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SOMATOFORM DISORDERS

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INTRODUCTION OF GROUP F40-48Neurotic, stress-related, and somatoform disordershave been brought together in one large overall group(F40-48) because of their historical association with theConcept of neurosis and the association of a substantial (though uncertain) proportion of these disorders withpsychological causation. The concept of neurosis hasn’t been retained as amajor organizing principle, but care has been taken to allow the easy identification of disorders that some users still might wish to regard as neurotic in their ownusage of the term.Mixed of symptoms are common (coexistent depresion& anxiety being by far the most frequent)

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THE MAIN FEATURE of F45 SOMATOFORM DISORDERS

• Repeated presentation of physical symptoms• Persisten request for medical investigation• Repeated negative findings & reassurances by

doctors that the symptoms have no physical basis (if any physical disorders are present, they don’t explain the nature & extent of the sympt. or the distress & preoccupation of the patient)

• The patient usually resists attempts to discuss the possibility of psychological causation (even be the case in the presence of obvious depressive and axiety sympt.

• There is often a degree of attention-seeking (histrionic) behaviour

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CLASSIFICATIONF45 Somatoform disorders

F45.0 Somatization disorderF45.1 Undifferentiated somatoform disorder.F45.2 Hypochondriacal disorder.F45.3 Somatoform autonomic dysfunction

.30 Heart and cardiovacular system .31 Upper gasstrointestinal tract .32 Lower gasstrointestinal tract .33 Respiratory system .34 Genitourinary system .38 Other organ or system

F45.4 Persistent somatoform pain disorder.F45.8 Other somatoform disorsder.F45.9 Somatoform disorder, unspecified

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F45.0 Somatization disorderThe main features are :

• Recurrent & frequently changing physical sympt.(which have usually been present for several years before the patient is referred to a psychiatrist)

• Most patients. have a long & complicated history of contact with both primary & specialist medical sevices, during which many negative investigations or fruitless operations may have been carried out

• Symptoms may be referred to any part or system of the body, but gastrointestinal sensations (pain, belching, regurgitation, vomiting, nausea, etc.) & abnormal skin sensations (itching, burning, tingling, numbness, soreness, etc.) & blotchiness are among the commonest

• Sexual & menstrual complaints are also common.• Marked depression & anxiety are frequently present• The course of the disorder is chronic & fluctuating (is often associated

with long-standing disruption of social, interpersonal & family behaviour)• The disorder is far more common in women, and usually starts in early

adult life

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DIAGNOSTIC GUIDELINES F45.0

D/ requires the presence of all of the following:(a) at least 2 years of multiple & variable physcl sympt

for which no adequate physcl explnation has ben found

(b) Persistent refusal to accept the advice or reas surance of several doctors that there is no physical explanation for the symptoms

(c) Some degree of impairmnt of social & family functioning attributable to the nature of the symptoms & resulting behaviour.

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Includes to these disorders• Multiple complaint syndrome• Multiple psychosomatic disorder

DD/• Physical disorder.• Affective (depressive) & anxiety disorder.• Hypochondriacal disorder.• Delusional disorder.

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F45.1 Undifferentiated somatic disorder.

• When physcl complaints are multiple, varying & persistent, but the complete & typical clinical picture of somatic disorder is not fulfilled

• Includes : undifferentiated psychosomatic. disorder.

• DD/: full syndrom of somatizatisation disorder.

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F45.2 Hypochondriacal disorderThe essential feature is :• a persist. prcupation with the possblity of having one or more serious &

progresive physical disorder.• Persist somatic complaints or preocupation with their physcl appearence• Normal or commonplace sensation & appearence are often intrepreted

as abnormal & distressing, • Attention is usually focus on 1 or 2 orgns/body’s systems• The feared physical disorder or disfigurement may be named by the

patient, but even so the degree of conviction about its presence & the emphasis upon one disor.der rather than another usually varies between consultations; the patient usually entertaint the possibility that other or additional physical disorder may exist in addition to the one given pre- eminence

• Marked depression & anxiety are often presence, and may justify additional diagnosis

• Occurs both man & woman, rarely present for the 1st time after the age of 50 yrs

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Diagnostic guidelines F45.2

Both of the following should be present :(a) Persistent belief in the presence of at least one serious

physcl illness underlying the presenting symptom / symptoms, even though repeated investigation & examination have identified no adequate physcl explanation, or a persisten preoccupation with a presumed deformity or disfigurement;

(b) Persistent refusal to accept the advice & reassurance of several different doctors that there is no physcal illness or abnormality underlying the symptoms

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*Includes :- Body dysmorphic disoder.- Dysmorphophobia

- Hypochondriacal neurosis- Hypochondriasis

- Nosophobia

DD/- Somatization disorder - Depressive disorder - Delusional disorder

- Anxiety & Panic disoder.

