Argosy University/Phoeniximages2.wikia.nocookie.net/__cb20101118074851/adult...Somatic symptoms •• The somatizationsomatizationof anxiety of anxiety is very common among North

Somatoform DisordersSomatoform Disorders

Cornelia Pinnell, Ph.D.Cornelia Pinnell, Ph.D.Argosy University/PhoenixArgosy University/Phoenix

Lecture Outline Lecture Outline

•• Hysteria & hysteriaHysteria & hysteria--like symptomslike symptoms•• Somatic symptoms & Somatic symptoms & somatizationsomatization•• Somatoform disordersSomatoform disorders•• Somatoform disordersSomatoform disorders

HysteriaHysteria--like syndromeslike syndromes

•• In In premodernpremodern societiessocieties, , hysteriahysteria--like syndromes like syndromes are most likely to manifest in trance or spirit are most likely to manifest in trance or spirit possession syndromes that include possession syndromes that include somatic somatic symptomssymptoms & symptoms of& symptoms ofsymptomssymptoms & symptoms of& symptoms of

••AnxietyAnxiety••DepressionDepression••DissociationDissociation

Somatization Disorder (in the DSM-IV-TR) v In premodern societies with different cultural schemas, hysteria-like syndromes are most likely to manifest in trance or spirit possession syndromes that include a cluster of anxiety, somatic, dissociative, and possibly depressive symptoms, with dissociative symptoms being the most prominent (e.g., ataques the nervios) v

HysteriaHysteria

•• South AsiaSouth Asia::–– Urban IndiaUrban India –– emotional distress (e.g., emotional distress (e.g., following a social stressor such as a family following a social stressor such as a family argument) is likely to be experienced as an argument) is likely to be experienced as an argument) is likely to be experienced as an argument) is likely to be experienced as an illness illness –– convulsions, tremors, crying, shouts convulsions, tremors, crying, shouts of abuse, amnesia; ‘of abuse, amnesia; ‘fitsfits’ of 30’ of 30--60 minutes 60 minutes duration likely to occur 2x/monthduration likely to occur 2x/month

–– Rural IndiaRural India -- emotional distress is likely to be emotional distress is likely to be epxeriencedepxerienced as as spirit possessionspirit possession; exorcism ; exorcism rituals would be performed with good rituals would be performed with good outcomeoutcome

Hysteria in (urban) India. A dissociative response to emotional distress is extremely common in South Asia. Urban Indian patients, as indigenous elite, are more likely to adopt illness concepts from the colonizing culture that, after decolonization, became part of the indigenous culture. In the DSM-IV Casebook: “Fits” – sudden onset, 30 to 60 minutes in duration, characterized by rigidity throughout the body, convulsions and unresponsiveness, frothing at the mouth, crying, shouts of abuse, amnesia for the episodes; fits recur once or twice/month, typically following a social stressor such as a family argument). In rural India, similar dissociative symptoms would be experienced as spirit possesison and appropriate exorcism rituals would be performed with good outcome (signifying the need of family members to treat the patient with more respect).

Somatic symptomsSomatic symptoms

•• The The somatizationsomatization of anxietyof anxiety is very is very common among North American and common among North American and British patients in primary care settingsBritish patients in primary care settings

•• CrossCross--cultural studies indicate that somatic cultural studies indicate that somatic symptoms are the most common clinical symptoms are the most common clinical manifestations of anxiety disorders manifestations of anxiety disorders worldwide worldwide

SOMATOFORM DISORDERS Cross-cultural studies indicate that somatic symptoms are the most common clinical manifestations of anxiety disorders worldwide. The somatization of anxiety is very common among North American and British patients in primary care settings. Castillo’s contention is that, from a client-centered perspective, separating mental disorders expressing emotional distress into distinct anxiety, somatoform, and mood groupings is questionable. (p.189)

SomatizationSomatization

•• A tendency to seek medical attention out A tendency to seek medical attention out of proportion to evident physiological of proportion to evident physiological signs and symptoms (Fink et al., 1999)signs and symptoms (Fink et al., 1999)

•••• Transduction of unrecognized negative Transduction of unrecognized negative affect into somatic symptoms (e.g., affect into somatic symptoms (e.g., unexplained pain) (unexplained pain) (WickramasekeraWickramasekera, , 1988)1988)


•• Common featureCommon feature::–– Presence of physical symptoms that suggest a Presence of physical symptoms that suggest a general medical condition but are not fully general medical condition but are not fully explained by a general medical condition, the explained by a general medical condition, the explained by a general medical condition, the explained by a general medical condition, the direct effects of a substance, or by another direct effects of a substance, or by another mental disorder mental disorder –– grouping based on clinical grouping based on clinical utilityutility

–– Symptoms cause clinically significant distress Symptoms cause clinically significant distress or impairment in social, occupational, or other or impairment in social, occupational, or other areas of functioningareas of functioning

