SOMATOFORM DISORDERS

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SOMATOFORM DISORDERS

• Maria L.A. Tiamson, MD
• Asst. Professor, Psychiatry
• New York Medical College

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SOMATIZATION, the concept

• Poorly understoodcrocks..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 medicines blind spots

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Psychosomatic Illnesses

• Asthma
• Ulcerative colitis
• Rheumatoid arthritis
• Eczematous disorders
• Irritable bowel syndrome

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Forms of Somatization

• Medically unexplained symptoms
• Hypochondriacal somatization
• Somatic presentation of psychiatric disorders
  (ie., depressive equivalents)

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Most common presenting symptoms

• Abdominal pain
• chest pain
• dyspnea
• headache
• fatigue

• Cough
• back pain
• nervousness
• dizziness

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Infectious Diseases

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

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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

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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)

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Pathophysiological Mechanisms

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

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Pathophysiological Mechanisms

• Psychological Mechanisms
• perceptual factors
• beliefs
• mood
• personality factors
• Interpersonal Mechanisms
• reinforcing actions of relatives and friends
• health care system
• disability system

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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

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DSM-IV Somatoform Disorders

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

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Somatization Disorder

• hysteria, Briquets Syndrome
• multiplicity of somatic complaints involving
  multiple organ systems
• female predominance
• before age 30
• chronic
• excessive medical help-seeking behavior

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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

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Somatization Disorder

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

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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

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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

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Conversion Disorder

• Symptom has a symbolic relation to the
  unconscious conflict
• la belle indifference

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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

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Conversion Disorder

• Symptoms do not conform to known anatomical
  pathways and physiological mechanisms
• often inconsistent
• DDX multiple sclerosis, myasthenia gravis,
  dystonias

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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

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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

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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

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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)

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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

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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

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Nonspecific Somatoform Disorders

• Undifferentiated somatoform disorder
• unexplained physical effects that last for at
  least six months
• Somatoform Disorder, NOS
• residual category

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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
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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
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Baron Karl Friedrich
Hieronymus von Munchausen
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Factitious Disorders

• Psychological symptoms
• Physical symptoms
• Munchausens syndrome, pseudologica fantastica,
  peregrination
• usually co-morbid with psychiatric conditions
• intentional production of symptoms but goal is
  intangible and psychologically complex

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ALERTALERTALERT...

• 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

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Symptom Types

• Total fabrications
• Exaggerations
• Simulations of the disease
• Self-induced disease

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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.

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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

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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 its all
  in your head.

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Remember...

• You should acknowledge the patients 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.

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Malingering

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

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