anesthesia and paresthesia, esp extremities distribution usually inconsistent with central or peripheral neuro dse characteristic stocking and glove anesthesia or hemianesthesia (along the midline) organs of special senses - deafness, blindness, tunnel vision --> N neuro exam 1. Sensory Sxs: anesthesia and paresthesia, esp extremities distribution usually inconsistent with central or peripheral neuro dse characteristic stocking and glove anesthesia or hemianesthesia (along the midline) organs of special senses - deafness, blindness, tunnel vision --> N neuro exam

2. Motor Sxs: abnormal movements, gait disturbance, weakness, paralysis generally worsen by attention 3. Seizure Sxs: pseudoseizure 4. Mixed presentation 2. Motor Sxs: abnormal movements, gait disturbance, weakness, paralysis generally worsen by attention 3. Seizure Sxs: pseudoseizure 4. Mixed presentation

Other associated features: Primary gain: represent an unconscious psychological conflict Secondary gain: accrue tangible advantages & benefits Le belle indifference: unconcerned about what appears to be a major impairment Identification: unconsciously model their sxs on those someone important to them Other associated features: Primary gain: represent an unconscious psychological conflict Secondary gain: accrue tangible advantages & benefits Le belle indifference: unconcerned about what appears to be a major impairment Identification: unconsciously model their sxs on those someone important to them

Differential Diagnosis Rule out medical disorder: thorough medical and neuro work-up 25-50% diagnosed with conversion DO --> neuro or non-psychiatric medical DO 1. Neuro DO - dementia, brain tumors, degenerative dse, basal ganglia dse 2. Psychiatric DO - schiz, deprssive DO, other somatoform, malingering, factitious DO Rule out medical disorder: thorough medical and neuro work-up 25-50% diagnosed with conversion DO --> neuro or non-psychiatric medical DO 1. Neuro DO - dementia, brain tumors, degenerative dse, basal ganglia dse 2. Psychiatric DO - schiz, deprssive DO, other somatoform, malingering, factitious DO

Course and Prognosis % resolve in few days to less than a month Good prognosis: sudden onset, easily identifiable stressor, good premorbid adjustment, no comorbid psychiatric or medical DO 25-50% --> neuro or non-psychiatric DO % resolve in few days to less than a month Good prognosis: sudden onset, easily identifiable stressor, good premorbid adjustment, no comorbid psychiatric or medical DO 25-50% --> neuro or non-psychiatric DO

Treatment Spontaneously resolve Insight-oriented supportive or behavioral therapy Spontaneously resolve Insight-oriented supportive or behavioral therapy

HYPOCHONDRIASIS Unrealistic or inaccurate interpretations of physical symptoms or sensations --> preoccupation and fear that they have serious disease Significant distress; impaired function Unrealistic or inaccurate interpretations of physical symptoms or sensations --> preoccupation and fear that they have serious disease Significant distress; impaired function

Epidemiology F = M Onset at any age F = M Onset at any age

Etiology 1. Misinterpretation of bodily symptoms 2. Social learning model 3. Variant form of other mental disorder - depression and anxiety DO (80%) 4. Aggressive and hostile wishes 1. Misinterpretation of bodily symptoms 2. Social learning model 3. Variant form of other mental disorder - depression and anxiety DO (80%) 4. Aggressive and hostile wishes

Diagnosis Preoccupied with false belief based misinterpretation of physical s/sxs At least 6 months Not a delusion or restricted to distress of appearance Preoccupied with false belief based misinterpretation of physical s/sxs At least 6 months Not a delusion or restricted to distress of appearance

Clinical Features Believe that they have a serious disease not yet detected Conviction persist despite negative lab results, benign course, reassurances Usually with depression and anxiety Believe that they have a serious disease not yet detected Conviction persist despite negative lab results, benign course, reassurances Usually with depression and anxiety

Differential Diagnosis 1. Non-psychiatric medical condition 2. Other somatoform disorders 3. MDD, anxiety DO, schiz, other psychotic DO 1. Non-psychiatric medical condition 2. Other somatoform disorders 3. MDD, anxiety DO, schiz, other psychotic DO

Course and Prognosis Episodic, months to years Good prognosis: high SE class, treatment-responsive anxiety or depression, sudden onset, (-) PD, (-) related non-psychiatric medical condition Episodic, months to years Good prognosis: high SE class, treatment-responsive anxiety or depression, sudden onset, (-) PD, (-) related non-psychiatric medical condition

Treatment Usually resistant to psychiatric treatment Focus on stress reduction and education in coping with chronic illness Group psychotherapy Regular scheduled PE Usually resistant to psychiatric treatment Focus on stress reduction and education in coping with chronic illness Group psychotherapy Regular scheduled PE

BODY DYSMORPHIC DO Preoccupation with an imagined bodily defect or an exaggerated distortion of a minimal or minor defect Causes significant distress; impaired function Preoccupation with an imagined bodily defect or an exaggerated distortion of a minimal or minor defect Causes significant distress; impaired function

Epidemiology Rare; poorly studied Most common age of onset: yo F > M, unmarried Commonly coexists with other mental DO (MDD, anxiety, psychotic DOs) Rare; poorly studied Most common age of onset: yo F > M, unmarried Commonly coexists with other mental DO (MDD, anxiety, psychotic DOs)

