Somatoform Disorder A Nightmare for physician GMC.ppt

Medically unexplained physical sym: a psychiatric perspective.

1. 19th Dec 2007 Somatoform Disorders 1
Medically unexplained
physical symptoms : a
psychiatric perspective.
Presenter:
Dr. Nirmal Lamichhane
MBBS (LMCH,Pakistan),MD (BPKIHS,Dharan)
Neuro psychiatrist

2. 19th Dec 2007 2Somatoform Disorders
Plan Of presentation
Introduction
Etiological factors
Demography/ Epidemiology
Classification
Clinical presentations
Management
Take home message
Further readings
Closing remarks by chairperson

3. 19th Dec 2007 3Somatoform Disorders
Abstract
Medically unexplained physical symptoms (MUPS)
are common in general practice (GP), and are even
more problematic as they become persistent.
referred to in the literature by many different labels,
including somatization, symptom-based conditions,
and functional somatic syndromes, among many
others.
In psychiatry, current taxonomies (Diagnostic and
Statistical Manual of Mental Disorder, 4th edition, and
The International Statistical Classification of Diseases
and Related Health Problems, 10th revision) classify
these syndromes together under the rubric of
somatoform disorders.

4. 19th Dec 2007 4Somatoform Disorders
Prevalence of psychiatric disorders by medical settings
Disorders General
Practice
Medical/surgicalPsychiatric
services
OPD Inpatient
Adjustment Disorders++ ++ +++ ++
Depression/Anxiety++ ++ +++ +++
Alcohol Abuse ++ ++ +++ +++
Personality Disorders++ ++ ++ +++
Somatoform Disorders+ +++ +++ +
Delirium - - +++ -
Psychosis - - - +++
Note: -rare; + uncommon; ++ common; +++ very common
Introduction

5. 19th Dec 2007 5Somatoform Disorders
15-25% of patients presenting to general
outpatients in Nepal will have mental disorders
14% will have neurotic conditions
2% of the population will be totally dysfunctional
due to their mental disorder
2.5 million people in Nepal have a mental
disorder
Only ~40 trained Psychiatrists
1:625,000
Introduction…………….
Scenario in Nepal

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Objectives
Recognize/ suspect the disorder in
time
Do’s and Don’ts
Preliminary management
Timely referral
Introduction…………….

7. 19th Dec 2007 7Somatoform Disorders
since antiquity
Known to ancient Egypt→Greek word Hystera (wandering uterus)
Hysteria
‘Antecedent Sorrows’-17
th
century : Thomas Sydenham psychosocial
factors involvement in pathogenesis.
Samuel Guze (1970)Briquette Syndrome:
multisymptomatic;1859;Paul Briquette
Jean Martin Charcotbiological/psychological
Charles beard in 1881:“The complaints are not imaginary”.
Pierre Janetdésegregation mentale(1920)
MonosymptomaticConversion (Freud)
Historical Perspective:
Introduction…………….

8. 19th Dec 2007 8Somatoform Disorders
1943, Wilhelm Stekel coined somatization disorder
DSM III onwardssomatoform (1980)
four illness types least liked by doctors[substance
abuse, neurological deficits, personality
disorders].
Not well understood and treated by western
medicine.
Frustrates physicianas if challenging the
education and good skill of the doctors.
Introduction…..

9. 19th Dec 2007 9Somatoform Disorders
Reflects weakness in scientific and clinical
medical educationwhich lack education about
how mind and body are integrated in their
function.
Much of the medical education views bodily
symptomsas evidence that there should be an
identifiable illnessin peripheral organs when
the search for this proposed illness ends
without explanation, the symptoms and the
patients are logically deemed to be inauthentic.
Introduction……

10. 19th Dec 2007 10Somatoform Disorders
Introduction
Etiological factors
Demography/ Epidemiology
Classification
Clinical presentations
Management
Take home message
Further readings
Closing remarks by chairperson

