Somatoform disorders

Somatoform Disorders

ARUN.MARUN.M

KVM COLLEGE KVM COLLEGE

Somatoform Disorders

A mental disorder characterized by a group A mental disorder characterized by a group of condition in which the physical pain and of condition in which the physical pain and symptoms a person feels are related to symptoms a person feels are related to psychological factors.psychological factors.

Somatoform Disorders

A mental disorder characterized by physical A mental disorder characterized by physical symptoms that suggest physical illness or symptoms that suggest physical illness or injury symptoms that cannot be explained injury symptoms that cannot be explained fully by a general medical condition or by fully by a general medical condition or by the direct effect of a substance and are not the direct effect of a substance and are not attributable to another mental disorder.attributable to another mental disorder.

Somatoform Disorders

Have you ever “played sick” in order to get out Have you ever “played sick” in order to get out of something?of something? How did that work out (did you How did that work out (did you get what you wanted)?get what you wanted)?

Sick Sick attention (friends, family, medical) = attention (friends, family, medical) = secondary gainssecondary gains

Likely link between secondary gains and Likely link between secondary gains and somatoform disorderssomatoform disorders

Some medical condition may actually existSome medical condition may actually exist

Types of Somatoform Disorders Conversion DisorderConversion Disorder

An expression of psychological conflict or need that involves an alteration An expression of psychological conflict or need that involves an alteration or loss of physical functioning that suggests a bodily cause in the absence or loss of physical functioning that suggests a bodily cause in the absence of a medical reasonof a medical reason

HypochondriasisHypochondriasis Preoccupation with having or contracting a serious disease in the absence Preoccupation with having or contracting a serious disease in the absence

of a medical reasonof a medical reason Somatization DisorderSomatization Disorder

Repeated concern with a variety of bodily complaints in the absence of a Repeated concern with a variety of bodily complaints in the absence of a medical reasonmedical reason

Body Dysmorphic DisorderBody Dysmorphic Disorder Preoccupation with an imagined defect in appearance of a normal-Preoccupation with an imagined defect in appearance of a normal-

appearing personappearing person Pain DisorderPain Disorder

Preoccupation with pain in the absence of an adequate physical basis for itPreoccupation with pain in the absence of an adequate physical basis for it

Somatization Disorder

Somatization disorder is an illness of Somatization disorder is an illness of multiple somatic complaints in multiple multiple somatic complaints in multiple organ systems that occurs over a period of organ systems that occurs over a period of several years and results in significant several years and results in significant impairment or treatment seeking, or bothimpairment or treatment seeking, or both

INCIDENCE

Lifetime prevalence:Lifetime prevalence: 0.2 – 2% in women0.2 – 2% in women less than 0.2% in menless than 0.2% in men

ETIOLOGYPsychosocial FactorsPsychosocial Factors The cause is unknown. The cause is unknown. Interpretations of the symptoms as social Interpretations of the symptoms as social

communication whose result is to avoid communication whose result is to avoid obligations (e.g., going to a job a person does obligations (e.g., going to a job a person does not like), to express emotions (e.g., anger at a not like), to express emotions (e.g., anger at a spouse), or to symbolize a feeling or a belief spouse), or to symbolize a feeling or a belief (e.g., a pain in the gut). (e.g., a pain in the gut).

Biological FactorsBiological Factors

Patients have characteristic attention and Patients have characteristic attention and cognitive impairments that result in the cognitive impairments that result in the faulty perception and assessment of faulty perception and assessment of somatosensory inputssomatosensory inputs

GeneticsGenetics Occurs in 10 to 20 percent of the first-Occurs in 10 to 20 percent of the first-

degree female, first-degree male relatives degree female, first-degree male relatives are susceptible to substance abuse and are susceptible to substance abuse and antisocial personality disorder. antisocial personality disorder.

