Somatization disorder

1. Somatization disorder in neurological practice Dr. Parag Moon Dept. Of Neurology, GMC ,Kota

2. Somatoform Disorders A group of disorders in which people experience significant physical symptoms for which there is no apparent organic cause Symptoms are often inconsistent with possible physiological processes People do not consciously produce or control the symptoms but truly experience the symptoms Symptoms pass only when the psychological factors that led to the symptoms are resolved

3. Conversion disorder Loss of functioning in some part of the body for psychological rather than physical reasons Somatization disorder History of complaints about physical symptoms, affecting many different areas of the body, for which medical attention has been sought but no physical cause found Pain disorder History of complaints about pain, for which medical attention has been sought but that appears to have no physical cause Hypchondriasis Chronic worry that one has a physical disease in the absence of evidence that one does; frequently seek medical attention Body dysmorphic disorder Excessive preoccupation with some part of the body the person believes is defective

4. Somatoform and Pain Disorders Subjective experience of many physical symptoms, with no organic causes Psychosomatic Disorders Actual physical illness present and psychological factors seem to be contributing to the illness Malingering Deliberate faking of physical symptoms to avoid an unpleasant situation, such as military duty Factitious Disorder Deliberate faking of physical illness to gain medical attention

5. Somatoform and Dissociative Disorders Somatoform disorders are problems that appear to be medical but are due to psychosocial factors Unlike psychophysiological disorders, in which psychosocial factors interact with physical ailments, somatoform disorders are psychological disorders masquerading as physical problems

6. Somatoform and Dissociative Disorders Dissociative disorders are patterns of memory loss and identity change that are caused almost entirely by psychosocial factors rather than physical ones

7. Somatoform Disorders When a physical ailment has no apparent medical cause, physicians may suspect a somatoform disorder People with a somatoform disorder do not consciously want, or purposely produce, their symptoms They believe their problems are genuinely medical There are two main types of somatoform disorders: Hysterical somatoform disorders Preoccupation somatoform disorders

8. What Are Hysterical Somatoform Disorders? People with hysterical somatoform disorders suffer actual changes in their physical functioning These disorders are often hard to distinguish from genuine medical problems It is always possible that a diagnosis of hysterical disorder is a mistake and that the patient’s problem has an undetected organic cause

9. What Are Hysterical Somatoform Disorders? DSM-IV-TR lists three hysterical somatoform disorders: Conversion disorder Somatization disorder Pain disorder associated with psychological factors

10. Somatization disorder  history Recognized since the time of ancient Egypt. An early name for somatization disorder was hysteria, a condition incorrectly thought to affect only women. (The word hysteria is derived from the Greek word for uterus, hystera .) In the 17th century, Thomas Sydenham recognized that psychological factors, which he called antecedent sorrows, were involved in the pathogenesis of the symptoms.

11. In 1859, Paul Briquet , a French physician, observed the multiplicity of the symptoms and the affected organ systems and commented on the usually chronic course of the disorder. The disorder was called Briquet's syndrome for a time, although the term somatization disorder became the standard in the United States when the third edition of DSM (DSM-III) was introduced in 1980. History ctd .

12. Somatization is “the tendency to experience and communicate somatic distress and symptoms unaccounted by pathological findings.” Can coincide with another illness. Somatization disorder

13. Prevalance - 0.2% to 2% among women and is less than 0.2% in men Usually begins in the teenage and young adulthood years. Onset after 30 years is extremely rare More common in less educated and lower socioeconomic groups Epidemilogy

14. Observed in 10% to 20% of female first-degree relatives. Male relatives of women with somatization disorder have an increased risk of antisocial personality, substance abuse disorders, and somatization disorder.

