K17 - Somatoform Disorders

* Elmeida EffendyDepartment of Psychiatry Medical Faculty- USU

Somatoform soma (Greek) : bodySomatoform disorders : a broad group of illnesses that have bodily signs and symptoms as a major component*

*

Categories of Somatoform Disorders in ICD-10 & DSM-IVICD-10Somatization disorderUndifferentiated somatoform disorderHypochondriacal disorderSomatoform autonomic dysfunctionPersistent pain disorderOther somatoform disordersNo categoryNo categoryNeurastheniaDSM-IV TRSomatization disorderConversion disorderHypochondriasisBody dysmorphic disorderPain disorderUndifferentiated somatoform disorderSomatoform disorderNo category

*

*DSM -5 :Somatic Symptom and Related Disorders

Somatic Symptom and Related Disorders)Somatic Symptom Disorder (311)Specify if: With predominant painSpecify if: PersistentSpecify current severity: Mild, Moderate, Severe Illness Anxiety Disorder (315)Specify whether: Care seeking type. Care avoidant typeConversion Disorder (Functional Neurological Symptom Disorder) (318)Feeding and Eating Disorder*

Specify symptom type:(F44.4) With weakness or paralysis(F44.4) With abnormal movement(F44.4) With swallowing symptoms(F44.4) With speech symptom{F44.5) With attacks or seizures(F44.6) With anesthesia or sensory loss(F44.6) With special sensory symptom(F44.7) With mixed symptomsSpecify if: Acute episode, PersistentSpecify if: With psychological stressor (specify stressor). Without psychological stressor

*

Psychological Factors Affecting Other Medical Conditions (322)Specify current severity: Mild, Moderate, Severe, ExtremeFactitious Disorder (includes Factitious Disorder Imposed on Self,Factitious Disorder Imposed on Another) (324)Specify Single episode. Recurrent episodesOther Specified Somatic Symptom and Related Disorder (327)Unspecified Somatic Symptom and Related Disorder (327)

*

Somatization DisorderEssential feature : multiple somatic complaints in of long duration, beginning before the age 30 multiple organ systems that occurs over a period of several years and results in significant impairment or treatment seeking, or bothDiffers from other somatoform disorders because of the multiplicity of the complaints and the multiple organ systems that are affected*

Chronic, associated with significant psychological distress,impaired social and occupational functioning and excessive medical-help seeking behavior

Early name for somatization disorder : hysteria (condition incorrectly thought to affect only women)

*

1859 Paul Briquet, French physician , observed the multiplicity of symptoms and affected organ systems and commented on the usually chronic course of the disorder: Briquets syndrome*

DSM-IV-TR CriteriaA. A history of many physical complaints beginning before age 30 yearsB. Each of the following criteria must have been met, with individual symptoms occuring at anytime during the course of disturbance :*

4 pain symptoms : head, abdomen, back, joints,extremities, chest, during menstruation 2 gastrointestinal symptoms : nausea, bloating, vomiting, diarrhea 1 sexual symptom : erectile/ejaculatory dysfunction,irregular menses, excessive menstrual bleeding1 pseudoneurological symtom : impaired coordination,paralysis,weakness, difficulty swallowing, urinary retention,hallucination,blindness*

EpidemiologyPrevalence : < 1 %Women : men = 2:1Treatment Continuing care by 1 doctor using only the essential investigations can reduce the use of health services & may improve patients functional state*

HypochondriasisThe term hypochondriasis is one of the oldest medical terms, originally used to describe disorders believed to be due to disease of the organs situated in the hypochondrium. It is now defined by DSM-IV & ICD-10 in terms of conviction & or fear of disease unsupported by the results of appropriate medical investigation*

DSM-IV described the condition as a preoccupation with a fear or belief of having a serious disease based on the individuals interpretation of physical signs of sensations as evidence of physical illness. Appropriate physical evaluation doesnt support the dx of any physical disorder than can account for the physical signs or sensations or for the individuals unrealistic interpretation of them*

AetioloyThe cause is unknownCognitive formulations suggest that there is faulty appraisal of normal bodily sensations which are interpreted as evidence of disease. This misinterpretation is maintained by behaviours such as continually seeking reassurance & examining or rubbing the supposedly affected part*

TreatmentRepeated reassurance is unhelpful & may serve to prolong the patients concerns.Investigations should be limited to those indicated by the medical priorities & not extended to satisfy the patients other concernMisinterpretations of the significance of bodily sensations should be corrected & encouragement given to constructive ways of coping with symptoms*

Body Dysmorphic DisorderDysmorphophobiaThe preoccupation with the imagined defect in appearance is usually an overvalued idea, but individuals can receive an additional diagnosis of Delusional Disorder, Somatic type*

Patients with dysmorphophobia are convinced that some part of their body is too large, too small or misshapen. To other people the appearance is normal or there is a trivial abnormalityThe common concerns are about the nose, ears, mouth, breasts, buttocks or penis, but any part of the body may be involved*

Assessment : questions about the nature of the preoccupations with the appearance & of the ways in which this has interfered with personal & social lifeEmbarrassmentmisdiagnosis as social phobia, panic disorder & OCDTreatment : secondary to a psychiatric disorder (MDD)Primary BDD difficult : establish a working relationship in which the patient feels that the psychiatrist is sympathetic, understands the severity of the problems & willing to help*

Pain DisorderChronic pain that is not caused by any physical or spesific psychiatric disorderDSM IV states that the essential feature : predominant focus of the clinical presentation & is of sufficient severity to cause distress or impairment of functioning, & no organic pathology or pathophysiological mechanism pain or resulting social or occupational impairment is grossly is excess of what would be expected from the physical findings*

AssessmentInvestigation of possible physical causewhen (-) remember that pain may be the first symptoms of a physical illness that cannot be detected at an early stageFull description of t/ pain & t/ circumstances in which it occursSearch for symptoms of a depressive or other psychiatric disorderDescription of pain behaviours : presentation of symptoms, request for medication, responses to painBeliefs about t/ causes of pain & of its implications*

TreatmentIndividually planned, comprehensive & involve t/ patients familySkill is required to maintain a working relationship w/ patients unwilling to accept an approach that uses psychological treatments as part of t/ treatment of pain*

Psychological care is directed to assessing any associated mental disorder Whether psychological techniques are indicated*

Some specific pain syndromes :HeadacheFacial painBack painChronic pelvic pain*

Conversion DisorderUsed in DSM-IV to replace the older term hysteriaEquivalent of dissociative (conversion) disorder in ICD-10Refers to a condition in which there are isolated neurological symptoms that cannot be explained in terms of mechanism of pathology & there has been a significant psychological stressor*

Clinical Features w/ motor symptom or deficit : impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat ,aphonia, urinary retentionw/ sensory symptom or deficit : loss of touch or pain sensation, double vision, blindness, deafness, hallucinationsw/seizures or convulsions : w/voluntay motor or sensory componentw/ mixed presentation*

Aetiology unknownPsychodynamic theories : emotional distress into physical symptoms which have a symbolic meaningSocial factors : determinants of onset & development of t/ symptomsNeurophysiological mechanism : malfunctioning of t/ normal interactions between regions of t/ brain concerned w/ t/ intention to move & those involved in t/ initiation of movement Cognitive explanationsCultural explanation*

TreatmentObtain medical & psychiatric history from patient & informantsAppropriate medical & psychiatric examination , arrange investigations for physical causesReassure that t/ condition is temporary, well recognized and for motor disorders due to a problem of converting intention into actionAvoid reinforcing symptoms or disabilityOffer continuing help w/ any related psychiatric or social problems*

*