29 percent in monozygotic twins and 10 29 percent in monozygotic twins and 10 percent in dizygotic twinspercent in dizygotic twins

CytokinesCytokines Cytokines are messenger molecules that the Cytokines are messenger molecules that the

immune system uses to communicate within immune system uses to communicate within itself and with the nervous system, itself and with the nervous system, including the brain. including the brain.

The abnormal regulation of the cytokine The abnormal regulation of the cytokine system may result in some of the symptoms system may result in some of the symptoms seen in somatoform disorders. seen in somatoform disorders.

CytokinesCytokines Cytokines are messenger molecules that the Cytokines are messenger molecules that the

immune system uses to communicate within immune system uses to communicate within itself and with the nervous system, itself and with the nervous system, including the brain. including the brain.

The abnormal regulation of the cytokine The abnormal regulation of the cytokine system may result in some of the symptoms system may result in some of the symptoms seen in somatoform disorders. seen in somatoform disorders.

Diagnosis

A history of many physical complaints A history of many physical complaints beginning before age 30 years that occur beginning before age 30 years that occur over a period of several years and result in over a period of several years and result in treatment being sought or significant treatment being sought or significant impairment in social, occupational, or other impairment in social, occupational, or other important areas of functioningimportant areas of functioning

Each of the following criteria must have Each of the following criteria must have been met, with individual symptoms been met, with individual symptoms occurring at any time during the course of occurring at any time during the course of the disturbance: the disturbance: four pain symptoms: a history of pain four pain symptoms: a history of pain

related to at least four different sites or related to at least four different sites or functionsfunctions

two gastrointestinal symptoms: a history two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms of at least two gastrointestinal symptoms other than painother than pain

one sexual symptom: a history of at least one one sexual symptom: a history of at least one sexual or reproductive symptom other than painsexual or reproductive symptom other than pain

one pseudoneurological symptom: a history of at one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a least one symptom or deficit suggesting a neurological condition not limited to pain neurological condition not limited to pain (conversion symptoms such as impaired (conversion symptoms such as impaired coordination or balance, paralysis or localized coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative blindness, deafness, seizures; dissociative symptoms) symptoms)

C. Either:C. Either:1) symptoms in Criterion B cannot be 1) symptoms in Criterion B cannot be fully explained by a known GMCfully explained by a known GMC

or 2) when a GMC does exist, the or 2) when a GMC does exist, the symptoms in Criterion B are in excess symptoms in Criterion B are in excess of of what would be expected based on what would be expected based on medical factsmedical factsD. Symptoms not intentionally D. Symptoms not intentionally producedproduced

Clinical FeaturesClinical Features Patients with somatization disorder have many Patients with somatization disorder have many

somatic complaints and long, complicated medical somatic complaints and long, complicated medical histories. histories.

Nausea and vomiting (other than during Nausea and vomiting (other than during pregnancy), difficulty swallowing, pain in the pregnancy), difficulty swallowing, pain in the arms and legs, shortness of breath unrelated to arms and legs, shortness of breath unrelated to exertion, amnesia, and complications of pregnancy exertion, amnesia, and complications of pregnancy and menstruation are among the most common and menstruation are among the most common symptoms. symptoms.

Patients frequently believe that they have Patients frequently believe that they have been sickly most of their lives. been sickly most of their lives.

Psychological distress and interpersonal Psychological distress and interpersonal problems are prominent; anxiety and problems are prominent; anxiety and depression are the most prevalent depression are the most prevalent psychiatric conditions. psychiatric conditions.

Suicide threats are common, but actual Suicide threats are common, but actual suicide is raresuicide is rare

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

Course and PrognosisCourse and Prognosis Somatization disorder is a chronic and relapsing Somatization disorder is a chronic and relapsing

disorder that rarely remits completely. disorder that rarely remits completely. It is unusual for the individual with somatization It is unusual for the individual with somatization

disorder to be free of symptoms for greater than disorder to be free of symptoms for greater than 1 year, during which time they may see a doctor 1 year, during which time they may see a doctor several times. several times.