11. 19th Dec 2007 11Somatoform Disorders
Etiology
Unknown etiology:
Simulates physical illnessbut physical & lab findings
normal
Psychological factors & conflicts -initiate, exacerbate &
maintain (c.f. psycho-somatic medicine)
? Neuro –chemistry, -immunology,-physiology (caused by yet
unknown brain mechanism)
?Psycho-dynamic/ socio-cultural
Bodily sensations or functions (pts primary
concern)→influenced by a disorder of mind
Although related to medical condition -Clearly in excess
Unrelated to other mental disorders in hierarchy

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Abnormal illness behavior:
Persistent suspicion of physical illness despite
repeated reassurance
Significant distress, socio-occupational dysfunction
Soma = body (Greek)+ to
form=Somatoform
Broad group of illnesses that have bodily
signs and symptoms as a major component
Etiology…………

13. 19th Dec 2007 13Somatoform Disorders
Mind-body interactions:
brain signals, impinge on awareness indicating a
serious problem in the body.
Magnified health concern (not imaginaryor under
control)
Charles Beard (1881): The modern physician
who dismisses his or her patient with the
statement that the complaint is imaginary
does a disservice to both the patient and the
profession.
Etiology…………

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Genetic theories:Family studies,Adoptionstudies,
Twin studies
Pre-occupation with body sensation or propensity to
amplify bodily sensation is genetically determined.
10-20% female FDR of women who have the disorder.
(though male relatives show increase risk of ASPD and
substance related disorders).
Learning and socio-cultural theories:
Early experiences & learning: *Children copy other
family members *Adults copy symptoms given
attention in childhood.
Psychodynamic theories:
Anger & hostility links to somatoform
Etiology…………

15. 19th Dec 2007 15Somatoform Disorders
Psycho-social formulation:
Interpretation of the symptoms as social communication whose
result is:
to avoid obligations ( e.g. Going to a job a
person does not like )
to express emotions (e.g. anger at a spouse)
to symbolize a feeling or a belief(e.g. a pain
in the gut).
Psycho-analytical interpretation:
The symptoms substitute for repressed instinctual impulses.
Patient who was traumatised as a child may have an
unconscious need to continue suffering
Patient who was neglected as a child may have learnt that the
only way to get support and nurturance is through being sick
Etiology…………

16. 19th Dec 2007 16Somatoform Disorders
Introduction
Etiological factors
Demography/ Epidemiology
Classification
Clinical presentations
Management
Take home message
Further readings
Closing remarks by chairperson

17. 19th Dec 2007 17Somatoform Disorders
Demography/ Epidemiology
High Prevalence:<1-30% of medical clinic visitors
Female preponderance, F:M 5:1 to 20:1
(Exception : Hypochondriasis)
Young age : onset < 30yrs
(exc. Pain ds: 4
th
or 5
th
decade)
Rural/ low socio-economic: “Inversely related”
Little educated & psychologically unsophisticated
Familial pattern: +ve history; parental substance abuse & antisocial
symptoms (risk factors)
Unmarried> Married
Non-white> White

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Introduction
Etiological factors
Demography/ Epidemiology
Classification
Clinical presentations
Management
Take home message
Further readings
Closing remarks by chairperson

19. 19th Dec 2007 19Somatoform Disorders
Classification
DSM –IV-TR ICD-10
Somatization disorderSomatization disorder
Conversion disorder*Dissociative (conversion
Disorder)
Hypochondriasis Hypochondriacal disorder^
Pain Disorder Persistent Somatoform Pain Disorder
Body Dysmorphic Disorder^ Somatoform Autonomic Dysfunction*
Undifferentiated somatoform disorderOther Somatoform disorders
Somatoform disorder NOS Neurasthenia*

20. 19th Dec 2007 20Somatoform Disorders
Introduction
Etiological factors
Demography/ Epidemiology
Classification
Clinical presentations
Management
Take home message
Further readings
Closing remarks by chairperson

21. 19th Dec 2007 21Somatoform Disorders
Clinical Presentations
Common symptoms
Patients Controls
–nervousness 92% 15%
–weakness 84% 11%
–joint pain 84% 27%
–dizziness 84% 9%
–fatigue 84% 47%
–abdominal pain 80% 22%
–nausea 80% 20%
–headache 80% 32%

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Common symptoms in Nepal
Jhum Jhum,nassako rog
Bhetne betha
Kapal/Tauko dukhne-Headache
Kokha hanne-Palpitations
Frequency of micturition
Gano jane-Abdominal cramps
Poor sleep,Poor appetite
Sarir hallane-Feeling tired and loss of energy (30% of
patients)
Ghumaune-Dizziness
Jiu kar kar khane-Unexplained pain
Clinical Presentations……….

