Somatoform Disorders

Somatoform Disorders

Dr. Okine

Somatoform Disorders

Have you ever used or faked Sx to get out of having to perform important activities (exams, classes, work, social functions)?

Have you ever used tactics to gain attention and sympathy?

Characteristics of the Somatoform Disorders

Somatization: the expression of psychological pain through physical sx or concerns

Unexplained physical symptoms or bodily preoccupations Somatization Disorder, Conversion Disorder, Pain

Disorder, Undifferentiated Somatoform Disorder: experiencing pain with no apparent medical basis

Hypochondriasis: preoccupation with having a serious medical condition or disease

Body Dysmorphic Disorder: preoccupation with a perceived serious defect in appearance

Characteristics of the Somatoform Disorders

Psychological factors are associated with the initiation or exacerbation of Sx

Diagnoses of exclusion – Dx requires you to rule out: Underlying general medical causes Other psychological disorders, e.g. an Anxiety

or Mood Disorder Intentional feigning or production of Sx, as in

Factitious Disorder (motivated by a desire to assume the sick role), or Malingering (motivated by external incentives for behavior, e.g. economic gain, avoiding legal responsibility)

Somatization Disorder: Diagnostic Criteria

A. History of physical symptoms: beginning before 30 occurring over several years resulting in TX being sought or

significant impairment in functioning


B. Must meet each of the following criteria during the course of the disorder:

4 Pain Sx: a Hx of pain related to at least 4 different sites (e.g. head, abdomen, back, joints, chest) or functions (e.g. menstruation, sexual intercourse, urination)

2 Gastrointestinal Sx: a Hx of at least 2 GI Sx other than pain (e.g. nausea, bloating, vomiting, diarrhea, intolerance of several foods)

1 Sexual Sx: a Hx of at least 1 sexual or reproductive Sx other than pain (e.g. sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)

1 Pseudoneurological Sx: a Hx of at least 1 Sx or deficit suggesting a neurological condition without pain (e.g. impaired coordination or balance, paralysis, localized weakness, difficulty swallowing, lump in throat, loss of touch or pain sensation, double vision, blindness, deafness, seizures, urinary retention)


C. Either (1) or (2):(1) Symptoms not fully accounted for by a general medical condition or the effects of a substance(2) When there is a related medical condition, the complaints and resulting social or occupational impairment exceed what would be expected

D. Symptoms are not intentionally feigned or produced, as in Factitious Disorder or Malingering

Somatization Disorder: General Characteristics

a complex medical history inconsistencies between subjective

complaints and objective findings colorful, dramatic quality to

complaints – exaggerating and elaborating on physical and psychiatric Sx

respond to psychological/social problems with physical symptoms

Somatization Disorder: Facts & Figures

Prevalence: 0.2-2% among women; less than 0.2% among men.

Course: chronic, fluctuating disorder; rarely remits completely

Onset: adolescence; before 25 years old

Most common among those who are: unmarried, female, & from lower SES groups

Somatization Disorder: Causes Hx of family illness or injury during

childhood Neurobiologically-based

disinhibition syndrome characterized by impulsive behavior and pleasure-seeking

Short-term gain of immediate attention and sympathy

Dependence

Somatization Disorder: Treatment Considerations

No well-established treatment. Most crucial issue is to “do no harm.” Harm can be

done by not considering a possible medical basis for Sx, by unnecessary medical tests & Tx, & by inadequate Tx for valid medical conditions

Comprehensive assessment: medical history – illnesses, surgeries, pain, fatigue,

distress produced by Sx current medications abused substances psychiatric symptoms – comorbid disorders that could

account for Sx Stressors – past, present, typical response to stress Use additional informants & review medical records

Somatization Disorder: Treatment Considerations

Long term supportive psychotherapy: therapist can provide an important, reassuring, sympathetic relationship; use brief, widely-spaced sessions

