Somatoform & Volitional Disorders

1. Somatoform & Volitional Disorders BabatundeIdowuOgundipe M.D. M.P.H. Comprehensive Clinical Services P.C. September 16 2011

2. Somatoform Disorders • Medically unexplained physical symptoms. • Prevalent in primary care-10-15% based on DSM IV criteria. • Associated functional impairment comparable with that seen in depressive & anxiety disorders. • Clinically significant somatization  excessive health care use costing the US health care system an estimated $100 billion annually. • Somatoform disorders include: • Somatization Disorder • Conversion Disorder • Hypochondriasis • Pain Disorder • Body Dysmorphic Disorder

3. Hypochondriasis • Unreasonable concern about one’s health & an unrealistic conviction that physical signs or symptoms indicative of serious medical disease, despite reasonable assurance that such a disease is not present. • Affects 10-15% of all patients seen in general medical practice. • Peak incidence in 4th or 5th decade. • More common in relatives patients with hypochondriasis than in general population. mental-health-disorders.org

4. Hypochondriasis DSM IV Diagnostic Criteria • A.Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms. • B.The preoccupation persists despite appropriate medical evaluation & reassurance. • C.The belief in Criterion A is not of delusional intensity (As in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder). • D.The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • E.The duration of the disturbance is at least 6 months. • F.The preoccupation is not better accounted for by a generalized anxiety disorder, obsessive compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder. • Specify if: • With poor insight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable.

5. Pain Disorder • Pain in > 1 sites not fully accounted for by a medical or neurological condition & symptoms of pain associated with emotional distress & functional impairment with plausible causal relation with psychological factors. • Pain = subjective experience that cannot be objectively measured & that is greatly influenced by many factors other than degree physical disease/injury: • (1)Patient’s psychological makeup. • (2)The presence of depression, anxiety, or psychotic disorders. • (3)The reactions elicited in the family, healthcare providers, the employer, & rest of patients environment. • (4)Stressors. • (5)Level of distraction by other stimuli.

6. Pain Disorder Somatic Pain Psychogenic or Neuropathic Pain No obvious nociceptive stimulus. Often poorly localized. Unusual, dissimilar from somatic pain. Only partially relieved by narcotic analgesics • Nociceptive stimulus evident. • Well localized: visceral pain may be referred. • Similar to other somatic pains in patient’s experience. • Relieved by anti-inflammatory or narcotic analgesics.

7. Pain Disorder Management • After ruling out medical & psychiatric causes painswitch to rehabilitation approach. • (1) Discuss with patient neurophysiological substrates of pain & explain how such factors  stress, influence behavior, and lead to impairments in functioning. • (2)Consider chronic pain programs. These provide medical + psychiatric treatment, individual therapy, group therapy, & rehabilitation programs. They minimize frustration treating physician. • (3)Consider cognitive therapy. i.e. Relaxation, visual imagery. • (4)Individual psychotherapy. • (5)Family therapy. Family plays important role in shaping patients behavior. • (6)Group therapy.

8. Somatization Disorder • Characterized by many somatic symptoms affecting multiple organ systems (i.e. gastrointestinal & neurological) that cannot be explained adequately by physical & lab exams. • Chronic disorder. Symptoms last for several years beginning prior to age 30. • Most common symptoms: painful menstruation> excessive gas/abdominal pain, & palpitations or chest pains. • Associated with severe psychological distress, impairment in social + occupational functioning, & excessive medical help-seeking behavior. http://www.ranker.com/list/somatization-disorder-symptoms/reference

9. Symptoms of somatisation disorder In DSM-IV, the diagnosis requires complaints of at least 14 symptoms (for women) and 12 symptoms (for men) from the 37 listed below: Abdominal pain Pain in extremities Joint pain Painful menstruation Chest pain Pain in genital area Pain on urination Back pain Nausea Other pain (not headaches) Vomiting spells Severe vomiting throughout Diarrhoea pregnancy or causing Bloating (“gassy”) hospitalisation during pregnancy Difficulty swallowing Intolerance of a variety of foods Shortness of breath Urinary retention or difficulty Loss of voice urinating Trouble walking Paralysis Blindness Deafness Double vision Dizziness Blurred vision Muscle weakness Memory loss Loss of consciousness or fainting Palpitations Seizures or convulsions Sexual indifference Belief that he/she has been sickly Menstrual irregularity for a good part of life Pain during intercourse Excessive menstrual bleeding Lack of pleasure during intercourse Expert rating of diagnostic usefulness of somatisation symptoms Most useful (common; patient insists cause is physical): Back pain, chest pain, muscular pain, dyspepsia, palpitations Useful (common; patients tend to accept a psychological explanation): Tension headaches, inability to relax, epigastric discomfort, feelings of heaviness or lightness in the head, breathlessness without exertion Useful (but specific to some cultures): Loss of voice, pain during intercourse, dizzy spells or seizure-like attacks without unconsciousness, burning in the sexual organs or rectum, unpleasant sensations in or around genitals Not useful (common but not specific): Sleep disturbance, irritability, abdominal pain, diarrhoea, dry mouth Not useful (rare and not specific): Deafness, complaints of vaginal discharge, urinary retention or difficulty urinating, amnesia, seizure or convulsion Singh, Bruce. Managing Somatoform Disorders. MJA Practice Essentials, 15, 90-95.

