Chapter 9 ： Neurosis(4) Somatoform Disorders

1. Chapter 9：Neurosis(4)Somatoform Disorders Zhonghua Su, P.h D & MD Jining Medical University

2. Introduction (1) • According to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the somatoform disorders are distinguished by physical symptoms suggesting a medical condition, yet the symptoms are not fully explained by the medical condition, by substance use, or by another mental disorder. • The symptoms are severe enough to cause patients significant distress or impaired social, occupational, or other functioning. • The physical symptoms of somatoform disorders are not intentionally produced as are those of factitious disorders and malingering, but no medical condition can fully explain the somatic symptoms. • Clinicians must judge that the onset, severity, and duration of symptoms are strongly linked to psychological factors to diagnose a somatoform disorder.

3. Introduction (2) • In DSM-IV, five specific somatoform disorders are recognized: • somatization disorder, characterized by many physical complaints affecting many organ systems; • conversion disorder, characterized by one or two neurological complaints; • hypochondriasis, characterized less by a focus on symptoms than by patients' beliefs that they have a specific disease; • body dysmorphic disorder, characterized by a false belief or exaggerated perception that a body part is defective; and • pain disorder, characterized by symptoms of pain that are either solely related to or significantly exacerbated by psychological factors. • DSM-IV also has two residual diagnostic categories for somatoform disorders: Undifferentiated somatoform disorder includes somatoform disorders not otherwise described that have been present for 6 months or longer; and somatoform disorder not otherwise specified is the category for somatoform symptoms that do not meet any of the previously mentioned somatoform disorder diagnoses.

4. Classification (DSM -IV) • somatization disorder, • conversion disorder • hypochondriasis • body dysmorphic disorder • pain disorder • Undifferentiated somatoform disorder • somatoform disorder not otherwise specified

5. Introduction (3) • The categories of somatoform disorders are similar in ICD-10 and DSM-IV, except that in ICD-10, body dysmorphic disorder is a subcategory. • ICD-10 also stresses that differential diagnosis of somatoform disorders requires that a clinician know the patient well. • A patient's "degree of conviction" may be temporarily lessened by a clinician's assurances and by a physical examination, but the disorders are a culturally accepted way of exhibiting physical illness and explaining physical symptoms.

6. Somatization Disorder

7. Introduction (1) • characterized by many somatic symptoms; • distinguished by "a combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms." ; • begins before the age of 30; • may continue for years; • multiplicity of the complaints and the multiple organ systems (differ from others); • associated with significant psychological distress; • impairment in social and occupational functioning; • excessive medical-help seeking behavior.

8. Introduction (2)--history • Somatization disorder has been recognized since the time of ancient Egypt. An early name for somatization disorder was hysteria, a condition incorrectly thought to affect only women. (The word hysteria is derived from the Greek word for uterus, hystera.) • In the 17th century, Thomas Sydenham recognized that psychological factors, which he called antecedent sorrows, were involved in the pathogenesis of the symptoms. • In 1859, Paul Briquet, a French physician, observed the multiplicity of the symptoms and the affected organ systems and commented on the usually chronic course of the disorder. • Because of these astute clinical observations, the disorder was called Briquet's syndrome for a time, although the term somatization disorder became the standard in the United States when the third edition of DSM (DSM-III) was introduced in 1980.

9. Epidemiology (1) • The lifetime prevalence of somatization disorder in the general population is estimated to be 0.1 or 0.2 percent, although several research groups believe that the actual figure may be closer to 0.5 percent. • Women with somatization disorder outnumber men 5 to 20 times, but the highest estimates may be due to the early tendency not to diagnose somatization disorder in male patients. Nevertheless, it is not an uncommon disorder. With a 5-to-1 female-to-male ratio, the lifetime prevalence of somatization disorder among women in the general population may be 1 or 2 percent.

10. Epidemiology (2) • Among patients in the offices of general practitioners and family practitioners, as many as 5 to 10 percent may meet the diagnostic criteria for somatization disorder. • The disorder is inversely related to social position and occurs most often among patients who have little education and low income levels. • Somatization disorder is defined as beginning before age 30; it most often begins during a person's teenage years. • Several studies have noted that somatization disorder commonly coexists with other mental disorders.

