Somatoform Disorders (1)

Somatoform Disorders

Behavioral Science II

"For each ailment that doctors cure with medications (as I am told they do occasionally succeed in doing) they produce 10 others in healthy individuals by inoculating them with that pathogenic agent 1000 times more virulent than all the microbes--the idea that they are ill." ---Marcel Proust

ObjectivesReview diagnostic criteria for Somatoform DisordersIdentify symptom presentation of somatoform and somatization Review patient management and treatment strategies for somatoform and somatization symptoms

Case example #1A 46 year old divorced female with no history of chronic medical illness presents to the ER with right side upper and lower extremity weakness, shortness of breath, unsteady gait, fainting spells, and difficulty speaking. Neurological insult is ruled out and medical tests are unremarkable. Her normal personality style is shy and soft spoken. She reports a recent traumatic, severely emotional experience at work. You should explore which of the following? A. MalingeringB. ConversionC. HypochondriasisD. Factitious disorderE. Panic disorder

Case example #2Harold is a 30-year-old male. For the past 5 years he has become more and more worried about the shape and size of his nose. He feels it is too big for his face and is asymmetrical, this results in feelings of embarrassment. He has recently refused to go to several work parties because of the way his nose looks. He has started growing a mustache which he hopes will help to hide the problem. What is his most likely diagnosis? A. HypochondriasisB . Body Dysmorphic DisorderC. Somatization DisorderD. Conversion DisorderE. Undifferenitated Somatoform Disorder

Somatoform DisordersThe blind spot of medicinePhysical symptoms without identified pathology or beyond expected medical findingsNOT factitious and NOT malingeringNOT intentionally produced.{keep in mind that many conditions are misdiagnosed and symptoms can be progressive}

Somatoform Disorders in DSM IV TRSomatization Disorder (hysteria, Briquets syndrome) polysymptomatic, begins before age 30, extends for a period of years, involves a combination of pain, gastrointestinal, sexual, and psueudoneurological symptoms.Undifferentiated Somatoform Disorder unexplained physical complaints for at least 6 months below threshold for somatization disorder

DSM IV TR Conversion Disorder unexplained symptoms or deficits affecting voluntary motor or sensory functions that suggest neurological or general medical condition. Psychological issues are thought to play a key role.Pain Disorder pain is focus of clinical attention psychological factors have key role in onset, severity, exacerbation, and maintenance. Can include the presence of medically documented pain.

DSM IV TRHypochondriasis preoccupation with fear of having, or the idea that one has a serious disease. Based on misinterpretation of bodily symptoms or functions.Body Dysmorphic Disorder preoccupation with imagined or exaggerated defect in physical appearance.Somatoform Disorder NOS symptoms that do not meet criteria for specific disorder but are focus of clinical attention.

Somatization

Somatization is the primary characteristic of somatoform disorders and is characterized by:In the absence of identified organic etiology, to experience somatic distress in response to psychological stressTo attribute this distress to physical illness or physical disorderTo seek medical attention for these symptoms (Stern & Herman, Massachusetts General Hospital, 2004)

The extreme of normal behvaiorMost of us somatize at times, but its frequency, the intensity of the stressor eliciting somatization, and the symptoms experienced often vary. Somatization is the connection that reveals the interdependence of the mind and body stress effects cause physical symptoms!

Somatization becomes clinically significant when it is associated with significant occupational and social dysfunction or excessive health care use.

Medically Unexplained SymptomsMedically unexplained symptoms, also known as functional somatic symptoms, are extremely common in patients in both community and clinic settings. In a study of 14 common symptoms in 1,000 patients in an ambulatory medical clinic, 74% were medically unexplained (Kroenke and Mangelsdorff 1989).

Kroenke K, Mangelsdorff D. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome. Am J Med, 1989:86: 2626.

Sexual and Physical Abuse

Both sexual and physical abuse have been linked with somatization1. Sexual AbuseChronic pelvic painGastrointestinal disorders 2. Physical AbuseHypochondriasisGenderThe relationship between gender and somatization is complex and poorly understood. Generally women report more unexplained symptoms than men.

Diagnosis of Somatoform SymptomsWe can only estimate symptoms severity based on samples and experience and must be careful when judging exaggeration or behavioral style. Tremendous variability in medical symptoms and pain experience can be so pervasive that we can only try to understand this individual, with this history, under these conditions. Observation over time has best diagnostic validity.Adaptive element in somatic behavior seeking the patient role, defenses not working, limited coping skills, emotionally overwhelmed, etc.Large percentage of cases misdiagnosed medical conditions.