10. Somatization Disorder Management • Principles: • Best managed with single physician as primary caretaker to avoid increased opportunities to express somatic complaints. • Primary physician should see patient during regularly scheduled visits i.e monthly intervals. Visits should be brief with partial physical exam to respond to each new somatic complaint. Avoid additional lab & diagnostic procedures. • After somatization disorder diagnosed listen to somatic complaints as emotional expressions not medical complaints. • Therapy: • Psychotherapy. Individual & group decreases health care expenditures by 50% (via hospitalization rate decrease). • Psychopharmacological treatment. Monitor as such patients use drugs erratically.

11. Conversion Disorder • Physical symptoms, in particular losses of physical functioning and alterations in physical functioning are result of some psychological conflict. • Symptoms typically neurologic (onset usually rapid in response to some acute stress): • Paralysis • Seizures • Blindness • Tunnel vision • Aphonia • Akinesia • Dyskinesia • Symptoms may achieve primary gain by keeping conflict unconscious or may achieve secondary gain by causing some desired change in the environment.

12. Conversion Disorder Management • Rule out medical disorder. • Psychotherapy. • Pharmacotherapy with anxiolytic.

13. Body Dysmorphic Disorder • Patients believe they look ugly or deformed. • “they may think they have a large & ‘repulsive’ nose, or severely scarred skin, when in reality they look normal”. • As a result of concerns over appearance they may stop working & socializing, becoming housebound & eventually commit suicide. • Equal gender ratio. • Most never married. • Many unemployed. • Often begins early adolescence. howtogetridofstuff.com

14. Body DysmorphicDisorder Clinical Features • Obsession about something wrong with how they look even though perceived appearance flaw actually minimal or nonexistent. • Concerns focus most often on face or head (i.e. acne or skin color, balding, or head size) but can include any area of body or entire body. Concern of multiple areas common. • Appearance preoccupations associated with fears of rejection + feelings of low self-esteem, shame, embarrassment, unworthiness, & being unlovable. • Performance of repetitive, compulsive behaviors to examine, improve, or hide defect.

15. Body DysmorphicDisorder Management • Selective Serotonin reuptake inhibitors (SSRI’s). • Cognitive-Behavioral Therapy (CBT).

16. Factitious Disorders • Patients intentionally produce signs medical or mental disorders & misrepresent their histories & symptoms. Only objective is to assume the sick role. • Munchausen’s Syndrome by Proxy: • Someone intentionally produces physical signs or symptoms in another person who is under the first person’s care. Apparent purpose is for caretaker to indirectly assume the sick role. • Self-Inflicted Dermatitis: • Self inflicted skin wounds in which patient denies that wounds self-inflicted complaining of a dermatologic disease. However pattern of lesions (linear/geometric in shape) pathognomonic of factitious disorder. todayinhealth.com accessmedicine.ca

17. Malingering • The voluntary production of false or grossly exaggerated symptoms to achieve some clearly identifiable objective. • External motives: • (1)To avoid responsibility, danger, punishment. • (2) To receive compensation, free room & board, or drugs. • (3) To retaliate after a loss. • Common, especially settings like prisons, military, & industrial settings. • Men> women. • Often in adults with antisocial personality disorder & in children/adolescents with conduct disorder.

18. References • FIRST AID for the USMLE 3, Tao Le, VikasBhushan, Robert W. Grow, Veronique Tache. • Psychiatry History Taking. Third Edition. A Current Clinical Strategies medical book. Alex Kolevzon, Craig L.Katz. • Pocket Handbook of Primary Care Psychiatry. Harold I kaplan, M.D. Benjamin J. Sadock, M.D. • Singh, Bruce. Managing Somatoform Disorders. MJA Practice Essentials, 15, 90-95. • Phillips, Katherine. A. Body Dysmorphic Disorder: Recognizing and treating imagined ugliness(2004). World Psychiatry, 3:1, 12-17. • Arnold, Ingrid. A. et al.Somatoform Disorder in Primary Care: Course and the Need for Cognitive-Behavioral Treatment (2006).Psychosomatics, 47:6, 498-503.