Somatoform Disorders (DSM IV TR) = Somatic Symptom and related disorders (DSM V)

1. Somatoform Disorders (DSM IV TR) = Somatic Symptom and related disorders (DSM V) Jacob Alexander Senior Lecturer/Consultant Psychiatrist CHSA

2. Introduction • Group of illnesses where bodily signs and symptoms are a major focus • Believed to originate from faulty mind-body interactions- the brain sends signals that impinge on the patients awareness falsely suggesting a serious problem in the body • The symptoms are medically unexplained • Patients are convinced that their suffering comes from some type of undetected and untreated bodily derangement

3. Historical background……. • “Somatoform”/ “ Somatic” derived from Greek “soma” – body • Grouped together for the first time in the DSM III in 1980 • Observed for a long time before that and several terms used to refer to these disorders including neurasthenia, hysteria and Briquet’s syndrome • Some famous contributors-Jean Marie Charcot, Paul Briquet, Sigmund Freud

4. Somatoform disorders • Somatization disorders- multiple organ system involvement • Conversion disorders- neurological complaints • Hypochondriasis- worried about being sick with a particular illness rather than a focus on physical symptoms (Now Illness Anxiety disorder in DSM V) • Body dysmorphic disorder- dissatisfaction with a body part (Now shifted to Obsessive disorders in the DSM V) • Persistent somatoform pain disorder- pain is the main complaint (Now part of Somatic Symptom disorder in DSM V) • Undifferentiated somatoform disorder • Somatoform disorder not otherwise specified

5. DSM V: Somatic Symptoms and related disorders • Somatic Symptom Disorder • Illness anxiety disorder (Hypochondriasis) • Conversion disorder (Functional Neurological Symptom disorder) • Psychological Factors affecting other medical conditions • Factitious disorders • Other specified Somatic Symptoms and related disorders (pseudocyesis) • Unspecified Somatic Symptom and related disorder

6. Somatic Symptom disorder • One or more somatic symptoms that are distressing or result in significant disruption of daily life • Excessive thoughts, feelings or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following: • Disproportionate and persistent thoughts about the seriousness of one’s symptoms • Persistently high levels of anxiety about health or symptoms • Excessive time and energy devoted to these symptoms or health concerns C. State of being symptomatic is persistent > 6 months Specify: predominant pain, persistent, severity

7. Somatic symptom disorder A- many physical symptoms - starting before the age of 30 - occur over a period of years - leads to multiple medical consultations and other attempts at seeking treatment -significant impairment in social, occupational, or other areas of functioning B -4 pain symptoms- related to at least 4 different sites or functions -2 gastrointestinal symptoms other than pain -1sexual or reproductive symptom -1 pseudoneurological symptom

8. Somatic Symptom disorder C- despite appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance -when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what could be expected from the history, physical examination, or laboratory findings. D- the symptoms are not intentionally produced or feigned

9. Somatic symptom disorder- some facts • Commoner in women (life time prevalence 0.2-2% of women and 0.2% of men) • 5-10 % of patients presenting to a GP • Inversely related to social position • Usually beginning in teenage years • Often co-morbid with other mental dis.-depression and anxiety • Common personality traits-avoidant, paranoid, self-defeating, obsessive- compulsive

10. Somatic Symptom disorder Psychodynamic factors Learning theory Social/Cultural factors Biological factors Genetic factors Cytokines

11. Somatization disorder-clinical features (commonest) Common characteristics of presenting problem • Long, complicated medical histories-confused time frames • Patients frequently report they have been sickly all their life • Psychological and interpersonal problems • Suicide threats common but rarely acted upon • Dramatic and emotional presentation of history and appearance • Self centred, hungry for admiration, manipulative Commonest Symptoms reported • Nausea and vomiting other than during pregnancy • Pain in the arms and legs • Shortness of breath unrelated to exertion • Amnesia • Complications of pregnancy and menstruation

12. Somatic Symptom disorder-DD, course and prognosis Differential Diagnosis • Genuine illness • Psychiatric syndromes-depression, anxiety • Life stressors with associated psychophysiological symptoms • Other somatic related disorder • Voluntary psychogenic symptoms or syndromes Course • chronic, undulating and relapsing illness • Rarely fully remits- unusual for patients to be symptom free for more than a year • Not more likely than others to develop a medical illness at 20 yr follow up

13. Somatic Symptom disorder-treatment • Single, identified physician as primary care giver • Regular, scheduled visits usually at monthly intervals • Keep interviews brief with a partial physical exam for each new symptom expressed • Generally avoid lab/diagnostic investigations • Once diagnosed view these problems as being communications of emotional distress • Try and raise awareness of these symptoms being responses to psychological pressures and see if you can motivate patient to see a mental health clinician • Individual or group psychotherapy