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Functional somatic syndromes by medical speciality
Cardiology –non-cardiac chest pain, benign palpitation
Gastroenterology –irritable bowel syndrome, non-ulcer
dyspepsia
Rheumatology –fibromyalgia, repetitive strain injury
Immunology –multiple chemical sensitivity
General medicine –chronic fatigue syndrome
ENT –globus syndrome
Neurology –conversion disorders, non-epileptic attacks,
chronic benign headache
Gynaecology –chronic pelvic pain
Paediatrics –non-specific abdominal pain
Clinical Presentations……….

24. 19th Dec 2007 24Somatoform Disorders
Disorder C/F DURATION PRIMARY D/D
Somatization Polysymptomatic
Recurrent & chronic
Sickly by history
>2 YRS Physical disease
Depression
Dissociative
(Conversion)
Monosymptomatic
Mostly acute
Simulates disease
Depression
Schizophrenia
Neurological ds*
Hypochondriasis Disease concern/
conviction
>6 mths Depression
Physical diseases
Delusional disorder
Body dysmorphicSubjective feeling of
ugliness or body defect
concern
Delusional disorder
depression
Pain Simulation or intensity
incompatible with
known physiology/
anatomy
>6 mths Depression
Alcohol & other
substance abuse
Hystrionic /dependant

25. 19th Dec 2007 25Somatoform Disorders
True Vs Pseudo-seizure
FEATURE EPILEPTIC PSEUDO
Nocturnal seizure common uncommon
Stereotype aura Usual None
Cyanotic skin changesCommon None
Self injury Common Rare
Incontinence Common Rare
Post-ictal confusion Present None
Body movements Tonic/clonic Non-stereotype &
asynchronous
Effect of suggestion Seldom Often
EEG changes + variable
Clinical Presentations……….

26. 19th Dec 2007 26Somatoform Disorders
DISORDER SYMPTOM
PRODUCTION
MOTIVATION
Somatoform Unconscious Unconscious
Factitious Conscious Unconscious
Malingering Conscious Conscious
Note: Malingering is not a Medical diagnosis
Clinical Presentations……….

27. 19th Dec 2007 27Somatoform Disorders
Triggers/Risk factors
Death of a loved one
Stress at work
Fear of failing an exam
Coping with a new marriage
Physical illness
The hard worked mother whose husband is away
Loneliness
Coping with illness in a relative
The spouse of an alcoholic
The medical student or doctor
Clinical Presentations……….

28. 19th Dec 2007 28Somatoform Disorders
Complaints from a typical somatoform
disorder patient
Sensory:
“My vision is blurry. It’s like seeing
through a fog, but the doctor said that
glasses wouldn’t help.”
I suddenly lost my hearing. It came back
but now I have an echo.”
Clinical Presentations……….

29. 19th Dec 2007 29Somatoform Disorders
Genitourinary:
“I’m not interested in sex, but I pretend to be to satisfy my
husband’s needs.”
“I had nerves cut going down into my uterus because of severe
cramps.”
“I’ve had red patches on my labia and I was told to use boric
acid.”
“I have had difficulty with bladder control, but nothing was
found.”
Clinical Presentations……….

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Gastrointestinal:
“ For 10 years I was treated for nervous
stomach, spastic colon, and gallbladder, but
nothing seemed to help.”
“I got a violent cramp after eating an apple
and felt terrible all the next day.”
“The gas was awful--I thought I was going to
explode.”
Clinical Presentations……….