15. Etiology Psychosocial Factors interpretations of the symptoms as social communication avoid obligations express emotions symbolize a feeling or a belief the symptoms substitute for repressed instinctual impulses A behavioral perspective Biological Factors characteristic attention and cognitive impairments decreased metabolism in the frontal lobes and in the nondominant hemisphere genetic components Research into cytokines

16. Patients with somatization disorder have the tendency to react to psychosocial distress and environmental stressors with physical bodily symptoms. Can be vague and dramatic in reporting their medical history. Frequently move abruptly from complaining of one symptom to another symptom. CLINICAL FEATURES

17. Usually present with numerous symptoms, such as headaches, back pain, persistent lack of sleep, stomach upset, and chronic tiredness Without demonstrable medical causes Have a persistent conviction of being ill, despite repeated negative results on laboratory tests, diagnostic tests, consultations with specialists, and recurrent hospitalizations Clinical features

18. Has impaired social/work/personal functioning Symptoms may be exacerbated by stress No element of feigning symptoms to occupy sick role ( Facititious Disorder) or for material gain (Malingerer)

19. Physical examination is normal May reveal some skin lesions or scars that resulted from previously performed surgeries Affects the patient’s perception of wellness Patient begins to believe that she or he is physically disabled and unable to work Characteristically deny the influences of psychosocial distress in producing the symptoms,resist psychiatric referral

20. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria DIAGNOSIS AND ASSESSMENT

21. Differential diagnosis Medical conditions - multiple sclerosis, brain tumour, hyperparathyroidism , hyperthyroidism, lupus erythematosus Affective (depressive) and anxiety disorders - 1or2 symptoms of acute onset and short duration H ypochondri asis - patient´ s focus is on fear of disease not focus on symptoms P anic disorder - somatic symptoms d uring panic episode only

22. Differential diagnosis C onversion disorder - only one or two P ain disorder - one or two unexplained pain complaints , not a lifetime history of multiple complaints D elusional disorders - schizophrenia with somatic delusions or depressive disorder with hypochondriac delusions , bizzare, psychotic sy. U ndifferentiated somatization disorder - s hort duration (e.g. less than 2 years) and less striking symptoms

23. Therapy and Prognosis The major importance for successful management  T rusting relationship between the patient and one ( if possible) primary care physician F requent changes of doctors are frustrating and countertherapeutic . R egularly scheduled visits every 4 or 6 weeks. Brief outpatient visits - perform ance of at least partial physical examination during each visit directed at the organ system of complaint.

24. Therapy and Prognosis Explain to the patient and family relationship between psych and somatic Empathic attitude Avoid more diagnostic tests, laboratory evaluations and operative procedures unless clearly indicated Treatment of underlying depression and anxiety. Potentially addicting medications should be avoided

25. Psychotherapy, both individual and group decreases personal health care expenditures (50%) decreasing their rates of hospitalization. helped to cope with their symptoms to express underlying emotions to develop alternative strategies for expressing their feelings

26. Increased Activity Involvement Combats stress Improves overall mood Provides Distraction from somatic symptoms Pain perception has a subjective component—improved mood and distraction reduce the experience of pain Exercise has physiological effects that combat somatization and stress Behavioral Techniques

27. Relaxation Techniques Directly acts on physical symptoms, given its effects on breathing, heart rate, muscle tension, etc. Patients report benefit soon upon learning the technique Helps with stress management Includes Diaphragmatic Breathing, Progressive Muscle Relaxation, Biofeedback

28. Sleep Strategies Establish consistent sleep patterns (same bedtime and waketime everyday) Go to bed only when sleepy (stimulus control) If not asleep within 20-30 minutes leave bed and return when sleep again (stimulus control ) Comfortable sleep environment Avoid alcohol/caffeine during 6 hours before bedtime Exercise regularly, but not within 4 hours of bedtime

29. Cognitive Strategies Much like CBT for depression Looking for adaptability of thoughts Eliminating distortions Use somatic symptoms as anchors for examining thoughts Look for variations in adaptability of thoughts and discuss their effect Patients are likely to have difficulty identifying thoughts/emotions .

30. Thanks

31. Somatization Disorders:Diagnosis , Treatment, and Prognosis;Psychosocial : vol 32no2 Feb 2011 Somatisation in neurological practice; J Neurol Neurosurg Psychiatry. Oct 200 4; 57(10): 1161–1164. Somatization A Debilitating Syndrome in Primary Care; Psychosomatics 42:1, January-February 2001 Kaplans and S adocks textbook of psychiatry References