Antidepressants Use of a “gate-keeper” physician Work in tandem with a primary care

physician & psychiatrist

Undifferentiated Somatoform Disorder: Diagnostic Criteria

A. One or more physical complaints (fatigue, loss of appetite, GI Sx, urinary complaints) which:

cause significant distress or impairment warrant medical attention last for at least 6 monthsB. R/O alternative explanations for sx: General medical conditions Effects of a substance Factitious Disorder or Malingering Other psychological disorders

Conversion Disorder:Diagnostic Criteria

A. One or more Sx or deficits affecting voluntary motor or sensory functioning and indicative of a neurological or other medical condition

B. Psychological factors are associated with the Sx – the initiation or exacerbation of Sx is preceded by conflicts or stressors

C. The Sx is not intentionally feigned or produced, as in Factitious Disorder or Malingering

D. The Sx cannot be fully explained by a general medical condition, the effects of a substance, or a culturally sanctioned behavior or experience

E. Sx cause significant distress or impairment in functioning or warrant medical attention

F. The Sx is not limited to pain or sexual dysfunction, does not occur exclusively in the course of Somatization Disorder, and is not better accounted for by another mental disorder

Conversion Disorder: Specifiers

Specifiers: With Motor Sx or Deficits – e.g. impaired

coordination or balance, paralysis, localized weakness, difficulty swallowing, lump in throat, urinary retention

With Sensory Sx or Deficits – loss of touch or pain sensation, double vision, blindness, deafness, hallucinations

With Seizures or Convulsions With Mixed Presentation

Conversion Disorder: Facts & Figures

More common in: rural populations lower SES less medically/psychologically sophisticated women than men (2-10x)

In women, sx are much more common on the left than right side of the body

11-500 out of 100,000 in general population meet criteria for conversion disorder

3% of outpatient referrals to mental health clinics 1-14% of medical/surgical inpatients Onset: late childhood through early adulthood;

rarely before 10 or after 35

Conversion Disorder:Assessment

Assess the following: physical sx, medical conditions, medications,

abused substances, psychiatric symptoms, and stressors and conflicts

the person’s level of medical knowledge whether the person may be intentionally feigning

symptoms manner of presenting symptoms – dramatic and

histrionic or la belle indifference R/O underlying neurological or general medical

conditions by referral for a thorough neuorological examination: 5-10% have real medical problems

Conversion Disorder: Theory

Psychoanalytic: The person experiences a traumatic event, which produces

anxiety and psychological conflict Anxiety and unconscious psychological conflict are

converted to somatic symptoms Sx provide primary gain (reduce anxiety and keep the

conflict out of awareness) Sx provide secondary gain (the person obtains external

benefits, such as attention or sympathy, or evades noxious duties and responsibilities)

Getting sick provides the person an escape from a traumatic situation

Hx of significant stress Over-involved and over-protective parents Prior experience with real physical problems Underlying psychopathology

Conversion Disorder: Treatment Considerations

Role of suggestibility – patients can be suggested into & out of Sx

Identify and attend to the traumatic or stressful life event Address current psychosocial stressors with environmental

manipulation, support, advice, and coping skills Reduce any reinforcing or supportive consequences from the

conversion Sx Insight-oriented therapies usually aren’t indicated or helpful For acute Sx: positive expectation for recovery; a face-saving

way for the patient to recover, e.g. physical therapy For chronic Sx: physical rehabilitation, suggestion, &

psychotherapy Work closely with a medical doctor and psychiatrist

Pain Disorder: Diagnostic Criteria

A. Pain in one or more anatomical sites is the predominant focus of clinical presentation and is of sufficient severity to warrant clinical attention.

B. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.

C. Pain causes clinically significant distress or impairment in important areas or functioning or warrants medical attention.