31. 19th Dec 2007 31Somatoform Disorders
Differential Diagnosis
Multiple sclerosis
Central nervous system syphilis
Brain tumor
Hyperparathyroidism
Acute intermittent porphyria
Lupus erythematosus
Hyperthyroidism
Myasthenia gravis
Clinical Presentations……….

32. 19th Dec 2007 32Somatoform Disorders
Psychiatric co-morbidity
2/3 rd
anxiety and mood symptoms are common
(Usually the reason for being seen in mental health settings).
Common associations are:
Depressive disorder
Panic disorder Axis I
Substance –related disorder
Histrionic personality disorder
Borderline personality disorder Axis II
Anti-social personality disorder
Clinical Presentations……….

33. 19th Dec 2007 33Somatoform Disorders
Introduction
Etiological factors
Demography/ Epidemiology
Classification
Clinical presentations
Management
Take home message
Further readings
Closing remarks by chairperson

34. 19th Dec 2007 34Somatoform Disorders
Management of Somatoform
Disorders
GENERAL PRINCIPLES
1.Good history
2.Thorough physical and relevant examinations to
r/o organicity or other primary mental illness
3.Establish diagnosis/ co-morbidity
4.Treatment
5.Referral

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Difficulties:
No definite therapy
High expectations (about symptom removal)
High tendency to change their doctor
(“doctor shoppers/ clinic hoppers”)
Goals: Care, not cure
•Reduce frequency and severity of physical
complaints
•Improvement in social adjustment
•Reduction in cost and frequency of medical
Rx.
Management……….

36. 19th Dec 2007 36Somatoform Disorders
Management: Basic Principle
Establish rapport and empathic relationwith a single
physician based on trust and confidence
Family doctor aided by liaison with a psychiatrist.
Limit the number of doctors the patient is seeing.
Explain the nature of illness-reassure that his illness has been properly
understood
Management……….
Never tell that there is nothing wrong

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Explaining negative results
Doctors’ explanations of MUPS have been analysed
and three types of explanation identified.
The commonest is rejection, in which the reality of the
symptoms is denied, negative results equated with
absence of cause, and an imaginary disorder or
stigmatising psychological problem implied.
In collusion, the doctor simply agrees with the
patient’s explanatory beliefs.
Positive explanations involving empowermentare
uncommon.
Empowering explanations are clearly the ideal as they
legitimise the patient’s suffering and ally rather than
alienate the patient and doctor.

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Avoid unnecessary diagnostic & laboratory
procedures
Prescription of medicine should be kept
minimum.
No Medication on “as needed basis”,
E.g. ALPRAZOLAM
Anti anxiety drug and antidepressant drug: in case of
underlying co-existing condition
Management……….

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Supportive psychotherapy
show minimum interest in physical complaint and more in personal and
social problem.
Simple behavioral management techniques
Relaxation technique
Biofeedback
Involvement of family members
Encourage patient’s autonomy
Self-sufficiency and independence
Discourage the sick role
Management……….

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Dissociative (Conversion) Disorder
Includes two phases:
1.Symptom removal
2.Dealing with Psychosocial stresses
Management……….

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1. Symptom Removal
Suggest the symptoms are going to disappear
Use mild sedation, anxiolytics, relaxation exercises,
hypnosis.
Amobarbital or Pentothal, Parenteral Lorazepam/ diazepam may be
used for medication assisted interview/ suggestion.
Cut down secondary gain.
Discourage patient’s sick role
Management……….

42. 19th Dec 2007 42Somatoform Disorders
2. Dealing with Psychosocial Stresses:
Acute Stress
Supportive therapy
Chronic Stress with significant psychopathology:
Insight oriented psychotherapy
Dynamic therapy
Management……….

43. 19th Dec 2007 43Somatoform Disorders
Somatoform Pain disorder
Goal: replace pain related behavior with normal activity.
Decreasing the subjective pain intensity
Increasing activities of daily living
Controlling Drug misuse
Behavioral Analysis: e.g. A B C chart
Explore Patient’s Beliefs
Multi-disciplinary approach:
Pharmacological, behavioral & psychotherapeutic
Concurrent mental disorders are diagnosed and treated.
Patient dependent on analgesics and hypnotics are detoxified.
Management……….