SOMATOFORM DISORDERS Somatization Disorder (in the DSM-IV-TR) v Hysteria or Briquet’s syndrome ( v DSM-IV-TR does not include the emotional or psychoform symptoms of the Briquet’s syndrome; thus, patients are given diagnoses of somatization disorder and comorbid diagnoses of panic disorder, generalized anxiety disorder, or major depressive disorder; this lead to administration of several medications designed to alleviate specific symptoms. v Hysteria in (urban) India Undifferentiated somatoform disorder: Residual category for persistent somatoform type illnesses that do not meet full criteria for somatization disorder. Neurasthenia in China is one of the most commonly diagnosed disorders in China. Conversion disorder (listed in the ICD-10 as a dissociative disorder) is characterized by pseudoneurological (dissociative somatic) symptoms such as amnesia, paralysis, impaired coordination, or balance, localized anesthesia, blindness, deafness, double vision, hallucination, tremors, seizures without medical explanations. These symptoms typically result from exposure to traumatic events and from emotional stress. Pain disorder. Is characterized by a subjective experience of pain that does not have sufficient medical justification. v With psychological factors v With both psychological factors and a general medical condition Hypochondriasis is characterized by persistent and unfounded fears of having serious disease based on misinterpretation of normal bodily functions or minor symptoms. Body dysmorphic disorder is characterized by a person’s belief that the appearance is somehow defective; complaints involve perceived defects in the face or head, but can involve any body part. In the US it frequently results in cosmetic surgery.


•• 300.81 Somatization Disorder300.81 Somatization Disorder•• 300.82 Undifferentiated Somatoform Disorder300.82 Undifferentiated Somatoform Disorder•• 300.11 Conversion Disorder300.11 Conversion Disorder•• 307.80 Pain Disorder Associated With Psychological 307.80 Pain Disorder Associated With Psychological •• 307.80 Pain Disorder Associated With Psychological 307.80 Pain Disorder Associated With Psychological

FactorsFactors•• 307.89 Pain Disorder Associated With Both Psychological 307.89 Pain Disorder Associated With Both Psychological

Factors & a General Medical ConditionFactors & a General Medical Condition•• 300.7 Hypochondriasis300.7 Hypochondriasis•• 300.7 Body Dysmorphic Disorder300.7 Body Dysmorphic Disorder•• 300.82 Somatoform Disorder NOS300.82 Somatoform Disorder NOS

SOMATOFORM DISORDERS Somatization Disorder (in the DSM-IV-TR) v Hysteria or Briquet’s syndrome ( v DSM-IV-TR does not include the emotional or psychoform symptoms of the Briquet’s syndrome; thus, patients are given diagnoses of somatization disorder and comorbid diagnoses of panic disorder, generalized anxiety disorder, or major depressive disorder; this lead to administration of several medications designed to alleviate specific symptoms. v Hysteria in (urban) India Undifferentiated somatoform disorder: Residual category for persistent somatoform type illnesses that do not meet full criteria for somatization disorder. Neurasthenia in China is one of the most commonly diagnosed disorders in China. Conversion disorder (listed in the ICD-10 as a dissociative disorder) is characterized by pseudoneurological (dissociative somatic) symptoms such as amnesia, paralysis, impaired coordination, or balance, localized anesthesia, blindness, deafness, double vision, hallucination, tremors, seizures without medical explanations. These symptoms typically result from exposure to traumatic events and from emotional stress. Pain disorder. Is characterized by a subjective experience of pain that does not have sufficient medical justification. v With psychological factors v With both psychological factors and a general medical condition Hypochondriasis is characterized by persistent and unfounded fears of having serious disease based on misinterpretation of normal bodily functions or minor symptoms. Body dysmorphic disorder is characterized by a person’s belief that the appearance is somehow defective; complaints involve perceived defects in the face or head, but can involve any body part. In the US it frequently results in cosmetic surgery.

Briquet’s SyndromeBriquet’s Syndrome

•• 1859 1859 -- Paul Briquet Paul Briquet -- first systematic description first systematic description of hysteria of hysteria

•• 1962 1962 -- Perley & Guze systematized the Perley & Guze systematized the diagnostic criteria for hysteria: 25 symptoms diagnostic criteria for hysteria: 25 symptoms diagnostic criteria for hysteria: 25 symptoms diagnostic criteria for hysteria: 25 symptoms (anxiety, somatic, depressive and dissociative (anxiety, somatic, depressive and dissociative type symptoms) without medical explanation type symptoms) without medical explanation

•• 1970 1970 -- Guze proposed the use of the term Guze proposed the use of the term Briquet’s syndrome instead of ‘hysteria’Briquet’s syndrome instead of ‘hysteria’

