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Case example

• D, a ten-year-old, arrived in the eye clinic complaining his vision was deteriorating. He was a bright boy and his family looked worried. He had thorough medical assessments, and was found to have reduced distance vision (6/18 in both eyes). No medical cause for this sight loss was found.

• He attended the eye clinic with his mother and father. It transpired his parents were divorced and had remarried. D lived with the stepfather he did not care for, and a new baby half-sister. Towards the end of the consultation, the mother volunteered that her father had a neurological disease. On airing these difficult emotional issues, D then said “I see better”. He left the clinic with his vision normal and age-appropriate.

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By: Ismah Haron

• Somatoform disorder- Pain disorder- Undifferentiated somatoform disorder- Somatoform disorder not otherwise

specific (NOS)

• Psychosomatic disorder

OUTLINE

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PAIN DISORDER

• Definition:Preoccupation with pain in the absence of physical disease. The pain doesn’t follow a neuroanatomic distribution. [1]

• Epidemiology:1 month prevalence is 0.15-1.26%, >Female [2]

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Etiology

behavioral

interpersonal

biological

psychodynamics

Pain can escape from dislike activity

Pain stabilize relationship

Pain threshold

Emotional pain body pain

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DSM IV diagnostic criteria for pain disorder

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

B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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

D. The symptom or deficit is not intentionally produced or feigned.

E. The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria for Dyspareunia.

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• Antidepressant• Analgesia

Biological

• Psychoeducation• Cognitive

behavioral therapy

• Massage

Psychosocial

Treatment:

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UNDIFFERENTIATED SOMATOFORM DISORDER

DSM IV

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SOMATOFORM DISORDER NOS

• Cannot be classified in any category

• Duration is <6 months

• Examples:- Pseudocyesis- Fatigue or body weakness in less than 6 months

and not due to other mental illness

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PSYCHOSOMATIC DISORDER

Definition

Prevalence

Classification

Diagnosis

Etiology

Treatment

1. Psychological factor medical condition

2. Physical illness emotional/ mental disorder

Psyche (mind) & Soma (body)

12.5% [3]

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Physical condition affected by psychological factors

• Hypertension- Psychological theories: inhibit anger, guilt

over hostile impulse, need to gain approval from authority

- Acute stress, chronic stress- Hormonal changes

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Medical problems that present with psychiatric symptoms

Disease Psychiatric symptoms

Impaired performance and

behavior

AIDS • Depression• Anxiety

Dementia

Hypothyroidism • Thought disorder• Somatic delusion• Hallucinations

Myxedema madness;• Delusional• Paranoid• Aggressive

behavior

Pheochromocytoma • Anxiety• Panic• Trembling

Inability to function during attack

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Diagnosis

DSM IV criteria for psychological factor affecting medical condition:

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• Examples:- MDD delaying recovery from MI- Anxiety exacerbating asthma- Pathological denial of the need of surgery

in cancer patient- Stress related exacerbation of ulcer

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Etiology

A. Stress factors

Prolonged stress + organ that genetically vulnerable to stress

B. Neurotransmitt

er response Catecolamines,

serotonin, dopamine

C. Endocrine response

Cortisol

D. Immune response

Cytokines increase glucocorticoids

E. Physiological

factors General

adaption syndrome; stress affect HPA axis

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Treatment

• Collaborative approach• Biological• Psychosocial - Supportive psychotherapy- Dynamic insight oriented psychotherapy- Group therapy- Family therapy- Cognitive behavioral therapy

?

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Case example

• D, a ten-year-old, arrived in the eye clinic complaining his vision was deteriorating. He was a bright boy and his family looked worried. He had thorough medical assessments, and was found to have reduced distance vision (6/18 in both eyes). No medical cause for this sight loss was found.

• He attended the eye clinic with his mother and father. It transpired his parents were divorced and had remarried. D lived with the stepfather he did not care for, and a new baby half-sister. Towards the end of the consultation, the mother volunteered that her father had a neurological disease. On airing these difficult emotional issues, D then said “I see better”. He left the clinic with his vision normal and age-appropriate.

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SUMMARY

• Pain disorder - Preoccupation with pain in the absence of

physical disease.- Treatment

• Undifferentiated somatoform disorder (≥6 months) vs. somatoform disorder NOS (<6 months)

• Psychosomatic disorder- Mind & body

Biological

Psychosocial

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THANK YOU

References:1. KAPLAN & SADOCK; Pocket Handbook of Clinical Psychiatry 5th Edition

2. LIU, L., BI, B., QIN, X., WEI, S., WANG, W., LI, Y., JIN, Q., AI, L., PHILLIPS, M. R. & DONG, G. 2012. The prevalence of somatoform disorders in internal medicine outpatient departments of 23 general hospitals in Shenyang, China. General Hospital Psychiatry

3. HIDAYAT, D., INGKIRIWANG, E., ANDRI, A., ASNAWI, E., WIDYA, R. S. & SUSANTO, D. H. 2011. The Usage of Two Minutes Method (M2M) to Determine Mental Disorder Prevalence in Primary Care. Journal of the Indonesian Medical Association, 60.

4. DSM IV TR