11. Etiology • Psychosocial Factors • interpretations of the symptoms as social communication • avoid obligations • express emotions • symbolize a feeling or a belief • the symptoms substitute for repressed instinctual impulses • A behavioral perspective • Biological Factors • characteristic attention and cognitive impairments • decreased metabolism in the frontal lobes and in the nondominant hemisphere • genetic components • Research into cytokines

12. Clinical Features (1) • many somatic complaints and long, complicated medical histories • most common symptoms :nausea and vomiting, difficulty in swallowing, pain in the arms and legs, shortness of breath unrelated to exertion, amnesia, and complications of pregnancy and menstruation • Patients frequently believe that they have been sickly most of their lives.

13. Clinical features -2 • Psychological distress and interpersonal problems are prominent; anxiety and depression are the most prevalent psychiatric conditions. • Suicide threats are common, but actual suicide is rare. If suicide does occur, it is often associated with substance abuse. • Patients' medical histories are often circumstantial, vague, imprecise, inconsistent, and disorganized. Patients classically but not always describe their complaints in a dramatic, emotional, and exaggerated fashion, with vivid and colorful language; they may confuse temporal sequences and cannot clearly distinguish current from past symptoms. • Female patients with somatization disorder may dress in an exhibitionistic manner. • Patients may be perceived as dependent, self-centered, hungry for admiration or praise, and manipulative.

14. Clinical features - 3 • Somatization disorder is commonly associated with other mental disorders, including major depressive disorder, personality disorders, substance-related disorders, generalized anxiety disorder, and phobias. • The combination of these disorders and the chronic symptoms results in an increased incidence of marital, occupational, and social problems.

15. Diagnosis criteria -1 A. A history of many physical complaints that occur over a period of several years and result in treatment being sought or significant impairment in functioning beginning before age 30 B. Each of the following must have been met, with individual symptoms occurring at any time during the course of the disturbance: • 4 pain symptoms • 2 gastrointestinal symptoms • 1 sexual symptom • 1 pseudoneurological symptom

16. Diagnosis criteria -2 • four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, during urination) • two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods) • one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy) • one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucination, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting

17. Diagnosis criteria -3 C. Either 1 or 2: 1. After appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known GMC or substance 2. When there is a related GMC, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings. D. The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering)

18. Differential diagnosis - 1 • nonpsychiatric medical conditions • multiple sclerosis, myasthenia gravis, systemic lupus erythematosus, acquired immune deficiency syndrome (AIDS), acute intermittent porphyria, hyperparathyroidism, hyperthyroidism, and chronic systemic infections. • Many mental disorders • major depressive disorder, generalized anxiety disorder, and schizophrenia • panic disorder • other somatoform disorders • hypochondriasis, conversion disorder, and pain somatization disorder,

19. Differential diagnosis - 2 • Clinicians must always rule out nonpsychiatric medical conditions that may explain a patient's symptoms. Several medical disorders often show nonspecific, transient abnormalities in the same age group. • These medical disorders include multiple sclerosis, myasthenia gravis, systemic lupus erythematosus, acquired immune deficiency syndrome (AIDS), acute intermittent porphyria, hyperparathyroidism, hyperthyroidism, and chronic systemic infections. • The onset of multiple somatic symptoms in patients older than 40 should be presumed to be caused by a nonpsychiatric medical condition until an exhaustive medical workup has been completed.

20. Differential diagnosis - 3 • Many mental disorders are considered in the differential diagnosis, which is complicated by the observation that at least 50 percent of patients with somatization disorder have a coexisting mental disorder. • Patients with major depressive disorder, generalized anxiety disorder, and schizophrenia may all have an initial complaint that focuses on somatic symptoms. • In all these disorders, however, the symptoms of depression, anxiety, or psychosis eventually predominate over the somatic complaints. • Although patients with panic disorder may complain of many somatic symptoms related to their panic attacks, they are not bothered by somatic symptoms between panic attacks.

21. Differential diagnosis - 4 • Among the other somatoform disorders, hypochondriasis, conversion disorder, and pain somatization disorder, patients with hypochondriasis falsely believe that they have a specific disease, whereas those with somatization disorder are concerned with many symptoms. • The symptoms of conversion disorder are limited to one or two neurological symptoms rather than to the wide-ranging symptoms of somatization disorder. • Pain disorder is limited to one or two complaints of pain symptoms.

22. Course and prognosis • chronic and often debilitating • begun before age 30 and have been present for several years • more than a year without seeking medical attention • an association between periods of increased stress and the exacerbation of somatic symptoms.