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F45.3 Somatoform autonomic dysfunctionThe symptoms are presented by the patient as if they were due to aphysical disorder of a system or origin that is largely or completely under autonomic innervation and control :Cardio vascular (cardiac neurosis): Respiratory (psychogenic hyperventllation & hiccough) GI (gastric neurosis & nervous diarrhoea), some aspects of GUrinary

First type : signs of autonomic arousal: palpittion, sweating, flushing, & tremor.

Second type is characterized by more idiosyncratic, subjective & non specific symptoms such as sensation of:fleeting aches & pains, burning, heaviness, tightness, beeing bloated & distended, these are referred by the patient to a specific organ or system (as the autonomic symptoms may also be).

It is the combination of clear autonomic involvement,additional nonspecific subjective complaints, and persistent referral to a particular organ or system as the cause of the disorder that gives the characteristic clinical picture.

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F45.3 Somatoform autonomic dysfunction -psychological stress, or current difficulties & problems that appear to be related to the disorder-minor disturbance of physiolgical function may also be present (hiccough, flatulence, & hyperventilation).

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DIAGNOSTIC GUIDELINES F45.3

Definite diagnosis requires all of the following:(a) symptoms of autonomic arousal, such as palpitations,

sweating, tremor, flushing, which are persistent & troublesome;

(b) Additional subjective symptoms referred to a specific organ or system;

(c) Preoccupation with & distress about the possblty of a serious (but often unspecified) disorder of the stated organ or system, which doesn’t respond to repeated explanation & reassurance by doctors;

(d) No evidence of a significant disturbance of structure or function of the stated system or organ.

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DD/- Generalized anxiety disorder (GAD)- Somatization disorder autonomic symptoms may

occur but they neither prominent nor persistent.

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Includes

A fifth character indicating the organ or system regarded by the patient as the origin of the symptoms :• F45.30 Heart & cardiovascular system

Includes : - cardiac neurosis, - Da costa syndrome, - neurocirculatory asthenia

• F45.31 Upper gastrointetsinal (GI) tractIncludes : - gastric neurosis,

- psychogenic aerophagy, - hiccough- dyspepsia, and- pylorospasm

• F45.32 Lower GI tractIncludes : - psychogenic flatulence,

- irritable bowel syndrome, - diarrhoea gas syndrome

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• F45.33. Respiratory systemIncludes : psychogenic form of cough & hyperventilation

• F45.34 Genitourinary system Includes : psychogenic increase of frequency of micturation & dysuria

• F45.38 Other organ or system.

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F45.4 Persistent somatoform pain disorder

- persistent, severe & distressing pain, which cannot be explained fully by a physiological process or physical disorder.

- Pain occurs in association with emotional conflict or psychosocial problems

- The result is usually a marked increase in support & attention, either personal or medical.

Includes : psychalgia,psychogenic backache or headache, somatoform pain disorder

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DD/

• Histrionic elaboration• Organically caused pain

Excludes:- backache NOS (M54.9)- pain NOS (acute/chronic)

(R52.-)- tension-type headache (G44.2)

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F45.8 Other somatoform disorder.

• complaints are not mediated through the autonomic nervous system, & are limited to specific systems or part of the body.

• Any other disorder of sensation not due to physical disorder which are closely associated in time with stressful events or problems, or which result in significantly increased attention for the parient, either personal or medical, should also be classified here. Sensation of swelling, movements on the skin, and paraesthesias (tingling and/or numbness) are common examples.

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Includes (a) Globus hystericus (a feeling of lump in the throat

causing dysphagia) & other forms of dysphagia;(b) Psychogenic torticolis, & other disor. of

spasmodic movements (but excluding Tourette’s syndrome)

(c) Psychogenic pruritus (but excluding specific skin lesions such as alopecia, dermatitis, eczema, or urticaria of psychogenic origin) (F54)

(d) Psychogenic dysmenorrhoea (but excluding dyspareunia (F52.6) and frigidity (F52.0)

(e) Teeth grinding

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F45.9 Somatoform disor. unspecified

Includes :Unspecfd psychophysiolgcl or psychosomtc disorder

DSM IV: 300.11 CONVERSION DISORDERA.One or more symptoms or deficits affecting involuntary motor or sensory function that suggest a neurological or other general medical condition.B.Psychological factors are judged to be associated with the symptom or deficit because the initation or exacerbation is preceded by conflicts or other stressorsC.Unexplained by general medication condition

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Type of symptoms: Motoric,sensoric,seizure or convulsions, mixed.

Notes: - relation with personality disorders.suicide - primary gain - secondary gain - la belle indifference - BODY DYSMORPHIC DISORDER

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