Early conceptualizations of somatization disorder was as hysteria or Briquet’s syndrome (Paul Briquet, 1859 provided the first systematic description of hysteria and recommended not to use the term because of its pejorative connotations; in 1970, Guze proposed to use the term Briquet’s syndrome, in recognition of Briquet’s contribution) v Perley & Guze (1962) systematized the diagnostic criteria for Briquet’s syndrome (hysteria); 25 symptoms (the list included anxiety, somatic, depressive and dissociative typs symptoms) without medical explanation distributed across 9 of 10 categories were necessary for the diagnosis. v The DSM-IV-TR does not include the emotional or psychoform symptoms of the Briquet’s syndrome; thus, patients are given diagnoses of somatization disorder and comorbid diagnoses of panic disorder, generalized anxiety disorder, or major depressive disorder; this lead to administration of several medications designed to alleviate specific symptoms. Undifferentiated somatoform disorder: Residual category for persistent somatoform type illnesses that do not meet full criteria for somatization disorder. It is an important category for cross-cultural assessment – patients may present only with symptoms associated with culture-bound syndrome and ignore other symptoms - chronic fatigue, loss of appetite, bodily pains, gastrointestinal symptoms without medical explanations. Neurasthenia in China (a term that is not used in USA). Neurasthenia is one of the most commonly diagnosed disorders in China, while mood disorders are relatively rare in China. The Chinese use physical symptoms as cultural idioms expressing emotional distress. Little attention is paid to depressive symptoms in both subjective and interpersonal expressions of distress; therefore, the patient primarily notices and reports somatic complaints. A Chinese trained clinician would have little trouble identifying and diagnosing ‘neurasthenia’. Conversion disorder (listed in the ICD-10 as a dissociative disorder) is characterized by pseudoneurological (dissociative somatic) symptoms such as amnesia, paralysis, impaired coordination, or balance, localized anesthesia, blindness, deafness, double vision, hallucination, tremors, seizures without medical explanations. These symptoms typically result from exposure to traumatic events and from emotional stress. �Hysteria in (urban) India. A dissociative response to emotional distress is extremely common in South Asia. Urban Indian patients, as indigenous elite, are more likely to adopt illness concepts from the colonizing culture that, after decolonization, became part of the indigenous culture. In the DSM-IV Casebook: “Fits” – sudden onset, 30 to 60 minutes in duration, characterized by rigidity throughout the body, convulsions and unresponsiveness, frothing at the mouth, crying, shouts of abuse, amnesia for the episodes; fits recur once or twice/month, typically following a social stressor such as a family argument). In rural India, similar dissociative symptoms would be experienced as spirit possesison and appropriate exorcism rituals would be performed with good outcome (signifying the need of family members to treat the patient with more respect). Pain disorder. Is characterized by a subjective experience of pain that does not have sufficient medical justification. v With psychological factors v With both psychological factors and a general medical condition The experience of pain becomes the center of a person’s cognitive processes and pain becomes amplified, leading to a downward spiral of inactivity, which causes further pain, social isolation, psychological problems and social stress. The process can start with anxiety or depression. The expression of pain varies cross-culturally and the meaning of pain also varies significantly. Hypochondriasis is characterized by persistent and unfounded fears of having serious disease based on misinterpretation of normal bodily functions or minor symptoms. It illustrates the close relationship between anxiety and somatoform disorders. Severe anxiety symptoms may result from the false cognition that the person has a severe medical condition. Part of the healing should be addressing the source of distress and treating it through symbolic healing in addition to appropriate medications. Body dysmorphic disorder is characterized by a person’s belief that the appearance is somehow defective; complaints involve perceived defects in the face or head, but can involve any body part. In the US it frequently results in cosmetic surgery. According to Castillo, these three categories are but cultural constructions.

300.81300.81 Somatization Disorder (aka Somatization Disorder (aka ‘Hysteria’ or ‘Briquet’s Syndrome’)‘Hysteria’ or ‘Briquet’s Syndrome’)

•• History of multiple physical/somatic complaints History of multiple physical/somatic complaints beginning before age 30; sxs occur over a beginning before age 30; sxs occur over a period of several years & result in seeking period of several years & result in seeking treatment or significant impairmenttreatment or significant impairmenttreatment or significant impairmenttreatment or significant impairment

•• Each criterion must be metEach criterion must be met::–– 4 pain symptoms (different sites)4 pain symptoms (different sites)–– 2 gastrointestinal symptoms2 gastrointestinal symptoms–– 1 sexual symptom1 sexual symptom–– 1 pseudoneurological symptom (e.g., conversion)1 pseudoneurological symptom (e.g., conversion)

Somatization Disorder (in the DSM-IV-TR) v Hysteria or Briquet’s syndrome ( v DSM-IV-TR does not include the emotional or psychoform symptoms of the Briquet’s syndrome; thus, patients are given diagnoses of somatization disorder and comorbid diagnoses of panic disorder, generalized anxiety disorder, or major depressive disorder; this lead to administration of several medications designed to alleviate specific symptoms. v Hysteria in (urban) India

300.81300.81 Somatization DisorderSomatization Disorder

•• Patients describe their symptoms in exaggerated Patients describe their symptoms in exaggerated terms terms –– specific factual information is absent; specific factual information is absent; inconsistent historiansinconsistent historians

•• Treatment sought for several conditions Treatment sought for several conditions •• Treatment sought for several conditions Treatment sought for several conditions simultaneously simultaneously –– resulting in complicated resulting in complicated treatment regimens (often hazardous)treatment regimens (often hazardous)

•• Comorbid anxiety & mood disorders (GAD Panic Comorbid anxiety & mood disorders (GAD Panic Disorder, Major Depressive Disorder)Disorder, Major Depressive Disorder)

patients are given diagnoses of somatization disorder and comorbid diagnoses of panic disorder, generalized anxiety disorder, or major depressive disorder; this lead to administration of several medications designed to alleviate specific symptoms

300.81300.81 Somatization DisorderSomatization Disorder

•• PrevalencePrevalence::–– Variable lifetime prevalence rates: less than 0.2% in Variable lifetime prevalence rates: less than 0.2% in

men & rates ranging between 0.2% and 2% in men & rates ranging between 0.2% and 2% in women (nonwomen (non--physician interviewers physician interviewers -- lower rates)lower rates)women (nonwomen (non--physician interviewers physician interviewers -- lower rates)lower rates)