Diagnostic ProcessesCollaborate with Referral SourcesTAKE A COMPLETE HISTORY how does this make sense?Review the Medical Records carefullyCollaborate with the patients family and friends if possibleBuild an Alliance With the Patient- Use of empathic comments such as: The symptoms sound very difficult or How has this illness or symptom affected your life? How has your life affected this illness?

Perform a Mental Status Examination screen for neurological conditions

Principles of Management(Abbey, 1996)Emphasize explanation, education, and formulation of symptom presentation explore possibilities and build collaboration with patient. Arrange for regular follow-up decreases escalation.Treat mood or anxiety disorders where indicated.Minimize polypharmacy avoid medication effects increasing symptoms.Provide specific therapy when indicated stress management, exercise, emotional support.

Principles of Management cont.Change social dynamics social skill building, life skills, assertiveness training, family interactions, etc. (Psychotherapy). Group therapy may be useful if available.Recognize and control provider negative reactions and dualistic (mind-body) thinking. These are complex patients and can evoke significant counter transference when we do not know what to do. Threatens our control

Somatization Disorder (Hysteria, Multisymptomatic Hysteria, or Briquets Disease)DSM-IV CriteriaA history of multiple and recurring physical complaints over several years, which begin before the age of 30. The physical complaints result in medical treatment or cause significant impairment in social, occupational, or other important areas of function.To make the diagnosis all four of the following criteria have to be met at some time during the course of the patients history:Four pain symptomsTwo non-pain related gastrointestinal symptomsOne sexual symptomOne pseudoneurological symptomThe symptoms, after appropriate investigation, are not caused by a known medical condition or substance.The symptoms are neither intentionally produced nor feigned

Somatization DisorderEpidemiologywomen have a 0.2-2% lifetime prevalence of somatoform disorders.In men the overall prevalence is 0.2%

Psychiatric Co-MorbidityAxis I: 50% of patients are likely to have comorbid mood disorders. Anxiety disorders, substance abuse, and post-traumatic stress disorder are also common.Axis II: 72% of patients with somatization disorder have personality disorders, most commonly histrionic, borderline, and antisocial personality disorders.The co-morbidity of a history of childhood sexual abuse and neglect and somatoform disorder is high (30-70%).DSM-IV-TR, 2000.

Somatization Disorder: TreatmentThe best treatment occurs in the context of a long-term relationship with an empathetic primary care provider (PCP). The PCP should be encouraged to:Allow the patient to maintain the sick role.Schedule regular follow-up appointments of a set length.Set the agenda of the visit.Limit work-ups to objective findings and not complaintsSet limits on contacts outside of visit time.Introduce psychosocial issues slowlyDo no more and no less for the somatic patient than for any other patient avoid reinforcing sick role behavior positively or negatively.

Somatization Disorder: Treatment cont.Psychiatric referral is useful to treat and manage co-morbid psychiatric disorders.Psychiatric consultation decreases health care costs and unnecessary utilization of services.The goal of psychiatric consultation is to provide a framework for treatment. It should not be viewed as the end of the relationship with the PCP.Co-morbid psychiatric disorders should be treated and managed by the PCP or psychiatric consultant.Individual or group psychotherapy can be usefulStress reductionA small number of studies report symptom improvement with antidepressant use (independent of depression).

Distinguishing Somatization Disorder fromGeneral Medical Conditions(general guidelines)

Involvement of multiple organ systemsEarly onset and chronic course without development of physical signs or structural abnormalities.Absence of lab abnormalities that are characteristic of the suggested gen med condition.

However, the onset of multiple physical symptoms late in life is almost always due to a gen med condition.

Undifferentiated Somatoform Disorder (Somatization Syndrome or Subthreshold Somatization Disorder)DSM CriteriaOne or more physical complaints (such as fatigue, loss of appetite, a gastrointestinal complaint or urinary complaint) must persist for 6 months or longer.Either:-The symptoms, after appropriate evaluation, cannot be fully explained by a known medical condition or substance or -The complaints or impairments are grossly in excess of what would be expected on the basis of the existing medical condition.The symptoms must cause significant distress or impairment in social, occupational, or another important area of functioning.The symptoms are neither intentionally produced nor feigned.

Undifferentiated Somatoform Disorder (Somatization Syndrome or Subthreshold Somatization Disorder)EpidemiologyIts lifetime prevalence is 4-11%. (DSM-IV-TR, 2000.)

TreatmentTreatment is similar to that of Somatization Disorder.

