1. Somatization Jameel Adnan, MD. Community & Primary Health Care KAAU-RABEG BRANCH

2. Round Map  Introduction  Somatoform disorders categories  Epidemiology  Clinical presentation  Screening  Treatment

3. Introduction

4.  Somatization refers to the tendency to experience psychological distress in the form of somatic symptoms and to seek medical help for these symptoms

5. Introduction  Emotional responses such as anxiety and depression can initiate symptoms.  Somatization can be conscious or unconscious and may be influenced by psychological distress or a desire for personal gain

6. Introduction  One study identified somatization, Patients with somatization generated twice the costs for medical care and utilized medical services (outpatient and inpatient) twice as often as non- somatizing patients.

7. Introduction  Somatization disorder, which was called hysteria or Briquet's syndrome in the past, is one of the somatoform disorders. It is diagnosed when the patient has requested help for numerous medically unexplained symptoms in various different organ systems. o Less than 1% of patients who present with unexplained somatic symptoms meet the criteria for somatization disorder

8. Somatoform disorder categories

9.  The DSM-IV divides the somatoform disorders into a spectrum of disorders that include the following categories  Somatization disorder  Undifferentiated somatoform disorder  Conversion disorder  Somatoform pain disorder  Hypochondriasis  Factitious disorder  Malingering

10. Somatoform disorder categories  Somatization disorder o Refers to patients with a history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning. o All of the following are present at any time during the course of illness: four pain symptoms; two gastrointestinal tract symptoms; one sexual symptom; and one pseudoneurologic symptom.

11. Somatoform disorder categories  Undifferentiated somatoform disorder o Refers to one or more physical symptoms that cause significant distress or impairment in functioning lasting at least six months.

12. Somatoform disorder categories  Conversion disorder o Refers to symptoms or deficits of voluntary or sensory function suggesting a neurologic or general medical condition and associated with psychological factors. o Typically there is a sudden onset of a dramatic but physiologically impossible condition like paralysis, aphonia, blindness, deafness, or pseudoseizures. The presentation fits the patient's view of the disorder rather than physiology. o Unlike somatization disorder, patients with conversion disorder focus upon only one symptom.

13. Somatoform disorder categories  Somatoform pain disorder o Refers to pain in one or more sites of significant focus or severity, causing significant distress or impairment and associated with psychological factors.

14. Somatoform disorder categories  Hypochondriasis o Refers to preoccupation with the fear of having a serious disease based on a misattribution of bodily symptoms or normal functions o often seen in generalized anxiety disorder, obsessive compulsive disorder, panic disorder, major depressive disorder, and separation anxiety.

15. Somatoform disorder categories  Body dysmorphic disorder o Refers to preoccupation with an imagined or exaggerated defect in physical appearance.

16. Somatoform disorder categories  Factitious disorder o Tends to occur in patients who have some medical knowledge. o Wound healing difficulty, infection, bleeding, hypoglycemia, and gastrointestinal ailments are common presentations. o Munchausen syndrome, occurs in a subgroup of patients who feign disease, move from hospital to hospital, and submit to repeated procedures for illness they have voluntarily manufactured

17. Somatoform disorder categories  Malingering o Malingering (ie, purposely faking symptoms) occurs in the setting of substance abuse, antisocial personality disorder, and legal battles over disability, criminal prosecution, or financial compensation. Patients will not cooperate with diagnostic evaluation; a discrepancy between findings and symptoms is evident.

18. Epidemiology

19.  True somatization disorder as defined by DSM-IV is relatively uncommon (0.3 % one year prevalence in the population)  The process of somatization is very common in the general population. Over one-half of people presenting to clinicians in an outpatient setting have no organic disease,and less than one-third of new complaints have an organic disease basis

20. Clinical Presentation

21.  almost any symptom that occurs in patients with organic pathology  Pain  Gastrointestinal symptoms  Cardiopulmonary symptoms  Pseudoneurologic symptoms  Reproductive organ symptoms

22.  Even Syndromes o Atypical chest pain, o Fibromyalgia, o Chronic fatigue syndrome, o Premenstrual syndrome, o Temporomandibular joint syndrome.

23. Screening

24. Screening tests  Amnesia, Burning in sex organs, Dysmenorrhea, Lump in throat, Painful extremities, Shortness of breath, and Vomiting.  In one study, the presence of three of these seven symptoms was highly accurate for diagnosing somatization disorder

25. Treatment

26. General Principles of treatment  There is no specific therapy for somatization.  Communication among physicians is key.

27. General Principles of treatment  Basic principles of care include o Taking a thorough history o Performing a physical examination o Arranging good communication o Treating associated depression and anxiety o Encouraging and facilitating psychotherapy (CBT)

28.  Naming the illness o Patients often feel better if they can have a name to describe his multiple symptoms o Avoid the debate of whether this is an organic or psychiatric illness. o more reasonable to explain that there is no evidence of a life-threatening illness results in the set of symptoms

29. Psychotropic medication  Major depressive disorder and anxiety disorder are commonly comorbid in patients with somatization. Thus, treatment with antidepressant medications should be considered. Somatization symptoms frequently resolve when clinical depression and anxiety disorder are treated appropriately

30. Psychosocial intervention In a review of randomized trials, cognitive behavioral treatments were the most effective intervention