–– Cultural factors may influence the sex ratio Cultural factors may influence the sex ratio –– higher higher prevalence rates in Greek and Puerto Rican menprevalence rates in Greek and Puerto Rican men

300.81 300.81 Somatization DisorderSomatization Disorder

•• Course & PrognosisCourse & Prognosis::

–– Onset: first symptoms emerge in adolescence; Onset: first symptoms emerge in adolescence; full criteria met in young adulthood, before full criteria met in young adulthood, before full criteria met in young adulthood, before full criteria met in young adulthood, before age 25age 25

–– Chronic & fluctuating courseChronic & fluctuating course

300.82300.82 Undifferentiated Undifferentiated Somatoform DisorderSomatoform Disorder

Diagnostic criteriaDiagnostic criteria::–– A. One or more physical complaints (fatigue, loss of A. One or more physical complaints (fatigue, loss of

appetite, gastrointestinal, urinary)appetite, gastrointestinal, urinary)–– B. Either (1) or (2):B. Either (1) or (2):–– B. Either (1) or (2):B. Either (1) or (2):

•• (1) No physical findings(1) No physical findings•• (2) When there is a medical condition, physical complaints or (2) When there is a medical condition, physical complaints or impairment exceed expectationsimpairment exceed expectations

–– C. Sxs cause significant distress or impairmentC. Sxs cause significant distress or impairment–– D. Duration of disturbance of at least 6 monthsD. Duration of disturbance of at least 6 months

Undifferentiated somatoform disorder: Residual category for persistent somatoform type illnesses that do not meet full criteria for somatization disorder. Neurasthenia in China is one of the most commonly diagnosed disorders in China. Conversion disorder (listed in the ICD-10 as a dissociative disorder) is characterized by pseudoneurological (dissociative somatic) symptoms such as amnesia, paralysis, impaired coordination, or balance, localized anesthesia, blindness, deafness, double vision, hallucination, tremors, seizures without medical explanations. These symptoms typically result from exposure to traumatic events and from emotional stress. Pain disorder. Is characterized by a subjective experience of pain that does not have sufficient medical justification. v With psychological factors v With both psychological factors and a general medical condition Hypochondriasis is characterized by persistent and unfounded fears of having serious disease based on misinterpretation of normal bodily functions or minor symptoms. Body dysmorphic disorder is characterized by a person’s belief that the appearance is somehow defective; complaints involve perceived defects in the face or head, but can involve any body part. In the US it frequently results in cosmetic surgery.

300.11300.11 Conversion DisorderConversion Disorder

•• Common symptomsCommon symptoms::–– AmnesiaAmnesia–– ParalysisParalysis–– Impaired coordination or balanceImpaired coordination or balance–– Impaired coordination or balanceImpaired coordination or balance–– Localized AnesthesiaLocalized Anesthesia–– Blindness, deafness, double visionBlindness, deafness, double vision–– HallucinationsHallucinations–– TremorsTremors–– Seizures without medical explanationsSeizures without medical explanations

symptoms such as amnesia, paralysis, impaired coordination, or balance, localized anesthesia, blindness, deafness, double vision, hallucination, tremors, seizures without medical explanations. These symptoms typically result from exposure to traumatic events and from emotional stress.


•• Diagnostic criteriaDiagnostic criteria::–– A. One or more sxs or deficits affecting voluntary A. One or more sxs or deficits affecting voluntary

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

–– B. Psychological factors are judged to be associated B. Psychological factors are judged to be associated with the sxswith the sxs

–– C. Sx or deficit is not intentionally producedC. Sx or deficit is not intentionally produced–– D. Sx or deficit cannot be fully explained by a general D. Sx or deficit cannot be fully explained by a general

medical conditionmedical condition

Neurasthenia in China is one of the most commonly diagnosed disorders in China. Conversion disorder (listed in the ICD-10 as a dissociative disorder) is characterized by pseudoneurological (dissociative somatic) symptoms such as amnesia, paralysis, impaired coordination, or balance, localized anesthesia, blindness, deafness, double vision, hallucination, tremors, seizures without medical explanations. These symptoms typically result from exposure to traumatic events and from emotional stress. Pain disorder. Is characterized by a subjective experience of pain that does not have sufficient medical justification. v With psychological factors v With both psychological factors and a general medical condition Hypochondriasis is characterized by persistent and unfounded fears of having serious disease based on misinterpretation of normal bodily functions or minor symptoms. Body dysmorphic disorder is characterized by a person’s belief that the appearance is somehow defective; complaints involve perceived defects in the face or head, but can involve any body part. In the US it frequently results in cosmetic surgery.


