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

5 Specific somatoform disorders:1. Somatization DO2. Conversion DO3. Hypochondriasis4. Body Dysmorphic DO5. Pain DO

SOMATIZATION DISORDERHysteria, Briquet’s SyndromeMany somatic symptomsMultiple complaints and organ systems

affectedChronic

Epidemiology Lifetime prevalence = 0.1-0.2%F > M (5-20X) = 5:1

Etiology

1. Psychosocial factors - social communication

2. Biological factors - attention and cognitive impairments

DiagnosisOnset before the age of 30 yearsComplain of at least 4 pain sxs, 2 GI

sxs, 1 sexual sx, 1 pseudoneurological sx

No physical or laboratory explanation

Clinical FeaturesMany somatic complaints; long

complicated medical historyPsychological distress: anxiety,

depressionCommon suicidal threatsMedical 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

Differential Diagnosis

1. Non-psychiatric medical condition2. Mental DO - MDD, GAD,

schizophrenia3. Other somatization DO

Course and PrognosisChronic, debilitatingOnset before age 30 years

Treatment Single identified MDVisits: regular, avoid additional

lab/diagnostic proceduresSomatic symptoms - emotional

expressionsPsychotherapy: individual, group

CONVERSION DISORDEROne or more neurological symptoms

(paralysis, blindness, paresthesias)Psychological factors --> onset,

exacerbation

Epidemiology F:M = 2:1 - 5:1Onset is any age (common during

adolescence and young adults)Rural population, little educated, low IQ,

low SE group, military personelComorbid 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

Diagnosis Symptoms or deficits affecting

neurological functionsPsychological factors --> onset,

exacerbationsNot intentionally feigned or produced

Clinical FeaturesMost common symptoms: paralysis,

blindness, mutismMost 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

2. Motor Sxs: abnormal movements, gait disturbance, weakness, paralysis

generally worsen by attention3. Seizure Sxs: pseudoseizure4. 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

Differential Diagnosis Rule out medical disorder: thorough medical

and neuro work-up 25-50% diagnosed with conversion DO -->

neuro or non-psychiatric medical DO1. Neuro DO - dementia, brain tumors,

degenerative dse, basal ganglia dse2. Psychiatric DO - schiz, deprssive DO, other

somatoform, malingering, factitious DO

Course and Prognosis90-100% resolve in few days to less

than a monthGood prognosis: sudden onset, easily

identifiable stressor, good premorbid adjustment, no comorbid psychiatric or medical DO

25-50% --> neuro or non-psychiatric DO

Treatment Spontaneously resolveInsight-oriented supportive or behavioral

therapy

HYPOCHONDRIASISUnrealistic or inaccurate interpretations

of physical symptoms or sensations --> preoccupation and fear that they have serious disease

Significant distress; impaired function

Epidemiology F = MOnset at any age

Etiology

1. Misinterpretation of bodily symptoms2. Social learning model3. 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/sxsAt least 6 monthsNot a delusion or restricted to distress

of appearance

Clinical FeaturesBelieve that they have a serious

disease not yet detectedConviction persist despite negative lab

results, benign course, reassurancesUsually with depression and anxiety

Differential Diagnosis

1. Non-psychiatric medical condition2. Other somatoform disorders3. MDD, anxiety DO, schiz, other

psychotic DO

Course and PrognosisEpisodic, months to yearsGood 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 illnessGroup psychotherapyRegular scheduled PE

BODY DYSMORPHIC DOPreoccupation with an imagined bodily

defect or an exaggerated distortion of a minimal or minor defect

Causes significant distress; impaired function

Epidemiology Rare; poorly studiedMost common age of onset: 15-30 yoF > M, unmarriedCommonly coexists with other mental

DO (MDD, anxiety, psychotic DOs)

Etiology SerotoninCultural and social effectsPsychodynamic models

Diagnosis Preoccupied with an imagined defect in

appearance or an overemphasis of a slight defect

Significant emotional distress; impaired functioning

Clinical FeaturesMost common concerns: facial flawsCommon associated symptoms: ideas

of reference, attempts to hide deformity, excessive mirror checking or avoidance

Avoid social or occupational exposureHousebound; attempt suicideTraits: O-C, schizoid, narcissistic PDComorbid: depression, anxiety DO

Differential DiagnosisAnorexia nervosa, gender identity DO,

brain damageDelusional DO, somatic typeNarcissistic PD, depressive DO, OCD,

schizophrenia

Course and PrognosisGradual onsetUsually chronic

Treatment Serotonin-specific drugs - clomipramine,

fluoxetineTreat coexisting mental DO

PAIN DISORDERPsychogenic pain DOPain in one or more sites --> no non-

psychiatric medical or neurological condition

Emotional distress; functional impairment

Epidemiology F > MPeak onset on 4th to 5th decadesBlue-collar occupation, 1st degree

relatives

Etiology 1. Psychodynamic: expression of

intrapsychic conflictdefense 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 painEmotional 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 - 60-100%

Differential Diagnosis

1. Physical pain VS Psychogenic pain1. 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 PrognosisAbrupt onset and increases in severity

Treatment Address rehabilitationPAIN 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 monthsSignificant emotional distress and

impaired functioning

2 types of somatoform pattern:1. Involving ANS: CV, GI, urogenital, derma

sxs2. Involving sensations of fatigue or

weakness (neurasthenia): mental or physical fatigue, physical weakness and exhaustion