Research has indicated that a person diagnosed Research has indicated that a person diagnosed with somatization disorder has approximately an with somatization disorder has approximately an 80 percent chance of being diagnosed with this 80 percent chance of being diagnosed with this disorder 5 years laterdisorder 5 years later

TreatmentTreatment Somatization disorder is best treated when Somatization disorder is best treated when

the patient has a single identified physician as the patient has a single identified physician as primary caretaker. When more than one primary caretaker. When more than one clinician is involved, patients have increased clinician is involved, patients have increased opportunities to express somatic complaints.opportunities to express somatic complaints.

Psychotherapy, both individual and group Psychotherapy, both individual and group therapytherapy

Conversion DisorderConversion Disorder

Conversion disorder is an illness of Conversion disorder is an illness of symptoms or deficits that affect voluntary symptoms or deficits that affect voluntary motor or sensory functions, which suggest motor or sensory functions, which suggest another medical condition, but that is another medical condition, but that is judged to be caused by psychological judged to be caused by psychological factors because the illness is preceded by factors because the illness is preceded by conflicts or other stressors.conflicts or other stressors.

INCIDENCEINCIDENCE

Highly prevalent Female Highly prevalent Female predominancepredominance

Young ageYoung ageRural and low social classRural and low social classLittle-educated and psychologically Little-educated and psychologically unsophisticatedunsophisticated

ETIOLOGYETIOLOGY Psychoanalytic FactorsPsychoanalytic Factors

Caused by repression of unconscious intra-Caused by repression of unconscious intra-psychic-conflict and conversion of anxiety psychic-conflict and conversion of anxiety into a physical symptom. into a physical symptom.

Learning TheoryLearning Theory

Conversion symptom can be seen as a piece Conversion symptom can be seen as a piece of classically conditioned learned behavior; of classically conditioned learned behavior; symptoms of illness, learned in childhood, symptoms of illness, learned in childhood, are called forth as a means of coping with are called forth as a means of coping with an otherwise impossible situation.an otherwise impossible situation.

Biological FactorsBiological Factors

Increasing data implicate biological Increasing data implicate biological and neuropsychological factors in the and neuropsychological factors in the development of conversion disorder development of conversion disorder symptomssymptoms

Clinical FeaturesClinical Features Paralysis, blindness, and mutism are the most Paralysis, blindness, and mutism are the most

common conversion disorder symptoms. common conversion disorder symptoms. Conversion disorder may be most commonly Conversion disorder may be most commonly

associated with passive-aggressive, dependent, associated with passive-aggressive, dependent, antisocial, and histrionic personality disorders.antisocial, and histrionic personality disorders.

Depressive and anxiety disorder symptoms often Depressive and anxiety disorder symptoms often accompany the symptoms of conversion accompany the symptoms of conversion disorder, and affected patients are at risk for disorder, and affected patients are at risk for suicide.suicide.

SYMPTOMSSYMPTOMS Motor SymptomsMotor Symptoms

Involuntary movementsInvoluntary movementsTicsTicsTorticollisTorticollisSeizuresSeizuresAbnormal gaitAbnormal gaitFallingFallingParalysisParalysisWeaknessWeaknessAphoniaAphonia

Sensory DeficitsSensory DeficitsAnesthesia, especially of extremitiesAnesthesia, especially of extremitiesBlindnessBlindnessTunnel visionTunnel visionDeafnessDeafness

Visceral SymptomsVisceral SymptomsPsychogenic vomitingPsychogenic vomitingUrinary retentionUrinary retentionDiarrheaDiarrhea

DIAGNOSISDIAGNOSIS One or more symptoms or deficits affecting One or more symptoms or deficits affecting

voluntary motor or sensory function that voluntary motor or sensory function that suggest a neurological or other general suggest a neurological or other general medical condition. medical condition.