•• Type of symptom or deficitType of symptom or deficit::–– With Motor Symptom or DeficitWith Motor Symptom or Deficit–– With Sensory Symptom or DeficitWith Sensory Symptom or Deficit–– With Sensory Symptom or DeficitWith Sensory Symptom or Deficit–– With Seizures of ConvulsionsWith Seizures of Convulsions–– With Mixed PresentationWith Mixed Presentation


•• Differential diagnosisDifferential diagnosis::–– Exclude occult neurological, other general medical Exclude occult neurological, other general medical

conditions & substanceconditions & substance--induced etiologiesinduced etiologies–– Pain DisorderPain Disorder or or Sexual DysfunctionSexual Dysfunction are diagnosed in are diagnosed in –– Pain DisorderPain Disorder or or Sexual DysfunctionSexual Dysfunction are diagnosed in are diagnosed in

sxs are limited to pain/sexual dysfunctionsxs are limited to pain/sexual dysfunction–– Sxs may be due to another mental disorder (e.g., Sxs may be due to another mental disorder (e.g.,

SchizophreniaSchizophrenia, other , other Psychotic DisordersPsychotic Disorders, , Mood Mood DisorderDisorder))

–– Hallucinations occur with intact insight; absence of Hallucinations occur with intact insight; absence of other psychotic sxs; more sensory modalitiesother psychotic sxs; more sensory modalities


•• Differential diagnosisDifferential diagnosis::–– HypochondriasisHypochondriasis –– preoccupation with a ‘serious preoccupation with a ‘serious

disease’ underlying the sxsdisease’ underlying the sxs–– In In Body Dysmorphic DisorderBody Dysmorphic Disorder the patient is the patient is –– In In Body Dysmorphic DisorderBody Dysmorphic Disorder the patient is the patient is

preoccupied with an imagined or slight defect in preoccupied with an imagined or slight defect in appearanceappearance

–– Shared features with Shared features with Dissociative DisorderDissociative Disorder –– if both if both are present, both should be diagnosedare present, both should be diagnosed

–– Factitious DisordersFactitious Disorders & & Malingering Malingering –– sxs are sxs are intentionally producedintentionally produced


•• Conversion Disorder symptoms typically Conversion Disorder symptoms typically result from: result from: result from: result from: ––Emotional stress Emotional stress ––Exposure to traumatic eventsExposure to traumatic events

Chronic painChronic pain

•• Affects 34 million AmericansAffects 34 million Americans

•• Accounts for more than $ 40 billion in Accounts for more than $ 40 billion in annual health care costsannual health care costs

Pain DisorderPain Disorder

•• Diagnostic criteriaDiagnostic criteria: : –– A. Pain in one or more anatomical sites is the A. Pain in one or more anatomical sites is the

predominant focus of the clinical presentation & is of predominant focus of the clinical presentation & is of sufficient severity to warrant clinical attentionsufficient severity to warrant clinical attentionsufficient severity to warrant clinical attentionsufficient severity to warrant clinical attention

–– B. The pain causes clinically significant distress or B. The pain causes clinically significant distress or impairmentimpairment

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

–– Sxs or deficits are not intentionally producedSxs or deficits are not intentionally produced


•• SubtypesSubtypes::–– 307.80 Pain Disorder Associated With Psychological 307.80 Pain Disorder Associated With Psychological

FactorsFactors–– 307.89 Pain Disorder Associated With Both 307.89 Pain Disorder Associated With Both –– 307.89 Pain Disorder Associated With Both 307.89 Pain Disorder Associated With Both

Psychological Factors and a General Medical Condition Psychological Factors and a General Medical Condition –– code on Axis IIIcode on Axis III

•• SpecifiersSpecifiers::–– AcuteAcute –– if the duration of pain is < 6 monthsif the duration of pain is < 6 months–– ChronicChronic –– if the duration of pain is > 6 monthsif the duration of pain is > 6 months


•• Associated featuresAssociated features::–– Severe disruption of aspects of daily life: Severe disruption of aspects of daily life:

unemployment, disability, family problemsunemployment, disability, family problems–– Iatrogenic Opioid/Benzodiazepines Dependence or Iatrogenic Opioid/Benzodiazepines Dependence or –– Iatrogenic Opioid/Benzodiazepines Dependence or Iatrogenic Opioid/Benzodiazepines Dependence or

AbuseAbuse–– Inactivity, social isolationInactivity, social isolation–– Severe depression & increased risk for suicide Severe depression & increased risk for suicide –– in in

chronic painchronic pain–– Anxiety Anxiety –– in acute painin acute pain

Etiology of Pain DisorderEtiology of Pain Disorder

•• Wickramasekera, 1995 Wickramasekera, 1995 –– Physiological activation Physiological activation in response to perceived threat places the in response to perceived threat places the individual at risk for development of somatic individual at risk for development of somatic symptoms and illness.symptoms and illness.symptoms and illness.symptoms and illness.–– High Risk Model of Threat Perception (HRMTP) High Risk Model of Threat Perception (HRMTP) –– 9 predisposing, triggering, and buffering factors9 predisposing, triggering, and buffering factors

High Risk Model High Risk Model of Threat Perception (HRMTP)of Threat Perception (HRMTP)

•• Predisposing factors Predisposing factors –– High & low hypnotic abilityHigh & low hypnotic ability–– RepressionRepression–– CatastrophizingCatastrophizing–– CatastrophizingCatastrophizing–– Negative affectNegative affect

•• Triggering factorsTriggering factors–– Real/perceived stressors (major life changes, daily Real/perceived stressors (major life changes, daily

hassles)hassles)

•• Buffering factors Buffering factors –– social support & coping skillssocial support & coping skills

,, and


•• PrevalencePrevalence: Relatively common : Relatively common –– 10%10%--15% of 15% of adults in US have some form of work disability adults in US have some form of work disability due to back paindue to back pain