23. Treatment • regularly scheduled visits • Additional laboratory and diagnostic procedures be avoided. • emotional expressions • Psychotherapy, both individual and group • decreases personal health care expenditures (50%) • decreasing their rates of hospitalization. • helped to cope with their symptoms • to express underlying emotions • to develop alternative strategies for expressing their feelings • Giving psychotropic medications • with coexisting mental disorders • Medication must be monitored

24. Hypochondriasis

25. Introduction • In DSM-IV, hypochondriasis is defined as a person's preoccupation with the fear of contracting, or the belief of having, a serious disease. • This fear or belief arises when a person misinterprets bodily symptoms or functions. • The term hypochondriasis is derived from the old medical term hypochondrium, ("below the ribs") and reflects the common abdominal complaints of many patients with the disorder. • Hypochondriasis results from patients' unrealistic or inaccurate interpretations of physical symptoms or sensations, even though no known medical causes can be found. • Patients' preoccupations result in significant distress to them and impair their ability to function in their personal, social, and occupational roles.

26. Epidemiology and etiology • One recent study reported a 6-month prevalence of hypochondriasis of 4 to 6 percent in a general medical clinic population. • Men and women are equally affected by hypochondriasis. • Although the onset of symptoms can occur at any age, the disorder most commonly appears in people 20 to 30 years of age. • Some evidence indicates that the diagnosis is more common among blacks than among whites, but social position, education level, and marital status do not appear to affect the diagnosis.

27. Clinical features-1 • Patients with hypochondriasis believe that they have a serious disease that has not yet been detected, and they cannot be persuaded to the contrary. • They may maintain a belief that they have a particular disease; as time progresses, they may transfer their belief to another disease. • Their convictions persist despite negative laboratory results, the benign course of the alleged disease over time, and appropriate reassurances from physicians. • Yet their beliefs are not so fixed as to be delusions. • Hypochondriasis is often accompanied by symptoms of depression and anxiety and commonly coexists with a depressive or anxiety disorder.

28. Clinical features-2 • Although DSM-IV specifies that the symptoms must be present for at least 6 months, transient hypochondriacal states can occur after major stresses, most commonly the death or serious illness of someone important to the patient, or a serious (perhaps life-threatening) illness that has been resolved but that leaves the patient temporarily hypochondriacal in its wake. • Such states that last fewer than 6 months should be diagnosed as somatoform disorder not otherwise specified. • Transient hypochondriacal responses to external stress generally remit when the stress is resolved, but they can become chronic if reinforced by people in the patient's social system or by health professionals.

29. Diagnostic criteria-1 • The DSM-IV diagnostic criteria for hypochondriasis require that patients be preoccupied with the false belief that they have a serious disease and that the false belief be based on a misinterpretation of physical signs or sensations . • The belief must last at least 6 months, despite the absence of pathological findings on medical and neurological examinations. • The diagnostic criteria also stipulate that the belief not have the intensity of a delusion (more appropriately diagnosed as delusional disorder) and that it not be restricted to distress about appearance (more appropriately diagnosed as body dysmorphic disorder). • The symptoms of hypochondriasis must be of an intensity that causes emotional distress or impairs the patient's ability to function in important areas of life. • Clinicians may specify the presence of poor insight; patients do not consistently recognize that the concerns about disease are excessive.

30. DSM-IV diagnosis criteria for ochondriasis • Preoccupation with fears of having, or the idea that one has, a serious disease based on the person-misinterpretation of bodily symptoms • The preoccupation persists despite appropriate medical evaluation and reassurance. • 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). • The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The duration of the disturbance is at least 6 months. • The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder.

31. Differential diagnosis-1 • Hypochondriasis must be differentiated from nonpsychiatric medical conditions, especially disorders that show symptoms that are not necessarily easily diagnosed. • Such diseases include AIDS, endocrinopathies, myasthenia gravis, multiple sclerosis, degenerative diseases of the nervous system, systemic lupus erythematosus, and occult neoplastic disorders.

32. Differential diagnosis-2 • Hypochondriasis is differentiated from somatization disorder by the emphasis in hypochondriasis on fear of having a disease and emphasis in somatization disorder on concern about many symptoms. • A subtle distinction is that patients with hypochondriasis usually complain about fewer symptoms than do patients with somatization disorder. • Somatization disorder usually has an onset before age 30, whereas hypochondriasis has a less specific age of onset. • Patients with somatization disorder are more likely to be women than are those with hypochondriasis, which is equally distributed among men and women.

