SOMATOFORM DISORDERSMaria L.A. Tiamson, MD

Asst. Professor, Psychiatry

New York Medical College

SOMATIZATION, the concept

Poorly understood…”crocks”..”turkeys”.. “hysterics”..”worried well”

the tendency to express and communicate psychological distress in the form of somatic symptoms for which they seek medical help

“one of medicine’s blind spots”

Psychosomatic Illnesses

Asthma Ulcerative colitis Rheumatoid arthritis Eczematous disorders Irritable bowel syndrome

Forms of Somatization

Medically unexplained symptoms Hypochondriacal somatization Somatic presentation of psychiatric

disorders (ie., depressive equivalents)

Most common presenting symptoms Abdominal pain chest pain dyspnea headache fatigue

Cough back pain nervousness dizziness

Infectious Diseases

Lyme disease AIDS Infectious mononucleosis Syphilis Chronic Fatigue Syndrome Post-infection syndromes

SOMATIZATION, the cost

10% of total direct healthcare costs with the potential to bankrupt the healthcare financing system

Somatizers have 9x more total charges, 6x more hospital charges, 14x more MD services

Somatizers are sick in bed an average of 7 days a month vs. 0.48 days for the general population

SOMATIC COMPLAINTS

Patients who experience their symptoms but do not deliberately produce them (SOMATOFORM DISORDERS)

Patients who knowingly create symptoms in themselves, either for material gain (MALINGERING), or for more subtle benefits, such as gratification of the patient role (FACTITIOUS DISORDERS)

Pathophysiological Mechanisms

Physiological Mechanisms• autonomic arousal• muscle tension • hyperventilation• vascular changes• cerebral information processing• physiological effects of inactivity• sleep disturbance

Pathophysiological Mechanisms Psychological Mechanisms

• perceptual factors• beliefs• mood• personality factors

Interpersonal Mechanisms• reinforcing actions of relatives and friends• health care system• disability system

DSM-IV Somatoform Disorders

A group of disorders that include medical symptoms and complaints FOR WHICH AN ADEQUATE MEDICAL EXPLANATION CANNOT BE FOUND.

Not intentionally produced Onset, severity and duration of symptoms

are strongly linked to psychological factors

DSM-IV Somatoform Disorders

Somatization Disorder Conversion Disorder Hypochondriasis Body Dysmorphic Disorder Somatoform Pain Disorder Undifferentiated Somatoform Disorder Somatoform Disorder, NOS

Somatization Disorder

“hysteria”, Briquet’s Syndrome multiplicity of somatic complaints

involving multiple organ systems female predominance before age 30 chronic excessive medical help-seeking behavior

Somatization Disorder

Cannot be fully explained by any known GMC or substance use

if GMC is present, physical complaints or impairment are in excess of what could be expected

significant impairment in functioning

Somatization Disorder

Four pain symptoms One sexual symptom One pseudoneurological symptom Two GI symptoms

Somatization Disorder

Complaints described in colorfiul, exaggerated terms but lack specific factual information

prominent anxiety and depressive symptoms

10-20% female 1st degree relatives of SD women, increased ASPD and SUD in male rrelatives

Conversion Disorder

Monosymptomatic (one or more neurological symptoms)

Most common in• adolescents, young adults• rural populations• low education and low IQ• low socioeconomic group• military personnel exposed to combat

Conversion Disorder

Symptom has a symbolic relation to the unconscious conflict

“la belle indifference”

Conversion Disorder

Impaired coordination, balance paralysis, weakness aphonia, difficulty swallowing, lump in the

throat urinary retention loss of touch/pain, double vision, blindness deafness, seizures

Conversion Disorder

Symptoms do not conform to known anatomical pathways and physiological mechanisms

often inconsistent DDX: multiple sclerosis, myasthenia gravis,

dystonias

Conversion Disorder

Dramatic or histrionic suggestible sx are self-limited and do not lead to

physical changes/disability associated with dissociative disorders,

MDD, histrionic, antisocial and dependent personality disorders

Hypochondriasis

Preoccupation with the fear of contracting, or the belief of having, a serious disease

Usually with co-morbid depression, anxiety Misinterpretation of physical symptoms and

sensations Request for admission to the “sick role”,

which offers an escape

Hypochondriasis

Preoccupation is with any of the ff: bodily functions, minor physical abnormalities, vague and ambiguous physical sensations

medical history is presented in great detail and length

“doctor shopping” associated with serious illness in childhood, past

experience with disease in a family member

Body Dysmorphic Disorder

Preoccupation with an imagined defect or an exaggerated distortion of a minimal or minor defect in physical appearance

dysmorphophobia Comorbid with major depression (90%),

anxiety disorder (70%), psychotic disorder (30%)

Body Dysmorphic Disorder

Marked distress over supposed deformity frequent mirror checking and checking in

other reflecting surfaces excessive grooming behavior use of special lighting or magnifying

glasses avoidance of usual activities

Somatoform Pain Disorder

Presence of pain that is the “predominant focus of clinical attention”

Not fully accounted by a nonpsychiatric medical or neurological condition

The symbolic meaning of body disturbances relate to atonement for perceived sin, to expiation of guilt, or to suppressed aggression

Nonspecific Somatoform Disorders Undifferentiated somatoform disorder

• unexplained physical effects that last for at least six months

Somatoform Disorder, NOS• residual category

Relation of Depression and Somatization Patients with SD have a high prevalence of

depression (48-94%) Patients with MDD have substantial levels

of somatization (63-84%) Depression can be treated successfully

when it coexists with SD

Smith, 1992

Relation of Depression and Pain

Patients with chronic pain have a significant current prevalence of depressive disorders

More than half of patients with MDD complain of pain

Pain is reduced with the treatment of depression

Smith, 1992

Baron Karl Friedrich Hieronymus

von Munchausen

Factitious Disorders

Psychological symptoms Physical symptoms Munchausen’s syndrome, pseudologica

fantastica, peregrination usually co-morbid with psychiatric conditions intentional production of symptoms but goal

is intangible and psychologically complex

ALERT…ALERT…ALERT...

Numerous surgical scars, usually in the abdominal area

Patient is truculent and evasive Personal and medical history were fraught

with acute and harrowing adventures History of many hospitalizations, malpractice

claims, insurance claims Involved in the healthcare profession

Symptom Types

Total fabrications Exaggerations Simulations of the disease Self-induced disease

A Physical Diagnosis is more likely if…. Symptoms do not meet DSM-IV criteria. Premorbid social history is unremarkable. There is an ABRUPT change in personality,

mood, or ability to function. There are RAPID fluctuations in mental

status. There is lack of response to usual biologic or

psychologic interventions.

Principles of Management

Emphasize explanation Arrange for regular follow-up Treat mood/anxiety disorder Minimize polypharmacy and multiple

diagnostic tests Provide specific treatment when indicated

Remember….

Reassurance that “nothing is wrong” does NOT help.

The patient does not want symptom relief but rather a RELATIONSHIP and understanding.

Little is to be gained by saying that “it’s all in your head”.

Remember...

You should acknowledge the patient’s plight, avoid challenging the patient.

A positive organic diagnosis will not cure the patient.

SOMATIZATION MAY CO-EXIST WITH ANY PHYSICAL ILLNESS AND MAY INITIALLY MASK THE ILLNESS.

Malingering

Intentional fabrication of symptoms to achieve a secondary gain, usually material benefits