•• CourseCourse::•• CourseCourse::–– Most acute pain resolves in relatively short periods of Most acute pain resolves in relatively short periods of

timetime–– Recovery from Pain Disorder is influenced by Recovery from Pain Disorder is influenced by

participation in regularly scheduled activities despite participation in regularly scheduled activities despite the pain & change in lifestylethe pain & change in lifestyle

Differential diagnosis Differential diagnosis in Pain Disorderin Pain Disorder

•• If pain sxs occur exclusively during the course of If pain sxs occur exclusively during the course of Somatization DisorderSomatization Disorder, Pain Disorder is not , Pain Disorder is not diagnoseddiagnosed

•• If presentation meets criteria for If presentation meets criteria for DyspareuniaDyspareunia, , •• If presentation meets criteria for If presentation meets criteria for DyspareuniaDyspareunia, , Pain Disorder is not diagnosedPain Disorder is not diagnosed

•• In In Conversion DisorderConversion Disorder, sxs are not limited to , sxs are not limited to painpain

•• Pain sxs are intentionally produced or feigned in Pain sxs are intentionally produced or feigned in Factitious DisorderFactitious Disorder and and MalingeringMalingering

International Association International Association for the Study of Painfor the Study of Pain

•• FiveFive--axis systemaxis system for categorizing chronic pain for categorizing chronic pain according to:according to:I.I. Anatomical regionAnatomical regionII.II. Organ systemOrgan systemII.II. Organ systemOrgan systemIII.III. Temporal characteristics of pain & pattern of Temporal characteristics of pain & pattern of

occurrenceoccurrenceIV.IV. Patient’s statement of intensity and time since Patient’s statement of intensity and time since

onset of painonset of painV.V. Etiology (Etiology (psychologicalpsychological or or psychophysiologicapsychophysiological)l)

300.7 300.7 HypochondriasisHypochondriasis

•• Diagnostic criteriaDiagnostic criteria::–– A. Preoccupation with fears of having a serious A. Preoccupation with fears of having a serious

disease based on the person’s misinterpretation of disease based on the person’s misinterpretation of bodily symptomsbodily symptoms

–– B. Preoccupation persists despite appropriate medical B. Preoccupation persists despite appropriate medical evaluation & reassuranceevaluation & reassurance

–– C. The Belief in Criterion A is not of delusional C. The Belief in Criterion A is not of delusional intensity & not restricted to appearanceintensity & not restricted to appearance

–– D. Causes clinically significant distress/impairmentD. Causes clinically significant distress/impairment–– E. Duration of disturbance of at least 6 monthsE. Duration of disturbance of at least 6 months

300.7 300.7 HypochondriasisHypochondriasis

•• SpecifierSpecifier::–– With Poor InsightWith Poor Insight –– if the person does not recognize if the person does not recognize

during the current episode that the concern about during the current episode that the concern about during the current episode that the concern about during the current episode that the concern about having a serious illness is excessive or unreasonablehaving a serious illness is excessive or unreasonable

300.7300.7 Body Dysmorphic DisorderBody Dysmorphic Disorder

•• Diagnostic criteriaDiagnostic criteria::–– A. Preoccupation with an imagined defect in A. Preoccupation with an imagined defect in

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

–– B. Causes clinically significant distress/impairmentB. Causes clinically significant distress/impairment–– C. The preoccupation is not better accounted for by C. The preoccupation is not better accounted for by

another mental disorderanother mental disorder

Phenomenology of BodyPhenomenology of BodyDysmorphic DisorderDysmorphic Disorder

•• Intense preoccupation with an imagined or real, Intense preoccupation with an imagined or real, but minor defect of the physical appearance but minor defect of the physical appearance --focus is usually on one aspect of the body, but focus is usually on one aspect of the body, but can shift during the course of the illnesscan shift during the course of the illness

•• Any part of the body can be the focus of Any part of the body can be the focus of •• Any part of the body can be the focus of Any part of the body can be the focus of concern, but most complaints are concerning concern, but most complaints are concerning aspects of the face or head (e.g. nose, hair aspects of the face or head (e.g. nose, hair thinning, acne, wrinkles, scars, facial asymmetry thinning, acne, wrinkles, scars, facial asymmetry or disproportion, or excessive facial hair)or disproportion, or excessive facial hair)


•• Differential diagnosisDifferential diagnosis::–– Normal concerns about appearanceNormal concerns about appearance–– Body Dysmorphic Disorder Body Dysmorphic Disorder may be underrecognized in may be underrecognized in

cosmetic surgery settingscosmetic surgery settingscosmetic surgery settingscosmetic surgery settings–– Body Dysmorphic Disorderis not diagnosed if the Body Dysmorphic Disorderis not diagnosed if the

excessive preoccupation is restricted to concerns excessive preoccupation is restricted to concerns about fatness in Anorexia Nervosa or primary or about fatness in Anorexia Nervosa or primary or secondary sex characteristics as in Gender Identity secondary sex characteristics as in Gender Identity DisorderDisorder


Differential diagnosisDifferential diagnosis::•• Healthy exercise vs. excessive exerciseHealthy exercise vs. excessive exercise•• Major Depressive Episode Major Depressive Episode -- preoccupation preoccupation •• Major Depressive Episode Major Depressive Episode -- preoccupation preoccupation that occurs exclusively during the episode that occurs exclusively during the episode

