Somatoform Disorders

1. Somatoform Disorders • Also know as Hysteria (Freud) • Conditions involving physical complaints or disabilities that occur without physical pathology • NOT psychosomatic disorders… • Somatization Disorder • Conversion Disorder • Pain Disorder • Hypochondriasis • Body Dysmorphic Disorder

2. Somatization disorder 1. Previously known as “hysteria” 2. Usually strikes before the age of 30 3. Commonly develop more symptoms during times of emotional distress 4. Generally history of vague symptoms related to specific body systems--cause him/her to see variety of physicians 5. Often self-rate their health as very poor even lower than people with chronic medical conditions 6. Significant social, occupational, and/or other impairment 7. Most common symptoms related to gastrointestinal, sexual/reproductive and neurologic body systems 8. Symptoms not intentionally produced

4. In the not too distant past, conditions like asthma were thought to be somatoformdisorders. QUESTION: Are the somatoform disorders, as defined by DSM IV (THX), purely psychological, or do youbelieve that they are biological and it is a matter of time until doctors identify the etiology?

5. Conversion Disorder • Conversion of emotional difficulties into the persistent loss of a physiological function • Paralysis, loss of feeling, exceptional sensitivity, mutism, blindness, deafness • Not faking a physical problem • Cannot be explained physically

6. Conversion disorder 1. Only one symptom (whereas a person with somatization disorder has several) which can appear at any age 2. Sensorimotor disturbance of bodily functions a. range of sensory symptoms: paresthesia (abnormal sensations, such as tingling, numbness, or heightened sensation), and anesthesia (loss of feeling) to blindness and deafness b. range of motor symptoms: tics to seizures to paralysis 3. Sometimes precipitated by a severe trauma such as rape, deep anger and frustration, disaster, war, etc. 4. Typically begins/ends abruptly relapsing within 5 yrs

7. Conversion disorder…cont. 5. Affected body part sometimes related to inner psychological conflict person is experiencing Example: A husband, who is denying his anger and growing dislike towards his spouse, may be experiencing a deep unconscious hatred and desire to hurt his wife. He could experience paralysis of his dominant arm and not know why. 6. Contracture may occur after disorder ends if there is long-term paralysis. 7. Tends to be strong denial against possible psychological explanations 8. Prognosis generally good with only 20% of patients relapsing within 5 years

9. Pain disorder 1. Patient consistently preoccupied with unexplained pain for period of over 6 months 2. Frequently prevents individual from attending work or school 3. Frequent medication use and relationship problems 4. Contributes to work disability in about 10 to 15 % of the population 5. Pain often leads to depression, suicide, social isolation and results in expenditure ofmany resources trying to find a cure 6. Treatment might include use of nerve blocks, and carefully controlled pain medications

11. Hypochondriasis 1. Preoccupation with fears of heaving serious disease or chronic belief that one has a serious illness 2. Hyperawareness of normal bodily sensations such as heartbeat or breathing 3. Do not want to be referred to psychiatrists 4. Most treated by family physicians with physicals and reassurance that they do not have serious ailment 5. 6+ mos.

14. Hippocrates used the term hypochondrium in the 4th century BC to refer to the anatomic area below the ribs. Later, the term hypochondriasis emerged to refer to the ill effects upon the psyche and soma of humors or fluids that emanate from the hypochondrium and cause disease. The term hypochondria is from the Greek - literally 'below the cartilage', referring to the lower ribs and the underlying spleen and liver. Its application to mental states comes from the theory of humours, relating moods to the liver and spleen. Similarly depression was called melancholia, literally black bile.

16. The Four Humors - Ancient Greeks (~2000 BC - 0 AD) Ancient Greek philosophers such as Hippocrates 400 BC and Galen, 140/150 AD classified 4 "humors" in people.  Each type was believed to be due to an excess of one of four bodily fluids, corresponding to their character.  The personalities were termed "humors" Character Humor Fluid Corresponding Type Irritable Choleric yellow bile Ruling type Depressed Melancholic black bile Avoiding type Optimistic Sanguine blood Socially useful type Openness to experience Calm Phlegmatic phlegm Leaning type/Neuroticism

17. Body Dysmorphic Disorder 1. Normal-appearing person is preoccupied with imagined or minor physical defect 2. Pervasive feeling of ugliness despite a normal appearance 3. Body parts that are often thought to be inferior – face, hair, breasts and genitalia 4. Average age of patient is 30 years—some as early as five. 5. Patients may appear shy, narcissistic and/or obsessive, and will seek plastic surgery as a definitive cure

18. Body Dysmorphic disorder Body Dysmorphic Disorder (BDD) was recognized formally in 1997 in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) under the somatoform disorders. BDD is defined as “…a preoccupation with an imagined or slight defect in appearance. This preoccupation causes significant distress or impairment in social, occupational, or other areas of functioning in the person's life.”

19. Body Dysmorphic Disorder Background: Europe: more than 100 years ago, EnricoMorselli, a psychiatrist in Italy described persons with a subjective feeling of ugliness or with a slight physical defect considered abnormal by the patient but undetectable by others. He stated that these people felt miserable, were tormented by their imagined defect, and were consumed by thoughts of this defect in any situation. The term dysmorphobia was coined by him.

21. Body Dysmorphic Disorder Many are dissatisfied with their appearance in some way, so does everyone have BDD? No. Individuals with BDD usually dislike every aspect of themselves to the point of total self hatred. Will spend hours a day thinking about everything from appearance, to communication, to mistakes they've made. Often perform rituals, looking at themselves in reflective surfaces repeatedly, or ask for constant reassurance. Additionally, co-morbid with depression For an diagnosis, appearance concerns must meet the 3 Ds.

22. Body Dysmorphic Disorder True incidence of BDD is unknown, due to the secrecy of the disorder ~many people with BDD have Social Phobia and are afraid of visiting the doctor BDD affects ~1-2% of the general population; However, this is thought to be an underestimate because BDD frequently is underdiagnosed. Patients are ashamed of their problem and do not report it to their physicians.

23. Body Dysmorphic Disorder Background: > The facial area, including the skin, hair, or nose, are the most common areas of concern for many patients. >Many patients affected with BDD have co-morbid conditions, such as obsessive- compulsive disorder (OCD), major depression, delusions, or social phobia. > Of those with a primary diagnosis of BDD, 30% meet criteria for OCD.  >Approximately 2-7% of patients who undergo plastic surgery have BDD. Patients who undergo plastic surgery generally are unhappy with the results and find another part of the body with which to be concerned or continue to be consumed with thoughts about the postoperative site.