14. Somatic Symptom disorder- tasks of psychotherapy • Decrease the patients personal health expenditures • Help to cope with their symptoms • Assist with expressing underlying emotions • Help to develop alternative strategies for expressing their feelings • Psychopharmacological intervention difficult

15. Conversion disorder Neurological complaint • With weakness or paralysis • With abnormal movement • With swallowing problems • With speech problems • With attacks or seizures • With anaesthesia or sensory loss • With special sensory symptoms • With mixed symptoms

16. Conversion disorder • Qaulifiers: • Acute Episode < 6 months • Persistent • With/out psychological stressor

17. Conversion disorder A- one or more symptoms of deficit affecting voluntary motor or sensory function that suggest a neurological or other general medical condition B-Psychological factors are judged to be associated with the symptom deficit because the initiation or exacerbation of the symptoms or deficit is preceded by conflicts or other stressors C-The symptom or deficit is not intentionally produced or feigned D-The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition or by the direct effects of a substance, or as a culturally sanctioned behaviour or experience E-Causes clinically significant distress or impairment in social, occupational or other important areas of functioning or warrants medical evaluation F-The symptoms or deficit is not limited to pain or sexual dysfunction, does not exclusively occur during the course of a somatisation disorder and is not better accounted for by another mental disorder

18. Conversion disorder Common amongst: -F>M -rural population -little education -low SES -military personnel exposed to combat situations Co-morbidities include-MDD, Anxiety, schizophrenia, somatisation, histrionic pd, passive-dependent pd

19. Motor symptoms Involuntary movements Tics Blepharospasm Torticollis Opisthotonus Seizures Abnormal gait Falling Astasia-Abasia Paralysis Weakness aphonia Sensory deficits Anaesthesia of extremities Midline anaesthesia Blindness Tunnel vision Deafness Visceral symptoms Psychogenic vomiting Pseudocyesis Globus hystericus Swooning or syncope Urinary retention diarrhoea Conversion disorder-clinical features

20. Conversion disorder-aetiology Psychodynamic factors- intra-psychic conflict, repression, sublimation, projection Learning theory/ social factors –nonverbal means of controlling and managing others Biological factors- impaired hemispheric function Genetic factors- women probands more prone to somatisation, depression and anxiety, male probands more prone to ASPD and substance abuse

21. Psychological Concepts in Somatoform disorders • Primary Gain- distracts from primary intra-psychic conflict • Secondary Gain-receives tangible benefits to sick role • La Belle indifference-indifference to what should normally be anxiety provoking symptoms • Identification-assumption of symptoms of a significant other

22. Conversion disorder-course and prognosis • Usually acute onset • 95% remit spontaneously within 2 weeks of hospital admission • If symptoms present for more than 6 months less than 50% remit spontaneously • Good prognostic factors- clearly identifiable stressor, acute onset, above average intelligence and quick institution of treatment

23. Conversion disorder- treatment • Relationship with a caring and confident psychotherapist • Insight-oriented supportive or behaviour therapy • Telling patients their symptoms are imaginary makes them worse • Hypnosis, anxiolytics and behavioural relaxation exercises • Psychodynamic psychotherapy

24. Illness Anxiety disorder • Preoccupation with having or acquiring a specific illness • Somatic symptoms not present or mild • Concern excessive if at high risk or if another medical condition present • High level of anxiety about health, easily alarmed about personal health status • Performs excessive health related behaviours or exhibits maladaptive avoidance • Lasting 6 months or more • Preoccupation causes significant impairment or distress in a person’s life

25. Illness Anxiety disorder-aetiology Psychodynamic factors- intra-psychic conflict, projection, deserving of punishment Learning theory/ social factors –symptoms often learnt from past experiences, often have related medical illnesses Biological factors- low threshold for and low tolerance of physical discomfort

26. Illness Anxiety disorder-Treatment • Psychiatric treatment in a medical setting • Focus on stress reduction and education in coping with a chronic illness • Appear to do well in group therapy because it provides them with the social support and interaction that they need • Long term regular follow up with physical exams and investigations as necessary reassures the patients that their physicians are not abandoning them and their complaints are being taken seriously. • Pharmacotherapy useful only when hypochondriacs have an underlying drug responsive condition.

27. Psychological Factors Affecting other Medical Conditions • Physical Medical condition is present • Psychological or Behavioural factors affect the medical condition: • Influence the course of the medical condition- exacerbation or delayed recovery • Interfere with treatment of the medical condition • Constitute additional well-established health risks for the individual • Factors influence underlying pathophysiology, precipitating or exacerbating symptoms necessitating medical attention Qualifiers: • Mild- increased medical risk • Moderate- aggravates underlying medical condition • Severe-results in hospitalisation or ED attendance • Extreme- results in life-threatening risk

28. Factitious disorders • Imposed on self • Imposed on another • Falsification of physical or psychological signs or symptoms • Presents as an ill person • Deception evident even in the absence of obvious external reward • Qualifiers: • Single episode • Recurrent episode

29. The End