Somatoform disorders

Somatoform

DisordersJayesh Patidar

www.drjayeshpatidar.blogspot.com

Objectives: Somatoform disorders

Identify the diagnostic features of the most common somatoform disorders

List characteristics differentiating somatoform disorders from malingering and factitious disorders

Outline management strategies for patients with somatoform disorders.

By the conclusion of the presentation, the student will be able to:


Somatoform disorders

Context and definitions

Epidemiology

Social and medical cost


Ms. AMs. A is a 43 year old divorced woman who complains of abdominal pain. She describes a searing pain that usually follows meals, and localizes it by pointing to an area just above her umbilicus. She insists that antacids and ranitidine are of no help. She is insistent on having an endoscopy right away.

Ms. A’s chart is now on its third volume. She has made frequent visits to the practice over about 20 years, sometimes for this complaint and sometimes for others. She has had multiple diagnostic procedures, and many trials of therapy. None has brought definitive diagnosis or effective resolution of symptoms.


Somatoform disorders

Somatization disorder

Hypochondriasis

Pain disorder

Body dysmorphic disorder

Conversion disorder



“Briquet’s syndrome”

Clinical features

Epidemiology


4 pain symptoms

2 gastrointestinal symptoms

1 sexual symptom

1 pseudoneurologic symptom


DSM IV criteria


Screening criteria I - 5 of:

Abdominal gas

Diarrhea

Abdominal pain

Chest pain

Pain in extremities

Weakness

Nausea

“Feeling sickly”

Dizziness

Fainting spells

Vomiting


Screening criteria II - 2 of:

Vomiting

Pain in extremities

Dyspnea without exertion

Amnesia

Dysphagia

Burning sensation in sexual organs or rectum

Painful menstruation


Frequency of common symptoms in somatization disorder

See Andreasen & Black (4th Ed.), Table 8-3


Ms. A - 2

You remind Ms. A that she had an upper GI series of X-ray studies less than a year ago, and an upper endoscopy about six months ago. The complaints were identical then, and the results were negative. You begin to make some recommendations about changes in eating patterns, when she interrupts.

“I’ve tried all that and it doesn’t work. I know I have an ulcer and the exams last year were negative because they missed it. I never had much faith in that gastroenterologist you referred me to, anyway. You’ve got to find someone who can make the diagnosis and take care of it properly.”


Hypochondriasis

Generalized fear of or belief in illness

Prevalence in men = women

Pervasive disruption of psychosocial function


Hypochondriasis - clinical

features

Complaints: GI, pain, cardiovascular

Chronic, variable

Preoccupied, disabled

Attitudes towards physicians


Pain disorder

Pain in one or more sites

Psychological factors in origin and/or maintenance of pain


Body dysmorphic disorder

Preoccupation with imagined or slight imperfection in appearance– Most commonly: skin, hair, nose

– Also: penis, muscles, breasts, buttocks

Men = women

Some family link to OCD

SSRIs modestly helpful with quality of life


Conversion disorder

Loss of, or alteration in, physical function, resulting from psychologic need or conflict

Historical roots


Jean-Marie Charcot



Sigmund Freud


Bertha Pappenheim (“Anna O”)


A. insistence on the presence of a particular illness.

B. large variety of unsubstantiated physical complaints.

C. persistent complaints of pain with disproportionate disability.

D. personality style featuring physical manifestations of psychological problems.

E. sensory or motor symptoms suggesting neurologic origin.

The defining characteristic of conversion disorder is:


A. insistence on the presence of a particular illness.

B. large variety of unsubstantiated physical complaints.

C. persistent complaints of pain with disproportionate disability.

D. personality style featuring physical manifestations of psychological problems.

E. sensory or motor symptoms suggesting neurologic origin.

The defining characteristic of conversion disorder is:


Sensory or motor symptoms suggesting neurologic origin

Positive evidence of psychologic etiology See Andreasen & Black (4th Ed.), Table 8-5 for DSM-IV

criteria

Conversion disorder


Differential diagnosis

Malingering / factitious disorder

Somatic delusions

Mood disorder


A. Both are different names for the same condition.

B. Factitious disorder attempts to achieve psychological benefit, malingering attempts to achieve external benefit.

C. Factitious disorder is conscious, malingering is primarily unconscious.

D. Malingering is a much more chronic condition than factitious disorder.

E. Malingering patients complain of a wider variety of symptoms.

The chief difference between malingering and factitious disorder is:


A. Both are different names for the same condition.

B. Factitious disorder attempts to achieve psychological benefit, malingering attempts to achieve external benefit.

C. Factitious disorder is conscious, malingering is primarily unconscious.

D. Malingering is a much more chronic condition than factitious disorder.

E. Malingering patients complain of a wider variety of symptoms.

The chief difference between malingering and factitious disorder is:


Diagnostic algorithm

Suspicious symptoms

or complaints

Conscious attempt

to deceiveNo conscious

attempt to deceive

Somatoform disorders, e.g.:


Conversion disorder

Hypochondriasis

Chief goal

psychological

(primary gain)

Factitious

disorder

Chief goal external

(secondary gain)

Malingering


Primary gain Solution to an

internal problem

Secondary gain Environmental

influences that

perpetuate somatization


Factitious Disorder

Production of symptoms under voluntary control

− Worsen when observed

− Bizarre or ridiculous

− Wax and wane with environmental events

Goal is to assume “patient role”

External incentives absent


Malingering: DSM-IV (V65.2)

Intentional production of false or grossly exaggerated symptoms, motivated by external incentives such as obtaining financial compensation or drugs, or avoiding work, military duty, or criminal prosecution


Malingering

Symptoms under voluntary control− Patient acknowledgement

− Direct observation

− Failure to cooperate with treatment

− Rapid remission when incentives removed

Causal relationship to environmental incentive− Avoidance of work, punishment, military service

− Financial gain

− Acquisition of drugs

Cannot be explained by desire to assume patient role, or by other mental disorder


ALL PAIN

IS REALwww.drjayeshpatidar.blogspot.com

Understanding somatization

Dimensional characteristic

Pain and depression


Pain and monoamines

Limbic system Thalamus

Locus coeruleusSerotonin

Norepinephrinewww.drjayeshpatidar.blogspot.com

“I thought I had something psychosomatic,

but it turned out to be just my imagination.”


The goal is

MANAGEMENT,

not cure


Keep in

control of the

case


Schedule regular

appointments

Break the cycle of symptoms ↔ attention


Management of somatoform

disorders

Explain chronic nature of condition

Explore impact on patient’s life

Avoid implying “It’s all in your head.”

Explain tension ↔ pain cycle



Management of somatoform

disorders

•Explain chronic nature of condition

•Explore impact on patient’s life

•Avoid implying “It’s all in your head.”

• Explain tension ↔ pain cycle

•Brief physical exam


20 minutes / month

= 4 hours / year


Signs and symptoms of

depression

Hopelessness

Guilt

Irritability

Diminished interest or pleasure

Diminished energy

Sleep or appetite disturbance



Education

Somatoform disorders