•• Trichotillomania Trichotillomania -- does not occur in response to does not occur in response to appearance concernsappearance concerns


Differential diagnosisDifferential diagnosis::•• Avoidant Personality Disorder or Social PhobiaAvoidant Personality Disorder or Social Phobia--

may worry about being embarrassed about real may worry about being embarrassed about real may worry about being embarrassed about real may worry about being embarrassed about real defects but it is not prominent, time consuming, defects but it is not prominent, time consuming, impairing, or distressingimpairing, or distressing

•• ObsessiveObsessive--Compulsive DisorderCompulsive Disorder--given only when given only when obsessions and compulsions are not restricted to obsessions and compulsions are not restricted to concerns about appearanceconcerns about appearance


Differential diagnosisDifferential diagnosis::•• Persons with BDD can receive additional diagnosis Persons with BDD can receive additional diagnosis

of Delusional Disorder, Somatic Type, if of Delusional Disorder, Somatic Type, if of Delusional Disorder, Somatic Type, if of Delusional Disorder, Somatic Type, if preoccupation with “defect” is held with delusional preoccupation with “defect” is held with delusional intensityintensity

•• KoroKoro -- culture related syndrome, preoccupation culture related syndrome, preoccupation that the penis (or labia, nipples, or breast in that the penis (or labia, nipples, or breast in women) is shrinking or retracting and will disappear women) is shrinking or retracting and will disappear in abdomenin abdomen

Behaviors Associated with Behaviors Associated with Body Dysmorphic DisorderBody Dysmorphic Disorder

•• Comparing with othersComparing with others•• Checking the defect directly or in mirrors Checking the defect directly or in mirrors •• Excessive grooming (e.g., hair cutting, makeup Excessive grooming (e.g., hair cutting, makeup

application, shaving, hair styling) application, shaving, hair styling) application, shaving, hair styling) application, shaving, hair styling) •• Seeking reassurance or attempting to convince Seeking reassurance or attempting to convince

others of the "defect's" uglinessothers of the "defect's" ugliness•• Skin picking, dieting, excessive exercising, Skin picking, dieting, excessive exercising,

steroid abusesteroid abuse•• Camouflaging (e.g., with a hat, clothes, or Camouflaging (e.g., with a hat, clothes, or

makeup)makeup)

Etiology of BDDEtiology of BDD

•• The cause of BDD is unknown The cause of BDD is unknown -- the the pathophyisology of BDD may involve serotoninpathophyisology of BDD may involve serotonin

•• Cultural concerns about appearance may Cultural concerns about appearance may •• Cultural concerns about appearance may Cultural concerns about appearance may influence or amplify preoccupations with an influence or amplify preoccupations with an imagined “defect”imagined “defect”

•• Commonly coexists with other mental disorders Commonly coexists with other mental disorders (e.g. major depressive episode, anxiety (e.g. major depressive episode, anxiety disorder, and a psychotic disorder)disorder, and a psychotic disorder)

Sociocultural FactorsSociocultural Factors

•• Family, friends, societal and cultural norms, Family, friends, societal and cultural norms, media, religion media, religion

•• Culture affects what is considered the ideal of Culture affects what is considered the ideal of beauty beauty -- for example, plumpness or thinness for example, plumpness or thinness beauty beauty -- for example, plumpness or thinness for example, plumpness or thinness (standards of beauty change over time) (standards of beauty change over time)

•• The value placed on beauty in a cultureThe value placed on beauty in a culture

Universal beauty (evolutionary)Universal beauty (evolutionary)

The “universalist” point of view is that The “universalist” point of view is that cultures provide nuances to a cultures provide nuances to a basically invariant, or universal, basically invariant, or universal, basically invariant, or universal, basically invariant, or universal, standard of beautystandard of beauty––Unblemished skin and facial symmetryUnblemished skin and facial symmetry

Cultural Variations in BDDCultural Variations in BDD

•• BDD affects men and women almost equal BDD affects men and women almost equal crosscross--culturallyculturally

•• Similar behaviors present in BDD, such as Similar behaviors present in BDD, such as mirror checking and camouflagingmirror checking and camouflagingmirror checking and camouflagingmirror checking and camouflaging

•• Men in the U.S. focus on hair or overall Men in the U.S. focus on hair or overall body build body build

•• Asians have more preoccupations with the Asians have more preoccupations with the eyelidseyelids

Body Dysmorphic Disorder Body Dysmorphic Disorder Examination (BDDE)Examination (BDDE)

•• 32 item clinical interview, measures 32 item clinical interview, measures cognitive and behavioral symptoms of BDDcognitive and behavioral symptoms of BDD

•• Looks into the selfLooks into the self--consciousness and consciousness and •• Looks into the selfLooks into the self--consciousness and consciousness and preoccupation with physical appearance, preoccupation with physical appearance, overvalued ideas about the importance of overvalued ideas about the importance of appearance in selfappearance in self--evaluation, avoidance of evaluation, avoidance of social situations or exposure of the social situations or exposure of the appearance defects, and body appearance defects, and body camouflaging and body checking behavior camouflaging and body checking behavior

