Somatoform Disorders

Somatoform Disorders Jacob Alexander Senior Lecturer/Consultant Psychiatrist CHSA

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

Historical background……. • “Somatoform” 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

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 • Body dysmorphic disorder- dissatisfaction with a body part • Persistent somatoform pain disorder- pain is the main complaint • Undifferentiated somatoform disorder • Somatoform disorder not otherwise specified

Somatization 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

Somatization 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

Somatization 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

Somatization disorder-aetiology Psychodynamic factors Learning theory Social/Cultural factors Biological factors Genetic factors Cytokines

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

Somatization disorder-DD, course and prognosis Differential Diagnosis • Genuine illness • Psychiatric syndromes-depression, anxiety • Life stressors with associated psychophysiological symptoms • Other somatoform disorders • 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

Somatization 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

Somatization 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

Conversion disorder Neurological complaint • With motor symptom or deficit • With sensory symptom or deficit • With seizure or convulsions • With mixed presentations

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

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

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

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

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

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

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

Hypochondriasis • Generalised and non-delusional preoccupation with fears of having a specific illness • Preoccupation persists despite appropriate medical evaluation and reassurance • Based on misinterpretation of bodily symptoms • Lasting 6 months or more • Preoccupation causes significant impairment or distress in a person’s life

Hypochondriasis-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

Hypochondriasis-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.

Body Dysmorphic disorder (BDD) • Preoccupation with an imagined defect in appearance that causes clinically significant distress or impairment in important areas of functioning. • If a slight physical anomaly is actually present, the person’s concern is excessive and bothersome. • Emil Kraeplin-dysmorphophobia • Pierre Janet- obsession de la hontu du corps

BDD • More likely to present to dermatologists, plastic surgeons, internists • Study of college students-50% preoccupied with at least one body feature, 25% reporting it had some impact on their feeling and functioning • F>M, onset at ages 15-30 • More likely to be single • Depression, anxiety, psychotic comorbidity common

BDD-commonest feature affected • Hair • Nose • Skin • Eyes • Head/face • Overall body build/ bone structure • Lips • Chin • Stomach, waist • teeth

Body Dysmorphic Disorder-etiology • Serotonin pathways? • Psychodynamic explanations- repression, dissociation, distortion, symbolization and projection, displacement • Familial and cultural concepts/ values around beauty • DD-OCD, delusional disorder, Psychosis, depression, anxiety

BDD-clinical symptoms • Ideas or delusions of reference • Avoidance of social and even occupational exposure • Excessive mirror checking or avoidance of reflective surfaces • House bound • Suicide in response to distress

BDD-course, prognosis and management • Begins in adolescence • Gradual or abrupt onset • Long and undulating course • TCAs, MAOIs, SSRIs • Augmentation of antidepressant • Psychotherapy • Surgical intervention largely unsuccessful

Pain disorder • Pain in one or more anatomical sites is the main focus • Of sufficient severity to warrant clinical attention • Causes significant distress and dysfunction • Psychological factors identified as having an important contributory role • Not intentionally produced or better accounted for by another medical condition

Aetiology Psychodynamic factors Behavioural factors Interpersonal factors Biological factors Clinical factors Heterogeneous group Long medical and surgical histories Lead pain-centric lives At risk for substance abuse/dependence Co-morbidity with depression (up to 50%) Pain disorder

Treatment Pharmacotherapy-avoid analgesics and consider antidepressants Psychotherapy-therapeutic alliance, identify source of psychological pain, cognitive strategies Other therapies-biofeedback, hypnosis, transcutaneous nerve stimulation, dorsal column stimulation Pain Control Program Course and Prognosis Abrupt onset often Increase in severity over weeks or months Acute pain prognosis better than chronic pain Pain disorder

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Somatoform Disorders