1. 1 Department of Psychiatry Medical Faculty- USU

2. Categories of Somatoform Disorders in ICD-10 & DSM-IV  ICD-10  Somatization disorder  Undifferentiated somatoform disorder  Hypochondriacal disorder  Somatoform autonomic dysfunction  Persistent pain disorder  Other somatoform disorders  No category  Neurasthenia  DSM-IV  Somatization disorder  Undifferentiated somatoform disorder  Hypochondriasis  No category  Pain disorder associated with psychological factors ( & a general medical condition)  Body dysmorphic disorder  Conversion disorder  No category 2

3. Somatization Disorder  Essential feature  : multiple somatic complaints of long duration, beginning before the age 30  Briquet’s syndrome; a form of hysteria 3

4.  Epidemiology  Prevalence : < 1 %  Women : men = 2:1  Treatment  Continuing care by 1 doctor using only the essential investigations can reduce the use of health services & may improve patient’s functional state 4

5. Hypochondriasis  The term hypochondriasis is one of the oldest medical terms, originally used to describe disorders believed to be due to disease of the organs situated in the hypochondrium. It is now defined by DSM-IV & ICD-10 in terms of conviction & or fear of disease unsupported by the results of appropriate medical investigation 5

6.  DSM-IV described the condition as a preoccupation with a fear or belief of having a serious disease based on the individual’s interpretation of physical signs of sensations as evidence of physical illness. Appropriate physical evaluation doesn’t support the dx of any physical disorder than can account for the physical signs or sensations or for the individual’s unrealistic interpretation of them 6

7.  Aetioloy  The cause is unknown  Cognitive formulations suggest that there is faulty appraisal of normal bodily sensations which are interpreted as evidence of disease. This misinterpretation is maintained by behaviours such as continually seeking reassurance & examining or rubbing the supposedly affected part 7

8.  Treatment  Repeated reassurance is unhelpful & may serve to prolong the patient’s concerns.  Investigations should be limited to those indicated by the medical priorities & not extended to satisfy the patient’s other concern  Misinterpretations of the significance of bodily sensations should be corrected & encouragement given to constructive ways of coping with symptoms 8

9. Body Dysmorphic Disorder  Dysmorphophobia  The preoccupation with the imagined defect in appearance is usually an overvalued idea, but individuals can receive an additional diagnosis of Delusional Disorder, Somatic type 9

10.  Patients with dysmorphophobia are convinced that some part of their body is too large, too small or misshapen. To other people the appearance is normal or there is a trivial abnormality  The common concerns are about the nose, ears, mouth, breasts, buttocks or penis, but any part of the body may be involved 10

11.  Assessment : questions about the nature of the preoccupations with the appearance & of the ways in which this has interfered with personal & social life  Embarrassmentmisdiagnosis as social phobia, panic disorder & OCD  Treatment :  secondary to a psychiatric disorder (MDD)  Primary BDDdifficult : establish a working relationship in which the patient feels that the psychiatrist is sympathetic, understands the severity of the problems & willing to help 11

12. Pain Disorder  Chronic pain that is not caused by any physical or spesific psychiatric disorder  DSM IV states that the essential feature : predominant focus of the clinical presentation & is of sufficient severity to cause distress or impairment of functioning, & no organic pathology or pathophysiological mechanism pain or resulting social or occupational impairment is grossly is excess of what would be expected from the physical findings 12

13.  Epidemiology  >> peopletransient  << peoplepersistent or recurrent disability  Pain most common symptom among people who consult doctors  Acute pain usually has an organic cause but psychological factors can affect the subjective response to pain whatever the main cause  Pain is particularly associated with depression, anxiety, panic & somatoform disorders  Patients w/ multiple pains are especially likely to have associated psychiatric disorder 13

14.  Assessment  Investigation of possible physical causewhen (-) remember that pain may be the first symptoms of a physical illness that cannot be detected at an early stage  Full description of t/ pain & t/ circumstances in which it occurs  Search for symptoms of a depressive or other psychiatric disorder  Description of pain behaviours : presentation of symptoms, request for medication, responses to pain  Beliefs about t/ causes of pain & of its implications 14

15.  Treatment  Individually planned, comprehensive & involve t/ patient’s family  Skill is required to maintain a working relationship w/ patients unwilling to accept an approach that uses psychological treatments as part of t/ treatment of pain 15

16.  Psychological care is directed to assessing  any associated mental disorder  Whether psychological techniques are indicated 16

17.  Some specific pain syndromes :  Headache  Facial pain  Back pain  Chronic pelvic pain 17

18. Conversion Disorder  Used in DSM-IV to replace the older term hysteria  Equivalent of dissociative (conversion) disorder in ICD-10  Refers to a condition in which there are isolated neurological symptoms that cannot be explained in terms of mechanism of pathology & there has been a significant psychological stressor 18

19.  Clinical Features  w/ motor symptom or deficit : impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or ‘lump in throat ’,aphonia, urinary retention  w/ sensory symptom or deficit : loss of touch or pain sensation, double vision, blindness, deafness, hallucinations  w/seizures or convulsions : w/voluntay motor or sensory component  w/ mixed presentation 19

20.  Aetiology unknown  Psychodynamic theories : emotional distress into physical symptoms which have a symbolic meaning  Social factors : determinants of onset & development of t/ symptoms  Neurophysiological mechanism : malfunctioning of t/ normal interactions between regions of t/ brain concerned w/ t/ intention to move & those involved in t/ initiation of movement  Cognitive explanations  Cultural explanation 20

21.  Treatment  Obtain medical & psychiatric history from patient & informants  Appropriate medical & psychiatric examination, arrange investigations for physical causes  Reassure that t/ condition is temporary, well recognized and for motor disorders due to a problem of converting intention into action  Avoid reinforcing symptoms or disability  Offer continuing help w/ any related psychiatric or social problems 21