Conversion DisorderConversion disorder involves the presence of symptoms or deficits that affect voluntary motor or sensory function in a fashion that suggests a neurological condition but which is not explained by the medical findings.Clinical FeaturesConversion-disordered patients are more likely to have had prior conversion symptoms or symptoms of dissociation.One-third of patients with Conversion Disorder have concurrent neurological illness.

Conversion DisorderEtiologyA dynamic hypothesis suggests that the conversion symptom is a solution to an unconscious conflict. For example, a woman whose husband had an affair may become paralyzed rather than walk away from the marriage.

EpidemiologyConversion disorder is the most common somatoform disorder. Approximately 33% of female psychiatric outpatients report an episode of conversion.A gender bias exists, with a ratio of 2-10:1, women to men. Left-handed women have a higher incidence.

Conversion DisorderPsychiatric Co-MorbidityConversion disorders can be a precursor to depression, somatization, and/or dissociative disorders.SymptomsAs opposed to the patient with somatization disorder or the patient with hypochondriasis who believes they are gravely ill, the patient with conversion disorder often presents with la belle indifference conversion provides relief.Symptoms are more likely to occur following extreme stress.Symptoms are inconsistent with the physical examination.The symptoms rarely cause longer term physical disability.The symptoms tend to recur.

Conversion DisorderDSM-IV CriteriaOne or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors The symptom or deficit is not intentionally produced or feigned The symptom or deficit cannot, after appropriate investigation be fully explained by a general medical condition or by the effects of a substance or as a culturally sanctioned behavior or experience.

Conversion DisorderDSM-IV Criteria cont.The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder. Specify type of symptom or deficitWith Motor Symptom or DeficitWith Sensory Symptom or DeficitWith Seizures or ConvulsionsWith Mixed Presentation

Conversion DisorderCourseConversion disorder is rarely reported in patients younger than 10 years, or older than 35 years of age; however, cases have been seen in people of all ages, including 90-year olds.The syndrome usually remits within 2-4 weeks after hospitalization, but it has a recurrence rate of 20-25% within the first year.Prior episodes increase the rate of recurrence.20% of patients with conversion disorder develop Somatization Disorder within 4 years of their first episode.

Conversion Disorder: TreatmentA good prognosis is associated with an acute onset of disease, a clear stressor, a short interval between the onset of symptoms and initiation of treatment, rapid improvement in the hospital, an above-average intelligence, and a presenting symptom of paralysis, aphonia, or blindness.A poor prognosis is associated with a presenting symptom of tremor and/or seizure, an increased interval between symptom onset and treatment, and a reduced intelligence level.Confrontation of the patient is not helpful, as it results in a loss of face.Indirect examination of stressors can lead to reliefBehavioral techniques should be instituted; referral to family therapy is often indicated.

Pain DisorderDSM-IV CriteriaPain occurs in one or more anatomical sites as the focus of attention presence of medical evidence of pain.Pain causes significant distress or impairment in social, occupational, or other areas of function.Psychological factors have a role in the onset, severity, exacerbation, and maintenance of the pain.The pain is not intentionally produced.Pain disorder is not totally due to a mood, anxiety, or psychotic disorder, or to dyspareunia.

Pain DisorderDSM-IV Criteria cont.Specifiers1. Pain Disorder Associated with Psychological Factors (acute < 6 months; chronic > 6 months)2. Pain Disorder Associated with Both Psychological Factors and a General Medical Condition (acute < 6 months; chronic > 6 months)3. Pain Disorder Associated with a General Medical Condition (Note: This is not a mental disorder but is included to assist in differential diagnosis and pain type should be coded on Axis III) questionable issues here when does significant pain NOT effect emotion or behavior?

Pain DisorderClinical FeaturesPain described as severe and constant, the pain may or may not be consistent with known anatomic pathways.The severity is disproportionate to clinical findings Pain is the main life focus of a patients energyThis behavior can lead to disability and complications that include Iatrogenic substance abuse (opiates/benzodiazepines) Depression (which occurs in 30-50% of those with chronic pain) Anxiety (with acute pain) Insomnia.

Pain DisorderEpidemiologyThe prevalence of these disorders is unknown. The peak incidence occurs in individuals in their 30s and 40s. Women complain of more headaches, men complain more of back pain.

CourseThe course is variable; the syndrome can persist for yearsA good prognosis is associated with continued work and the absence of pain as a focus of life.