Etiology Serotonin Cultural and social effects Psychodynamic models Serotonin Cultural and social effects Psychodynamic models

Diagnosis Preoccupied with an imagined defect in appearance or an overemphasis of a slight defect Significant emotional distress; impaired functioning Preoccupied with an imagined defect in appearance or an overemphasis of a slight defect Significant emotional distress; impaired functioning

Clinical Features Most common concerns: facial flaws Common associated symptoms: ideas of reference, attempts to hide deformity, excessive mirror checking or avoidance Avoid social or occupational exposure Housebound; attempt suicide Traits: O-C, schizoid, narcissistic PD Comorbid: depression, anxiety DO Most common concerns: facial flaws Common associated symptoms: ideas of reference, attempts to hide deformity, excessive mirror checking or avoidance Avoid social or occupational exposure Housebound; attempt suicide Traits: O-C, schizoid, narcissistic PD Comorbid: depression, anxiety DO

Differential Diagnosis Anorexia nervosa, gender identity DO, brain damage Delusional DO, somatic type Narcissistic PD, depressive DO, OCD, schizophrenia Anorexia nervosa, gender identity DO, brain damage Delusional DO, somatic type Narcissistic PD, depressive DO, OCD, schizophrenia

Course and Prognosis Gradual onset Usually chronic Gradual onset Usually chronic

Treatment Serotonin-specific drugs - clomipramine, fluoxetine Treat coexisting mental DO Serotonin-specific drugs - clomipramine, fluoxetine Treat coexisting mental DO

PAIN DISORDER Psychogenic pain DO Pain in one or more sites --> no non- psychiatric medical or neurological condition Emotional distress; functional impairment Psychogenic pain DO Pain in one or more sites --> no non- psychiatric medical or neurological condition Emotional distress; functional impairment

Epidemiology F > M Peak onset on 4th to 5th decades Blue-collar occupation, 1st degree relatives F > M Peak onset on 4th to 5th decades Blue-collar occupation, 1st degree relatives

Etiology 1. Psychodynamic: expression of intrapsychic conflict defense mechanism-displacement, substitution, repression 2. Behavioral: reinforced with reward and inhibited when ignored/punished 3. Interpersonal: manipulation and gaining advantages 4. Biological: 5HT and endorphins 1. Psychodynamic: expression of intrapsychic conflict defense mechanism-displacement, substitution, repression 2. Behavioral: reinforced with reward and inhibited when ignored/punished 3. Interpersonal: manipulation and gaining advantages 4. Biological: 5HT and endorphins

Diagnosis Significant complaints of pain Emotional distress and functional impairment Significant complaints of pain Emotional distress and functional impairment

Clinical Features Collection of different histories of various pains Pain maybe post-traumatic, neuropathic, neurological, iatrogenic, musculoskeletal (+) psychological factor Long history of medical and surgical care, visits many MDs, requests many meds Complicated by SRD MDD: 25-50% of patients Dysthymic or depressive DO sxs % Collection of different histories of various pains Pain maybe post-traumatic, neuropathic, neurological, iatrogenic, musculoskeletal (+) psychological factor Long history of medical and surgical care, visits many MDs, requests many meds Complicated by SRD MDD: 25-50% of patients Dysthymic or depressive DO sxs %

Differential Diagnosis 1. Physical pain VS Psychogenic pain 1. Physical Pain: fluctuates in intensity, highly sensitive to emotional, cognitive, attentional and situational influence 2. Psychogenic Pain: does not vary, insensitive to any of above factors, does not wax or wane, not temporarily relieved by distraction 2. Other somatoform DO 1. Physical pain VS Psychogenic pain 1. Physical Pain: fluctuates in intensity, highly sensitive to emotional, cognitive, attentional and situational influence 2. Psychogenic Pain: does not vary, insensitive to any of above factors, does not wax or wane, not temporarily relieved by distraction 2. Other somatoform DO

Course and Prognosis Abrupt onset and increases in severity

Treatment Address rehabilitation PAIN IS REAL Pharmacotherapy - antidepressant Behavioral therapy Psychotherapy Pain control program Address rehabilitation PAIN IS REAL Pharmacotherapy - antidepressant Behavioral therapy Psychotherapy Pain control program

UNDIFFERENTIATED SOMATOFORM DO One or more physical complaints that can’t be explained by known medical condition Doesn’t meet the diagnostic criteria for any somatoform DO At least 6 months Significant emotional distress and impaired functioning One or more physical complaints that can’t be explained by known medical condition Doesn’t meet the diagnostic criteria for any somatoform DO At least 6 months Significant emotional distress and impaired functioning

2 types of somatoform pattern: 1. Involving ANS: CV, GI, urogenital, derma sxs 2. Involving sensations of fatigue or weakness (neurasthenia): mental or physical fatigue, physical weakness and exhaustion 2 types of somatoform pattern: 1. Involving ANS: CV, GI, urogenital, derma sxs 2. Involving sensations of fatigue or weakness (neurasthenia): mental or physical fatigue, physical weakness and exhaustion