Psychological factors are judged to be Psychological factors are judged to be associated with the symptom or deficit associated with the symptom or deficit because the initiation or exacerbation of the because the initiation or exacerbation of the symptom or deficit is preceded by conflicts symptom or deficit is preceded by conflicts or other stressors. or other stressors.

The symptom or deficit is not intentionally The symptom or deficit is not intentionally produced. produced.

The symptom or deficit cannot, after The symptom or deficit cannot, after appropriate investigation, be fully explained appropriate investigation, be fully explained by a general medical condition, or by the by a general medical condition, or by the direct effects of a substance, or as a direct effects of a substance, or as a culturally sanctioned behavior or culturally sanctioned behavior or experience. experience.

The symptom or deficit causes clinically The symptom or deficit causes clinically significant distress or impairment in social, significant distress or impairment in social, occupational, or other important areas of occupational, or other important areas of functioning or warrants medical evaluation. functioning or warrants medical evaluation.

The symptom or deficit is not limited to The symptom or deficit is not limited to pain or sexual dysfunction, does not occur pain or sexual dysfunction, does not occur exclusively during the course of exclusively during the course of somatization disorder, and is not better somatization disorder, and is not better accounted for by another mental disorder.accounted for by another mental disorder.

Course and PrognosisCourse and Prognosis

Symptoms or deficits are usually of Symptoms or deficits are usually of short duration, and approximately 95 short duration, and approximately 95 percent of acute cases remit spontaneously, percent of acute cases remit spontaneously, usually within 2 weeks in hospitalized usually within 2 weeks in hospitalized patients.patients.

TreatmentTreatment

Insight-oriented supportive or behavior therapy. Insight-oriented supportive or behavior therapy.

Hypnosis, anxiolytics, and behavioural relaxation Hypnosis, anxiolytics, and behavioural relaxation exercises are effective in some cases.exercises are effective in some cases.

HypochondriasisHypochondriasis

Hypochondriasis is characterized Hypochondriasis is characterized by 6 months or more of a general and by 6 months or more of a general and nondelusional preoccupation with fears nondelusional preoccupation with fears of having, or the idea that one has, a of having, or the idea that one has, a serious disease based on the person's serious disease based on the person's misinterpretation of bodily symptoms.misinterpretation of bodily symptoms.

EpidemiologyEpidemiology Men and women are equally affected by Men and women are equally affected by

hypochondriasis. hypochondriasis. Onset of symptoms can occur at any age, Onset of symptoms can occur at any age,

the disorder most commonly appears in the disorder most commonly appears in persons 20 to 30 years of age.persons 20 to 30 years of age.

EtiologyEtiology

Psychodynamic theory Psychodynamic theory According to this theory, aggressive and hostile According to this theory, aggressive and hostile

wishes toward others are transferred (through wishes toward others are transferred (through repression and displacement) into physical repression and displacement) into physical complaints. complaints.

Hypochondriasis is also viewed as a defence Hypochondriasis is also viewed as a defence against guilt, a sense of innate badness, an against guilt, a sense of innate badness, an expression of low self-esteem, and a sign of expression of low self-esteem, and a sign of excessive self-concern.excessive self-concern.

Learning theory Learning theory Sick role made by a person facing Sick role made by a person facing

seemingly insolvable problems. seemingly insolvable problems. The sick role offers an escape that allows a The sick role offers an escape that allows a

patient to avoid obligations, to postpone patient to avoid obligations, to postpone unwelcome challenges, and to be excused unwelcome challenges, and to be excused from usual duties.from usual duties.

A third theory suggests that A third theory suggests that hypochondriasis is a variant form of other hypochondriasis is a variant form of other mental disorders, among which depressive mental disorders, among which depressive disorders and anxiety disorders are most disorders and anxiety disorders are most frequently included. An estimated 80 frequently included. An estimated 80 percent of patients with hypochondriasis percent of patients with hypochondriasis may have coexisting depressive or anxiety may have coexisting depressive or anxiety disorders.disorders.