33. Differential diagnosis-3 • Hypochondriasis must also be differentiated from the other somatoform disorders. • Conversion disorder is acute and generally transient and usually involves a symptom rather than a particular disease. The presence or absence of la belle indifference indifference is an unreliable feature with which to differentiate the two conditions. • Pain disorder is chronic, as is hypochondriasis, but the symptoms are limited to complaints of pain. • Patients with body dysmorphic disorder wish to appear normal but believe that others notice that they are not, whereas those with hypochondriasis seek out attention for their presumed diseases.

34. Differential diagnosis-4 • Hypochondriacal symptoms can also occur in patients with depressive disorders and anxiety disorders. • If a patient meets the full diagnostic criteria for both hypochondriasis and another major mental disorder, such as major depressive disorder or generalized anxiety disorder, the patient should receive both diagnoses, unless the hypochondriacal symptoms occur only during episodes of the other mental disorder. • Patients with panic disorder may initially complain that they are affected by a disease (for example, heart trouble), but careful questioning during the medical history usually uncovers the classic symptoms of a panic attack. • Delusional hypochondriacal beliefs occur in schizophrenia and other psychotic disorders but can be differentiated from hypochondriasis by their delusional intensity and by the presence of other psychotic symptoms. • In addition, schizophrenic patients' somatic delusions tend to be bizarre, idiosyncratic, and out of keeping with their cultural milieus.

35. Differential diagnosis-5 • Hypochondriasis is distinguished from factitious disorder with physical symptoms and from malingering in that patients with hypochondriasis actually experience and do not simulate the symptoms they report.

36. Course and prognosis • The course of hypochondriasis is usually episodic; the episodes last from months to years and are separated by equally long quiescent periods. • There may be an obvious association between exacerbations of hypochondriacal symptoms and psychosocial stressors. • Although well-conducted large outcome studies have not yet been reported, an estimated one third to one half of all patients with hypochondriasis eventually improve significantly. • A good prognosis is associated with a high socioeconomic status, treatment-responsive anxiety or depression, the sudden onset of symptoms, the absence of a personality disorder, and the absence of a related nonpsychiatric medical condition. • Most children with hypochondriasis recover by late adolescence or early adulthood.

37. Treatment-1 • Patients with hypochondriasis are usually resistant to psychiatric treatment although some accept this treatment if it takes place in a medical setting and focuses on stress reduction and education in coping with chronic illness. • Among such patients, group psychotherapy is the modality of choice, in part because it provides the social support and social interaction that seem to reduce their anxiety. • Individual insight-oriented psychotherapy may be useful, but is generally unsuccessful.

38. Treatment-2 • Frequent, regularly scheduled physical examinations are useful to reassure patients that their physicians are not abandoning them and that their complaints are being taken seriously. • Invasive diagnostic and therapeutic procedures should only be undertaken, however, when objective evidence calls for them. • When possible, the clinician should refrain from treating equivocal or incidental physical examination findings.

39. Treatment-3 • Pharmacotherapy alleviates hypochondriacal symptoms only when a patient has an underlying drug-responsive condition, such as an anxiety disorder or major depressive disorder. • When hypochondriasis is secondary to another primary mental disorder, that disorder must be treated in its own right. • When hypochondriasis is a transient situational reaction, clinicians must help patients cope with the stress without reinforcing their illness behavior and their use of the sick role as a solution to their problems.

40. Body dysmorphic disorder

41. Introduction-1 • DSM-IV defines body dysmorphic disorder as a preoccupation with an imagined defect (for example, a misshapen nose) or an exaggerated distortion of a minimal or minor defect in physical appearance. • To be considered a mental disorder, the preoccupation must cause patients significant distress or be associated with impairment in the patient's personal, social, or occupational life.

42. Introduction-2 • The disorder was recognized and named dysmorphophobia more than 100 years ago by Emil Kraepelin, who considered it a compulsive neurosis; Pierre Janet called it obsession de la honte du corps (obsession with shame of the body). • Freud wrote about the condition in his description of the Wolf-Man, who was excessively concerned about his nose. • Although dysmorphophobia was widely recognized and studied in Europe, it was not until the publication of DSM-III in 1980 that dysmorphophobia, as an example of a typical somatoform disorder, was specifically mentioned in the United States diagnostic criteria. • In DSM-IV, the condition is known as body dysmorphic disorder, because the DSM editors believed that the term dysmorphophobia inaccurately implied the presence of a behavioral pattern of phobic avoidance.

