Somatic symptom disorders 21st Nov. 2015 Dr. SAMI ADIL

MUPS = SAD Stress Defined negatively rather than positively with or without medical dx No FDA approved drug

DSM-5 Somatic Symptom Disorders 2. Illness anxiety disorder 3. Conversion disorder (Funcitonal Neurological Symptom) psychological factors affecting medical condition Factitious disorder Other

The prevalence rates differ across countries and times The prevalence rates differ across countries and times. It is generally believed that their prevalence is decreasing in developed countries. Mosul 5 yrs UK before 1950 (1).

In a study about the use of traditional and spiritual healers is was found that 35.1% of the cases who go to those healers were complaining of somatoform disorders, while 24.8% of the cases were having schizophrenic disorders (2).

There is no FDA approved drug for any of the somatic symptom disorders

Somatic Symptom Disorder One or more symptoms Distress and functional impairment Disproportionate ABC With or without medical dx

epidemiology intro

Etiology: unknown Low threshold … cognitive Sick role in face of problems Variant of mental illness Aggression turned inward (repression and displacement)

Diagnosis: A false belief, not to the degree of delusion, that they have serious illness based on misinterpretation of physical signs or sensations. The belief must last at least 6 months despite the absence of pathological findings. This should not be restricted to distress about appearance. Specify if: with predominant pain.

Ddx.: 1. Medical illnesses that are difficult to diagnose (e.g. endocrinopathies, MD, occult neoplastic disorders) 2. Illness anxiety disorder in which there is no symptom, but only the fear. 3. Conversion disorder is acute and neurological, and the patient is not concerned about being ill (la belle indifference). 4. Body dysmorphic disorder. 5. Mood disorders (depression). 6. Anxiety disorders (panic). 7. Psychotic disorders. 8. Malingering and factitious disorders.

Treatment One physician …. scheduled visits Patients can develop real physical illnesses Psychotherapy: insight-oriented, cognitive behavioral, and group psychotherapy all can be helpful. Hypnosis is also helpful sometimes. See the note in the introduction about spiritual healers. Medication can lead to abuse

2. Illness Anxiety Disorder Persistent, excessive thoughts and feelings about having a serious physical illness; not reassured. Few or no somatic symptoms. Essential feature is preoccupation with being ill. It may be present with or without medical diagnoses.

Epidemiology: mostly unknown. Etiology: similar to etiology of somatic symptom disorder.

Dx. the belief must last at least 6 months. No physical findings Dx. the belief must last at least 6 months. No physical findings. Not delusional, not body dysmorphic disorder. Causes distress and/or dysfunction.

Ddx: (i) Other somatic symptom disorder (ii) Mood disorders (iii) Anxiety disorder (iv) Psychotic disorder (v) OCD

3. Functional Neurological Symptom Disorder (Conversion Disorder) Hysteria

مسمر Franz Anton Mesmer 1734-1815

تختفي الأعراض حين نتذكر أول نشأتها تختفي الأعراض حين نفهم سبب نشأتها

Funct. Neuro. (conversion) Usually occurs acutely after stress, then resolves within 2 weeks. The sx resemble neurological symptoms (either sensory, motor, seizure, or mixed )

Epidemiology: paragraph in the introduction above taken from reference no. 1. More in left side Two to 10 times more common in females. The onset is rare before 10 years of age or after 35 years of age. Rural, little education, low IQ, those in low SES, and military personnel who have been exposed to combat situations.

Etiology: Previous experience (such as childhood abuse) is a predisposing factor, psychological or physical trauma is a precipitating factor, and special rewards for disability a perpetuating factor.

Brain-imaging studies have found hypometabolism of the dominant hemisphere and hypermetabolism of the nondominant hemisphere and have implicated impaired hemispheric communication in the cause of conversion disorder.

Clinical features Paralysis, blindness, and mutism Neurological exam (-ve) Pseudoseizures Primary and seconday gain La belle indifference

Paralysis --- hoover test Aphonia – ask to cough Patient’s dignity

ddx Neurological disorders (25-50%) Other somatoform disorders Malingering and factitious

Slater BJP

Course and prognosis Acute, spontaneuous

Treatment Spontaneous Abreaction Spiritual healers

In my opinion, sometimes the conversion cases are met with negative attitude by the medical staff and receive some punitive treatments like the painful I.M. normal saline injection, or injections of furosemide (Lasix) and this is unethical. What is Evidence Based Medicine??? Can we write in our lectures things like (in my opinion….)??

End of part one