44. 19th Dec 2007 44Somatoform Disorders
Pharmacotherapy:
Analgesic: NSAIDs: e.g. aspirin
Anti-Depressant
Amitryptyline, Nortriptyline, Impiramine, Doxepin,
Nefazodone
Anticonvulsants
Phenytoin, Carbamazepine, and Clonazepam
Antianxiety/ Sedatives to be prescribed cautiously
Management……….

45. 19th Dec 2007 45Somatoform Disorders
DIAGNOSIS THERAPY PROGNOSIS
Somatization disorderTherapeutic alliance
Regular F/U
Crisis Intervention
Poor to fair
Conversion disorder Suggestion & persuation
Multiple approach
Excellent except in chronic
cases
Hypochondriasis Document symptoms
Psychosocial review
Psychotherapy
Fair to good
Waxes and wanes
Body dysmorphic disorderTherapeutic alliance
Stress management
Psychotherapies
Antidepressants
Guarded
Pain disorder Therapeutic alliance
Redefine goals of Rx
Antidepressants
Guarded, variable

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ABC….
A–Accommodate initially for rapport building
B -Behavior modification (ignore symptoms; praise for
improved behavior)
C–Confrontation later about effects of behavior style
D–Decrease drug gradually
E–Educate about course and meaning of illness
F–Family involvement to give information &help with Rx
G–Guilt should be removed
H–Hospitalize only for serious suicide risk, substance
abuse or other extreme behavior
I–Inter-current depression: treat conservatively
Management……….

47. 19th Dec 2007 47Somatoform Disorders
SUMMARY
Simulates physical illness, but no patho-
physiological basis
Significant and genuinedistress
Very common
Non-pharamacological management
Caring/ Authoritative relationship
No unnecessary drugs and investigations
Psychotherapy
Behavioral therapy: Relaxation, Biofeedback

48. 19th Dec 2007 48Somatoform Disorders
Model for discussion of
somatoform disorder
Problem
Patient
Patient
Problem

49. 19th Dec 2007 49Somatoform Disorders
Introduction
Etiological factors
Demography/ Epidemiology
Classification
Clinical presentations
Management
Take home message
Further readings
Closing remarks by chairperson

50. 19th Dec 2007 50Somatoform Disorders
Take Home Messages
“The symptoms are not imaginary” Charles Beard (1881):
The modern physician who dismisses his or her patient
with the statement that the complaint is imaginary does a
disservice to both the patient and the profession.
Malingering is a medico legal diagnosis
If symptoms does not have a patho-physiological
correlates do not simply dismiss it.
Avoid iatrogenic harm/ unnecessary investigations & x
Timely referral, if preliminary management fails

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Further Readings
1.American Psychiatric Association 2000: DSM-IV-TR
2.Gelder M, Harrison P, Cowen P(2006):Shorter Oxford Textbook Of
Psychiatry, 5
th
edition, Oxford University Press
3.Sadock BJ, Sadock VA (2007): Kaplan & Sadock’s Synopsis Of
Psychiatry Behavioral Sciences/Clinical Psychiatry, 10
th
Edn,
Lippincot Williams And Wilkins
4.Sadock BJ, Sadock VA (2004): Kaplan & Sadock’s Comprehensive
Textbook of Psychiatry , 8
th
Edn, Lippincot Williams And Wilkins
5.Vyas JN, Ahuja N (1999): Textbook Of PG Psychiatry, 2
nd
Ed,
Jaypee Brothers.
6.WHO 1992: ICD-10: Classification fo mental and Behavioral
Disorders Clinical Description and diagnostic guidelines
7.Davidson’sPrinciple and Practice of Medicine.20th ed.
8.Sean H. Yutzy M.D.:Chapter 13. Somatoform Disorders,Textbook of
clinical psychiatry©2005 American Psychiatric Publishing, Inc.
9.Harrison's Principles of Internal Medicine.6th edition

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