SOMATOFORM DISORDERS

1. SOMATOFORM DISORDERS Maria L.A. Tiamson, MD Asst. Professor, Psychiatry New York Medical College

3. SOMATIZATION, the concept • Poorly understood…”crocks”..”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 medicine’s blind spots”

4. Psychosomatic Illnesses • Asthma • Ulcerative colitis • Rheumatoid arthritis • Eczematous disorders • Irritable bowel syndrome

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

6. Abdominal pain chest pain dyspnea headache fatigue Cough back pain nervousness dizziness Most common presenting symptoms

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

8. 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

9. 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)

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

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

13. 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

14. DSM-IV Somatoform Disorders • Somatization Disorder • Conversion Disorder • Hypochondriasis • Body Dysmorphic Disorder • Somatoform Pain Disorder • Undifferentiated Somatoform Disorder • Somatoform Disorder, NOS

15. Somatization Disorder • “hysteria”, Briquet’s Syndrome • multiplicity of somatic complaints involving multiple organ systems • female predominance • before age 30 • chronic • excessive medical help-seeking behavior

16. 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

17. Somatization Disorder • Four pain symptoms • One sexual symptom • One pseudoneurological symptom • Two GI symptoms

18. 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

19. 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

20. Conversion Disorder • Symptom has a symbolic relation to the unconscious conflict • “la belle indifference”

21. 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

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

23. 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

25. 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

26. 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

27. 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%)

28. 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

29. 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

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

32. 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

33. 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

34. Baron Karl Friedrich Hieronymus von Munchausen

35. Factitious Disorders • Psychological symptoms • Physical symptoms • Munchausen’s syndrome, pseudologica fantastica, peregrination • usually co-morbid with psychiatric conditions • intentional production of symptoms but goal is intangible and psychologically complex

36. ALERT…ALERT…ALERT... • 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

37. Symptom Types • Total fabrications • Exaggerations • Simulations of the disease • Self-induced disease

38. A PhysicalDiagnosis 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.

39. 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

41. 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 “it’s all in your head”.

42. Remember... • You should acknowledge the patient’s 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.

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