Clinical FeaturesClinical Features Patients with hypochondriasis believe that Patients with hypochondriasis believe that

they have a serious disease that has not yet they have a serious disease that has not yet been detected. been detected.

They may maintain a belief that they have a They may maintain a belief that they have a particular disease or, as time progresses, particular disease or, as time progresses, they may transfer their belief to another they may transfer their belief to another disease. disease.

Their convictions persist despite negative Their convictions persist despite negative laboratory results.. laboratory results..

Hypochondriasis is often accompanied by Hypochondriasis is often accompanied by symptoms of depression and anxiety and symptoms of depression and anxiety and commonly coexists with a depressive or commonly coexists with a depressive or anxiety disorder.anxiety disorder.

DiagnosisDiagnosis Preoccupation with fears of having, or the idea Preoccupation with fears of having, or the idea

that one has, a serious disease based on the that one has, a serious disease based on the person's misinterpretation of bodily symptoms. person's misinterpretation of bodily symptoms.

The preoccupation persists despite appropriate The preoccupation persists despite appropriate medical evaluation and reassurance. medical evaluation and reassurance.

The belief in Criterion A is not of delusional The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern and is not restricted to a circumscribed concern about appearance (as in body dysmorphic about appearance (as in body dysmorphic disorder). disorder).

The preoccupation causes clinically significant The preoccupation causes clinically significant distress or impairment in social, occupational, distress or impairment in social, occupational, or other important areas of functioning. or other important areas of functioning.

The duration of the disturbance is at least 6 The duration of the disturbance is at least 6 months. months.

The preoccupation is not better accounted for The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or depressive episode, separation anxiety, or another somatoform disorder.another somatoform disorder.

Course and PrognosisCourse and Prognosis The course of hypochondriasis is usually episodic; The course of hypochondriasis is usually episodic;

the episodes last from months to years and are the episodes last from months to years and are separated by equally long quiescent periods.separated by equally long quiescent periods.

A good prognosis is associated with high A good prognosis is associated with high socioeconomic status, treatment-responsive anxiety socioeconomic status, treatment-responsive anxiety or depression, sudden onset of symptoms, the or depression, sudden onset of symptoms, the absence of a personality disorder, and the absence absence of a personality disorder, and the absence of a related nonpsychiatric medical condition. of a related nonpsychiatric medical condition.

Most children with hypochondriasis recover by late Most children with hypochondriasis recover by late adolescence or early adulthood.adolescence or early adulthood.

TreatmentTreatment Patients with hypochondriasis usually resist Patients with hypochondriasis usually resist

psychiatric treatment.psychiatric treatment. Group psychotherapy often benefits such Group psychotherapy often benefits such

patients, in part because it provides the social patients, in part because it provides the social support and social interaction that seem to support and social interaction that seem to reduce their anxiety. reduce their anxiety.

Other forms of psychotherapy, such as Other forms of psychotherapy, such as individual insight-oriented psychotherapy, individual insight-oriented psychotherapy, behavior therapy, cognitive therapy, and behavior therapy, cognitive therapy, and hypnosis may be useful.hypnosis may be useful.

Pharmacotherapy alleviates Pharmacotherapy alleviates Hypochondriacal symptoms only when a Hypochondriacal symptoms only when a patient has an underlying drug-responsive patient has an underlying drug-responsive condition, such as an anxiety disorder or condition, such as an anxiety disorder or major depressive disordermajor depressive disorder

Body Dysmorphic DisorderBody Dysmorphic Disorder

Body dysmorphic disorder is Body dysmorphic disorder is characterized by a preoccupation with an characterized by a preoccupation with an imagined defect in appearance that causes imagined defect in appearance that causes clinically significant distress or impairment clinically significant distress or impairment in important areas of functioning.in important areas of functioning.