Pain DisorderTreatment Pain is what the patient says it is!!!!Emphasize living with pain and not removal of pain. Teach skills of functional movement, weight loss, sleep hygiene.The physician should also explain how brain regions involved with emotion (i.e., the limbic system) may influence sensory pain pathways.Employ a multi-modal treatment approach, combining physical, family, group and cognitive-behavioral therapy.Avoid iatrogenic complications. Medications do not cure structural damage or stop pain.Treat concomitant problems as they arise sleep deprivation, depression, anxiety, etc.

Physical Pain Versus Psychogenic Pain

The three gross categories of pain which are not mutually exclusive. Neurogenic pain results from damage to the CNS can be unrelenting and not exacerbated by movement. Physical in origin.

Structural (mechanical) pain fluctuates in intensity and movement. Is highly sensitive to emotional, cognitive, attentional, and situational influences. Physical in origin.

Psychogenic pain does not vary and is insensitive to any of these cognitive and behavioral factors. When pain does not wax and wane and is not even temporarily relieved by distraction or analgesics, clinicians can suspect that there is a major psychogenic component to the pain.

HypochondriasisDSM-IV CriteriaHypochondriasis is a preoccupation with fears of having, or the idea that one has, a serious disease based on ones misinterpretation of bodily symptoms.This preoccupation persists despite appropriate medical evaluation and reassuranceThe preoccupation is not of delusional intensity and is not restricted to a circumscribed concern about appearanceThis preoccupation causes significant distress or impairment.Hypochondriasis lasts at least 6 months.Specify: With Poor Insight

HypochondriasisClinical CourseThe preoccupation with bodily functions (e.g., heartbeat, sweating,); with minor physical abnormalities (e.g., a small sore or an occasional cough); or vague and ambiguous physical sensations (e.g., feeling worn out, aching veins). The onset is generally in early adulthoodA chronic waxing and waning course is typicalEpisodes may be precipitated by stress, especially the death of someone close.EpidemiologyHypochondriasis occurs in about 3-13% of the general population in the United States. In Africa it occurs in 1% of the population.The incidence is approximately equal in males and femalesThe history often includes a childhood illness or illness of a significant family member when the patient was a child.

HypochondriasisTreatmentA good prognosis for hypochondriasis is associated with an acute onset and high levels of general medical co-morbidity.They may be more accepting of psychiatric treatment if it takes place in a medical setting and is focused on stress reduction and education regarding coping with a chronic illness. Regular contact with a caring medical physician should be maintained with palliation, and not cure, as the goal.Work-ups should be based only on objective findings.Cognitive-educational group treatments work for some.Use of selective serotonin reuptake inhibitors (SSRIs) may have some benefit in these patients.

Body Dysmorphic Disorder (BDD)DefinitionBDD is a disease of imagined ugliness.DSM-IV CriteriaPreoccupation with an imagined deficit in appearance. If a slight physical anomaly is present, the persons concern is markedly excessiveThe 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

Body Dysmorphic DisorderClinical FeaturesPatients complain often of a facial deformity (e.g., asymmetry, size of nose), but it can be anything.Patients feel too ashamed to present for treatmentPatients may frequently check and groom themselvesThey may try to compensate for the imagined anomaly, e.g., wearing a hat if hair loss is imagined or wearing gloves to cover ugly fingersComplications include social isolation, suicide and Iatrogenic complications (7-9% of patients who undergo cosmetic surgery meet criteria for BDD).

Body Dysmorphic DisorderClinical Course30 is the mean age for diagnosis. It can become chronic.Research from the Feb. 2010 issue of the Archives of General Psychiatry found differences in the areas of the brain involved in visual processingEpidemiologyThe frequency is equal in males and femalesDepression, delusional disorder, social phobia, and/or OCD are often co-morbid conditions.TreatmentThe use of SSRIs can be helpful. Relapse is common when the drug is discontinued.Cognitive Behavioral Therapy

Somatoform Disorder Not Otherwise SpecifiedDefinitionThese disorders are residual categories for disorders where physical symptoms are the focus of treatment but which do not meet criteria for another somatoform disorder.ExamplesPseudocyesis, or the belief that one is pregnant.Couvade Syndrome in males: sympathy symptomsHypochondriasis lasting less than 6 monthsUnexplained physical complaints lasting less than 6 months.

Functional Somatic Syndromes (aka, Medically Unexplained Conditions)Broad group of disorders that have the common component of physical complaints which cannot be verified by medical examination.Not listed in the current DSM as somatoform disorders.

Functional Somatic Syndromes (aka, Medically Unexplained Conditions)FibromyalgiaChronic Fatigue SyndromeIrritable Bowel SyndromeMultiple Chemical Sensitivity

Chronic Fatigue Syndrome(Myalgic Encephalomyelitis Canada, UK)

Not a DSM diagnosis. Not considered a mental illness, however, has no known physical cause.