Rosen, Reiter, & Orosan, 1995Rosen, Reiter, & Orosan, 1995

TreatmentTreatment

•• PharmacotherapyPharmacotherapy-- serotonin specific serotonin specific drugs have been useful in some cases in drugs have been useful in some cases in reducing symptoms: clomipramine reducing symptoms: clomipramine reducing symptoms: clomipramine reducing symptoms: clomipramine ((Anafranil)Anafranil) and fluoxetine (and fluoxetine (ProzacProzac) )

•• Cognitive behavioral body image Cognitive behavioral body image therapytherapy-- group and/or individual therapy, group and/or individual therapy, useful for persons with various degrees useful for persons with various degrees of body image disorderof body image disorder

300.82300.82 Somatoform Disorder NOSSomatoform Disorder NOS

•• PseudocyesisPseudocyesis–– False belief of being pregnant, associated with False belief of being pregnant, associated with

objective signs of pregnancy (e.g., abdominal objective signs of pregnancy (e.g., abdominal enlargement, reduced menstrual flow, amenorrhea, enlargement, reduced menstrual flow, amenorrhea, enlargement, reduced menstrual flow, amenorrhea, enlargement, reduced menstrual flow, amenorrhea, subjective sensations of fetal movement, nausea, subjective sensations of fetal movement, nausea, breast engorgement & secretions, labor pains at the breast engorgement & secretions, labor pains at the expected date of delivery) expected date of delivery)

–– Endocrine changes may be presentEndocrine changes may be present

300.82300.82 Somatoform Disorder NOSSomatoform Disorder NOS

•• A disorder involving nonpsychotic A disorder involving nonpsychotic hypochondriacal symptoms of less that 6 months hypochondriacal symptoms of less that 6 months durationduration

•• A disorder involving unexplained physical A disorder involving unexplained physical complaints (e.g., fatigue or body weakness) of complaints (e.g., fatigue or body weakness) of less than 6 months’ duration that are not due to less than 6 months’ duration that are not due to another mental disorderanother mental disorder

NeurastheniaNeurasthenia

•• 1860s, George Miller Beard 1860s, George Miller Beard –– ‘nervous ‘nervous exhaustion’exhaustion’

•• EpidemiologyEpidemiology: Cultural differences : Cultural differences –– It is one of It is one of •• EpidemiologyEpidemiology: Cultural differences : Cultural differences –– It is one of It is one of the most commonly diagnosed disorders in the most commonly diagnosed disorders in ChinaChina (the Chinese use physical sxs as cultural (the Chinese use physical sxs as cultural idioms to express emotional distress)idioms to express emotional distress)

•• EtiologyEtiology –– depletion theory (due to stress)depletion theory (due to stress)

NEURASTHENIA (George Miller Beard, 1860s) (Undifferentiated Somatoform Disorder; “nervous exhaustion”) Epidemiology – cultural differences The Chinese use physical symptoms as cultural idioms expressing emotional distress. Etiology – hypothesized role of stress; depletion theory (neuroendocrine dysregulation) Diagnosis & Clinical Features – (not used as a diagnostic category in all countries) · Chronic weakness & fatigue (both physical & mental) · Aches & pains · General anxiety & nervousness, irritability Differential diagnosis: to be differentiated from anxiety disorders Course & Prognosis: Untreated, it has a chronic pattern Treatment: · Medical workup · Medication to relieve medical symptoms; antidepressants & anxiolytics · Psychotherapy

NeurastheniaNeurasthenia

•• Clinical featuresClinical features: : –– Chronic weakness & fatigueChronic weakness & fatigue–– Aches and painsAches and pains–– General anxietyGeneral anxiety–– General anxietyGeneral anxiety–– NervousnessNervousness–– IrritabilityIrritability

Diagnosis & Clinical Features – (not used as a diagnostic category in all countries) · Chronic weakness & fatigue (both physical & mental) · Aches & pains · General anxiety & nervousness, irritability

Chronic Fatigue SyndromeChronic Fatigue Syndrome

•• EpidemiologyEpidemiology:approx. 1/1,000; female to male :approx. 1/1,000; female to male ration 2:1; ages 20ration 2:1; ages 20--4040

•• EtiologyEtiology: unknown: unknown•• EtiologyEtiology: unknown: unknown

•• Clinical featuresClinical features: various physical symptoms: various physical symptoms

CHRONIC FATIGUE SYNDROME Epidemiology – estimated 1/1,000; female to male ratio 2:1; ages 20-40 Etiology: unknown Diagnosis & Clinical Features: various physical symptoms Differential diagnosis: differentiate from endocrine, neurological, infectious, and psychiatric disorders Course & Prognosis: best prognosis with improvement in patients with no psychiatric history Treatment: supportive psychotherapy; CBT; analgesics for symptomatic treatment of pain

Treatment of Neurasthenia and Treatment of Neurasthenia and Chronic Fatigue SyndromeChronic Fatigue Syndrome

•• Medical workup Medical workup •• Supportive psychotherapySupportive psychotherapy•••• CBTCBT•• Analgesics for symptomatic treatment of painAnalgesics for symptomatic treatment of pain

Argosy University/Phoeniximages2.wikia.nocookie.net/__cb20101118074851/adult...Somatic symptoms •• The somatizationsomatizationof anxiety of anxiety is very common among North

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Argosy University/Phoeniximages2.wikia.nocookie.net/__cb20101118074851/adult...Somatic symptoms •• The somatizationsomatizationof anxiety of anxiety is very common among North