EpidemiologyEpidemiology Most common age of onset is between 15 Most common age of onset is between 15

and 30 years and 30 years Women are affected more often than men. Women are affected more often than men. Affected patients are also likely to be Affected patients are also likely to be

unmarried. unmarried. Body dysmorphic disorder commonly Body dysmorphic disorder commonly

coexists with other mental disorderscoexists with other mental disorders

EtiologyEtiology The cause of body dysmorphic disorder is The cause of body dysmorphic disorder is

unknown. unknown. Some patients, the pathophysiology of the Some patients, the pathophysiology of the

disorder may involve serotonin and may be disorder may involve serotonin and may be related to other mental disorders. related to other mental disorders.

Stereotyped concepts of beauty emphasized in Stereotyped concepts of beauty emphasized in certain families and within the culture at large certain families and within the culture at large may significantly affect patients with body may significantly affect patients with body dysmorphic disorder. dysmorphic disorder.

In psychodynamic models, body In psychodynamic models, body dysmorphic disorder is seen as reflecting dysmorphic disorder is seen as reflecting the displacement of a sexual or emotional the displacement of a sexual or emotional conflict onto a nonrelated body part. conflict onto a nonrelated body part.

Clinical FeaturesClinical Features The most common concerns involve facial The most common concerns involve facial

flaws, particularly those involving specific flaws, particularly those involving specific parts parts

Common associated symptoms include Common associated symptoms include ideas of delusions of reference , either ideas of delusions of reference , either excessive mirror checking or avoidance of excessive mirror checking or avoidance of reflective surfaces, and attempts to hide the reflective surfaces, and attempts to hide the presumed deformity (with makeup or presumed deformity (with makeup or clothing). suicide.clothing). suicide.

The effects on a person's life can be The effects on a person's life can be significant; almost all affected patients significant; almost all affected patients avoid social and occupational exposure. avoid social and occupational exposure.

As many as one third of the patients may be As many as one third of the patients may be housebound because of worry about being housebound because of worry about being ridiculed for the alleged deformities, and ridiculed for the alleged deformities, and approximately one fifth attempt suicide.approximately one fifth attempt suicide.

DiagnosisDiagnosis Preoccupation with an imagined defect in Preoccupation with an imagined defect in

appearance. If a slight physical anomaly is appearance. If a slight physical anomaly is present, the person's concern is markedly present, the person's concern is markedly excessive. excessive.

The preoccupation causes clinically significant The preoccupation causes clinically significant distress or impairment in social, occupational, or distress or impairment in social, occupational, or other important areas of functioning. other important areas of functioning.

The preoccupation is not better accounted for by The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).body shape and size in anorexia nervosa).

TreatmentTreatment Treatment of patients with body Treatment of patients with body

dysmorphic disorder with surgical, dysmorphic disorder with surgical, dermatological, dental, and other medical dermatological, dental, and other medical procedures to address the alleged defects is procedures to address the alleged defects is almost invariably unsuccessful. almost invariably unsuccessful.

AntidepressentsAntidepressents Tricyclic drugs, monoamine oxidase Tricyclic drugs, monoamine oxidase

inhibitors (MAOIs), SSRIhave reportedly inhibitors (MAOIs), SSRIhave reportedly been useful.been useful.

Pain DisorderPain Disorder

A pain disorder is characterized by the A pain disorder is characterized by the presence of, and focus on, pain in one or presence of, and focus on, pain in one or more body sites and is sufficiently severe to more body sites and is sufficiently severe to come to clinical attention.come to clinical attention.

EpidemiologyEpidemiology The prevalence of pain disorder appears to The prevalence of pain disorder appears to

be common. be common. Recent work indicates that the 6-month and Recent work indicates that the 6-month and

lifetime prevalence is approximately 5 lifetime prevalence is approximately 5 percent and 12 percent, respectively.percent and 12 percent, respectively.