Main characteristics are persistent and unexplained fatigue resulting in severe impairment in daily functioning. The illness is defined by means of symptoms, disability, and exclusion of explanatory illnesses, and not by means of physical signs or abnormalities or in lab test results. Prevalence rates in the US are around 0.23% - 0.42%More common in women.

CDC Criteria: Chronic Fatigue Syndrome

Chronic Fatigue Syndrome Notes:

Many individuals with this disorder complain of pain and cognitive dysfunction that is just as severe as the fatigue.Depressive Disorders are frequently co-morbid. Depression and anxiety are frequent premorbid diagnoses. An acute psychological stressor often triggers the onset of the syndrome. No known viral or neuroendocrine etiologies explain the breadth of symptoms. Antidepressants are not helpful in the treatment of Chronic Fatigue symptoms.However, Cognitive Behavioral Therapy designed to change cognitions and behaviors regarding the fatigue symptoms is the treatment of choice.

Fibromyalgia

Fibromyalgia is a controversial polysymptomatic syndrome of unknown etiology characterized by chronic widespread musculoskeletal pain, multiple tender points, abnormal pain sensitivity, and additional symptoms such as:fatigue irritable bowel (e.g., diarrhea, constipation, etc.) sleep disorder (or sleep that is unrefreshing) chronic headaches (tension-type or migraines) jaw pain (including TMJ dysfunction) cognitive or memory impairment post-exertional malaise and muscle pain morning stiffness (waking up stiff and achy) menstrual cramping numbness and tingling sensations dizziness or lightheadedness skin and chemical sensitivities

Fibromyalgia Notes: The etiology of the disorder is unknown. Its existence as a disease entity remains controversial.

Much more common in women than men.

Anecdotally, often co-morbid with a personality disorder (typically borderline or histrionic may be chicken or egg issue high prevalence of childhood physical or sexual abuse).

Prevalence is 2% in the US.

Best treatment seems to be a combination of SNRI and aerobic exercise.

A word about MunchausenExtreme form of factitious disorder noted by chronic pattern. Many somatoform characteristics.Person intentionally fakes, simulates, worsens, or self-induces injury or illness for the purpose of being treated as a medical patient. Dramatic symptom presentation.Often requires hospitalization eager for invasive procedures.Can be by proxyPatients move from doctor, hospital, towns to seek care.Follow Abbey mgmt guidelines + SSRI for mood and Low dose antipsychotic for severe personality disorder (borderline).Rule out all possible medical conditions.

DSM V Somatic Symptom DisorderCriteria A, B, and C must all be fulfilled to make the diagnosis:Somatic symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: at least one of the following must be present.Chronicity: Although one symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).Disproportionate and persistent thoughts about the seriousness of ones symptoms.Persistently high level of anxiety about health symptoms.Excessive time and energy devoted to these symptoms or health concerns

Somatic Symptom Disorder (cont)SpecifiersPredominant Pain (previously pain disorder).This category is reserved for individuals presenting predominantly with pain complaints who also satisfy category B and C of this diagnosis. Some patients in pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting medical condition.

DSM V changes cont.Somatic Symptoms and Related Disorders new title.Focus on positive symptoms rather than medically unexplained Ex/distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to symptoms.Hypochondriasis no longer diagnosis Illness Anxiety Disorder.Psychological Factors Affecting Other Medical Conditions and Factitious Disorder now in this section.Conversion Disorder (Functional Neurological Symptom Disorder) importance of neuro exam.

Case example #1A 46 year old divorced female with no history of chronic medical illness presents to the ER with right side upper and lower extremity weakness, shortness of breath, unsteady gait, fainting spells, and difficulty speaking. Neurological insult is ruled out and medical tests are unremarkable. Her normal personality style is shy and soft spoken. She reports a recent traumatic, severely emotional experience at work. You should explore which of the following? A. MalingeringB. ConversionC. HypochondriasisD. Factitious disorderE. Panic disorder

Case example #2Harold is a 30-year-old male. For the past 5 years he has become more and more worried about the shape and size of his nose. He feels it is too big for his face and is asymmetrical, this results in feelings of embarrassment. He has recently refused to go to several work parties because of the way his nose looks. He has started growing a mustache which he hopes will help to hide the problem. What is his most likely diagnosis? HypochondriasisBody Dysmorphic DisorderSomatization DisorderConversion DisorderUndifferentiated Somatoform Disorder

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