Somatization

SOMATOFORM DISORDERSMaria L.A. Tiamson, MDAsst. Professor, PsychiatryNew York Medical College

SOMATIZATION, the conceptPoorly understoodcrocks..turkeys.. hysterics..worried wellthe tendency to express and communicate psychological distress in the form of somatic symptoms for which they seek medical helpone of medicines blind spots

Psychosomatic IllnessesAsthmaUlcerative colitisRheumatoid arthritisEczematous disordersIrritable bowel syndrome

Forms of SomatizationMedically unexplained symptomsHypochondriacal somatizationSomatic presentation of psychiatric disorders (ie., depressive equivalents)

Most common presenting symptomsAbdominal painchest paindyspneaheadachefatigueCoughback painnervousnessdizziness

Infectious DiseasesLyme diseaseAIDSInfectious mononucleosisSyphilisChronic Fatigue SyndromePost-infection syndromes

SOMATIZATION, the cost10% of total direct healthcare costs with the potential to bankrupt the healthcare financing systemSomatizers have 9x more total charges, 6x more hospital charges, 14x more MD servicesSomatizers are sick in bed an average of 7 days a month vs. 0.48 days for the general population

SOMATIC COMPLAINTSPatients 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)

Pathophysiological Mechanisms Physiological Mechanismsautonomic arousalmuscle tension hyperventilationvascular changescerebral information processingphysiological effects of inactivitysleep disturbance

Pathophysiological MechanismsPsychological Mechanismsperceptual factorsbeliefsmoodpersonality factorsInterpersonal Mechanismsreinforcing actions of relatives and friendshealth care systemdisability system

DSM-IV Somatoform DisordersA group of disorders that include medical symptoms and complaints FOR WHICH AN ADEQUATE MEDICAL EXPLANATION CANNOT BE FOUND.Not intentionally producedOnset, severity and duration of symptoms are strongly linked to psychological factors

DSM-IV Somatoform DisordersSomatization DisorderConversion DisorderHypochondriasisBody Dysmorphic DisorderSomatoform Pain DisorderUndifferentiated Somatoform DisorderSomatoform Disorder, NOS

Somatization Disorderhysteria, Briquets Syndromemultiplicity of somatic complaints involving multiple organ systemsfemale predominancebefore age 30chronicexcessive medical help-seeking behavior

Somatization DisorderCannot be fully explained by any known GMC or substance useif GMC is present, physical complaints or impairment are in excess of what could be expectedsignificant impairment in functioning

Somatization DisorderFour pain symptomsOne sexual symptomOne pseudoneurological symptomTwo GI symptoms

Somatization DisorderComplaints described in colorfiul, exaggerated terms but lack specific factual informationprominent anxiety and depressive symptoms10-20% female 1st degree relatives of SD women, increased ASPD and SUD in male rrelatives

Conversion DisorderMonosymptomatic (one or more neurological symptoms)Most common inadolescents, young adultsrural populationslow education and low IQlow socioeconomic groupmilitary personnel exposed to combat

Conversion DisorderSymptom has a symbolic relation to the unconscious conflictla belle indifference

Conversion DisorderImpaired coordination, balanceparalysis, weaknessaphonia, difficulty swallowing, lump in the throaturinary retentionloss of touch/pain, double vision, blindnessdeafness, seizures

Conversion DisorderSymptoms do not conform to known anatomical pathways and physiological mechanismsoften inconsistentDDX: multiple sclerosis, myasthenia gravis, dystonias

Conversion DisorderDramatic or histrionicsuggestible sx are self-limited and do not lead to physical changes/disabilityassociated with dissociative disorders, MDD, histrionic, antisocial and dependent personality disorders

HypochondriasisPreoccupation with the fear of contracting, or the belief of having, a serious diseaseUsually with co-morbid depression, anxietyMisinterpretation of physical symptoms and sensationsRequest for admission to the sick role, which offers an escape

HypochondriasisPreoccupation is with any of the ff: bodily functions, minor physical abnormalities, vague and ambiguous physical sensationsmedical history is presented in great detail and lengthdoctor shoppingassociated with serious illness in childhood, past experience with disease in a family member

Body Dysmorphic DisorderPreoccupation with an imagined defect or an exaggerated distortion of a minimal or minor defect in physical appearancedysmorphophobiaComorbid with major depression (90%), anxiety disorder (70%), psychotic disorder (30%)

Body Dysmorphic DisorderMarked distress over supposed deformityfrequent mirror checking and checking in other reflecting surfacesexcessive grooming behavioruse of special lighting or magnifying glassesavoidance of usual activities

Somatoform Pain DisorderPresence of pain that is the predominant focus of clinical attentionNot fully accounted by a nonpsychiatric medical or neurological conditionThe symbolic meaning of body disturbances relate to atonement for perceived sin, to expiation of guilt, or to suppressed aggression

Nonspecific Somatoform DisordersUndifferentiated somatoform disorderunexplained physical effects that last for at least six monthsSomatoform Disorder, NOSresidual category

Relation of Depression and SomatizationPatients 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

Relation of Depression and PainPatients with chronic pain have a significant current prevalence of depressive disordersMore than half of patients with MDD complain of painPain is reduced with the treatment of depressionSmith, 1992

Baron Karl Friedrich Hieronymusvon Munchausen

Factitious DisordersPsychological symptomsPhysical symptomsMunchausens syndrome, pseudologica fantastica, peregrinationusually co-morbid with psychiatric conditionsintentional production of symptoms but goal is intangible and psychologically complex

ALERTALERTALERT...Numerous surgical scars, usually in the abdominal areaPatient is truculent and evasivePersonal and medical history were fraught with acute and harrowing adventuresHistory of many hospitalizations, malpractice claims, insurance claimsInvolved in the healthcare profession

Symptom TypesTotal fabricationsExaggerationsSimulations of the diseaseSelf-induced disease

A Physical Diagnosis 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.

Principles of ManagementEmphasize explanationArrange for regular follow-upTreat mood/anxiety disorderMinimize polypharmacy and multiple diagnostic testsProvide specific treatment when indicated

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 its all in your head.

Remember...You should acknowledge the patients 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.

MalingeringIntentional fabrication of symptoms to achieve a secondary gain, usually material benefits