EtiologyEtiology

Psychodynamic FactorsPsychodynamic Factors Patients who experience bodily aches and Patients who experience bodily aches and

pains without identifiable and adequate pains without identifiable and adequate physical causes may be symbolically physical causes may be symbolically expressing an intra-psychic conflict through expressing an intra-psychic conflict through the body.the body.

Behavioral FactorsBehavioral Factors Pain behaviors are reinforced when Pain behaviors are reinforced when

rewarded and are inhibited when ignored or rewarded and are inhibited when ignored or punished.punished.

Interpersonal FactorsInterpersonal Factors Means for manipulation and gaining Means for manipulation and gaining

advantage in interpersonal relationships. advantage in interpersonal relationships. Such secondary gain is most important to Such secondary gain is most important to

patients with pain disorder.patients with pain disorder.

Biological FactorsBiological Factors

Serotonin and endorphins play a role in pain Serotonin and endorphins play a role in pain disorders. disorders.

DiagnosisDiagnosis Pain in one or more anatomical sites is the Pain in one or more anatomical sites is the

predominant focus of the clinical presentation predominant focus of the clinical presentation and is of sufficient severity to warrant clinical and is of sufficient severity to warrant clinical attention. attention.

The pain causes clinically significant distress or The pain causes clinically significant distress or impairment in social, occupational, or other impairment in social, occupational, or other important areas of functioning. important areas of functioning.

Psychological factors are judged to have an Psychological factors are judged to have an important role in the onset, severity, important role in the onset, severity, exacerbation, or maintenance of the pain. exacerbation, or maintenance of the pain.

The symptom or deficit is not intentionally The symptom or deficit is not intentionally produced or feigned (as in factitious produced or feigned (as in factitious disorder or malingering). disorder or malingering).

The pain is not better accounted for by a The pain is not better accounted for by a mood, anxiety, or psychotic disorder and mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia.does not meet criteria for dyspareunia.

CLINICAL FEATURESCLINICAL FEATURES Low back pain, headache, atypical facial Low back pain, headache, atypical facial

pain, chronic pelvic pain, and other kinds of pain, chronic pelvic pain, and other kinds of pain.pain.

Patients with pain disorder often have long Patients with pain disorder often have long histories of medical and surgical care. histories of medical and surgical care.

Patients often deny any other sources of Patients often deny any other sources of emotional dysphoria and insist that their emotional dysphoria and insist that their lives are blissful except for their pain.lives are blissful except for their pain.

Their clinical picture can be complicated by Their clinical picture can be complicated by substance-related disorders, because these substance-related disorders, because these patients attempt to reduce the pain through patients attempt to reduce the pain through the use of alcohol and other substances.the use of alcohol and other substances.

Course and PrognosisCourse and Prognosis The pain in pain disorder generally begins The pain in pain disorder generally begins

abruptly and increases in severity for a few abruptly and increases in severity for a few weeks or months. weeks or months.

The prognosis varies, although pain The prognosis varies, although pain disorder can often be chronic, distressful, disorder can often be chronic, distressful, and completely disabling.and completely disabling.

TreatmentTreatment

PharmacotherapyPharmacotherapy Analgesic medications do not generally benefit Analgesic medications do not generally benefit

most patients with pain disorder. most patients with pain disorder. Sedatives and antianxiety agents are not Sedatives and antianxiety agents are not

especially beneficial and are also subject to especially beneficial and are also subject to abuse, misuse, and adverse effects.abuse, misuse, and adverse effects.

Antidepressants, such as tricyclics and SSRIs, Antidepressants, such as tricyclics and SSRIs, are the most effective pharmacological agentsare the most effective pharmacological agents

PsychotherapyPsychotherapy

Some outcome data indicate that Some outcome data indicate that psychodynamic psychotherapy benefits psychodynamic psychotherapy benefits patients with pain disorder.patients with pain disorder.