43. Epidemiology • The cause of body dysmorphic disorder is unknown. • The high comorbidity with depressive disorders, a higher-than-expected family history of mood disorders and obsessive-compulsive disorder, and the reported responsiveness of the condition to serotonin-specific drugs indicate that in at least some patients the pathophysiology of the disorder may involve serotonin and may be related to other mental disorders. • Stereotyped concepts of beauty emphasized in certain families and within the culture at large may significantly affect patients with body dysmorphic disorder. • In psychodynamic models, body dysmorphic disorder is seen as reflecting the displacement of a sexual or emotional conflict onto a nonrelated body part. • Such an association occurs through the defense mechanisms of repression, dissociation, distortion, symbolization, and projection.

44. Clinical features • The most common concerns involve facial flaws, particularly those involving specific parts (for example, the nose). • Sometimes the concern is vague and difficult to understand, such as extreme concern over a "scrunchy" chin. • One study found that, on average, patients had concerns about four body regions during the course of the disorder. The specific body part may change during the time a patient is affected with the disorder. • Common associated symptoms include ideas or frank delusions of reference , either excessive mirror checking or avoidance of reflective surfaces, and attempts to hide the presumed deformity. • The effects on a person's life can be significant; almost all affected patients avoid social and occupational exposure. • As many as one third of the patients may be housebound because of worry about being ridiculed for the alleged deformities, • and as many as one fifth attempt suicide. • As previously discussed, comorbid diagnoses of depressive disorders and anxiety disorders are common, and patients may also have traits of obsessive-compulsive, schizoid, and narcissistic personality disorders.

45. Diagnosis criteria • Preoccupation with an imagined defect in appearance. If a slight physical anomoly is present, the person-concern is markedly excessive. • The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

46. Preoccupation with an imagined defect in appearance. If a slight physical anomoly is present, the person-concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa). 想象的外表缺陷的先占观念。如果有轻微身体异常，但患者的关心明显过份。 上述先占观念导致具有临床意义的痛苦或社会、职业或其它重要功能损害。 上述先占观念不能由其它精神障碍解释（如神经性厌食症对体形或身材的不满） Diagnostic Criteria

47. Differential diagnosis-1 • Distortions of body image occur in anorexia nervosa, gender identity disorders, and some specific types of brain damage (for example, neglect syndromes); body dysmorphic disorder should not be diagnosed in these situations. • Body dysmorphic disorder must also be distinguished from a person's normal concern about appearance. • In body dysmorphic disorder, however, a person experiences significant emotional distress and functional impairment because of the concern.

48. Differential diagnosis-2 • Although distinguishing between a strongly held idea and a delusion is difficult, if a patient's preoccupation with the perceived body defect is, in fact, of delusional intensity, the appropriate diagnosis is delusional disorder, somatic type. • Other diagnostic considerations are narcissistic personality disorder, depressive disorders, obsessive-compulsive disorder, and schizophrenia. • In narcissistic personality disorder, concern about a body part is only a minor feature in the general constellation of personality traits. • In depressive disorders, schizophrenia, and obsessive-compulsive disorder, the other symptoms of these disorders usually evidence themselves in short order, even when the initial symptom is excessive concern about a body part.

49. Course and prognosis • The onset of body dysmorphic disorder is usually gradual. • An affected person may experience increasing concern over a particular body part until the person notices that functioning is being affected. • Then the person may seek medical or surgical help to address the presumed problem. • The level of concern about the problem may wax and wane over time, although the disorder is usually chronic if left untreated.

50. Treatment • Treatment of patients with body dysmorphic disorder with surgical, dermatological, dental, and other medical procedures to address the alleged defects is almost invariably unsuccessful. • Although tricyclic drugs, monoamine oxidase inhibitors, and pimozide (Orap) have been reported to be useful in individual cases, a larger body of data indicate that serotonin-specific drugs-for example, clomipramine (Anafranil) and fluoxetine (Prozac)-are effective in reducing symptoms in at least 50 percent of patients. • In any patient with a coexisting mental disorder, such as a depressive disorder or an anxiety disorder, the coexisting disorder should be treated with the appropriate pharmacotherapy and psychotherapy. • How long treatment should be continued when the symptoms of body dysmorphic disorder have remitted is unknown.