D. Pain is not intentionally feigned or produced, as in Factitious Disorder or Malingering.

E. Pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder.

3 Types of Pain Disorder Pain Disorder Associated with Psychological

Factors: psychological factors have a major role in the onset, severity, exacerbation, or maintenance of pain

Pain Disorder Associated with a General Medical Condition: GMC or site of pain is coded on Axis III, e.g. low back, sciatic, pelvic, headache, chest, joint, abdominal, throat, urinary

Pain Disorder Associated with Both Psychological Factors and a General Medical Condition: most common

Pain Disorder: Specifiers

Acute: duration less than 6 months

Chronic: duration 6 months or longer

Pain Disorder: Treatment Considerations

Collect info regarding physical Sx, medical conditions, medications, abused substances, psychiatric symptoms, stressors and conflicts

Distinguish from Factitious Disorder or Malingering

Target both the physical and psychological aspects of chronic pain

Validate the person’s pain, rather than challenging or insight

Enlist the person’s cooperation in developing strategies for dealing with pain

Pain Disorder: Treatment Considerations

Pain management: teach techniques for coping with pain; use of analgesic, anti-inflammatory, and antidepressant medications

Cognitive behavioral techniques: distraction, stress management, cognitive restructuring, activity pacing, sleep management, logging activities attempted and level of pain associated with each

Attend to factors that influence recovery: acknowledging pain; giving up unproductive efforts to control pain; participating in regularly scheduled activities despite pain; recognizing and treating comorbid disorders; adapting to a potentially chronic condition; not allowing the pain to become the determining factor in one’s lifestyle

Hypochondriasis: Diagnostic Criteria

A. Preoccupation with fear of having or belief that one has a serious illness, based on misinterpretation of bodily Sx or functions

B. Preoccupation persists despite appropriate medical evaluation, reassurance, and the person’s not developing the feared disease

C. Preoccupation lasts at least 6 monthsD. Preoccupation causes clinically significant distress

or impairment in important areas of functioningE. Preoccupation is not better accounted for by other

disorders, such as GAD, OCD, Panic Disorder, Major Depression, Separation Anxiety, or another Somatoform Disorder

Hypochondriasis

Specifier: With Poor Insight: person doesn’t

recognize the preoccupation is excessive or unreasonable

Prevalence: 1-5% in general population Gender Differences: Sex ratio is 50-50

Hypochondriasis: Causes Faulty interpretation of bodily cues and

sensations as evidence of physical illness Enhanced sensitivity to, & over-focusing

on, physical sensations and illness cues Stressful life events Disproportionate incidence of disease in

family during childhood Secondary gains associated with the sick

role: decreased responsibility and increased attention

Hypochondriasis: Treatments

Cognitive behavioral treatment: identifying & challenging illness-related misinterpretations of bodily sensations; showing patients how to create Sx by focusing attention on certain body areas

Stress management Explanatory therapy: reassurance &

education regarding the source and origins of Sx

Body Dysmorphic Disorder: Diagnostic Considerations

A. Preoccupation with an imagined defect in appearance or markedly excessive concern about a slight physical anomaly

B. The preoccupation causes clinically significant distress or impairment in important areas or functioning

C. The preoccupation is not better accounted for by another mental disorder, such as distorted body image in Anorexia Nervosa

Body Dysmorphic Disorder: Common Features

Constant and excessive use of mirrors Avoidance of mirrors Lots of time spent grooming Lots of grooming rituals Attempts to hide parts of body Constantly seeking reassurance about

looks, while discounting feedback Anxiety or depression about one’s

appearance

Body Dysmorphic Disorder: Facts & Figures

People with BDD often seek help from dermatologists and plastic surgeons (rates of BDD in these settings is 6-15%)

BDD is under-recognized & under-diagnosed in nonpsychiatric settings

BDD is infrequent in mental health settings Onset: adolescence and young adulthood

Body Dysmorphic Disorder: Causes

Defense mechanism of displacement: displacing underlying psychological conflict and anxiety onto a body part

Variant of OCD

Body Dysmorphic Disorder: Treatment

There is little to no research on treatments for BDD

Distinguish BDD from normal concerns about appearance or overvaluing of appearance (resistant to reality testing and reassurance; cause significant distress or impairment; delusional)

Pharmacotherapy: SSRI’s at higher doses & for longer duration

CBT strategies: exposure and response prevention, self-esteem building, modifying distorted thinking, and coping strategies

Documents

Somatoform Disorders