Somatoform disorder.pdf............ ......

Psychiatric nursing students

1. Somatoform disorderSomatoform disorder

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The term somatoform derives from the Greek word
soma for body
The somatoform disorders are a broad group of
illnesses that have bodily signs and symptoms as a
major component.
These disorders encompass “mind-body’’ interactions
the brain, in ways still not well understood, sends
various signals that impinge/ interrupt/ on the
patient's awareness, indicating a serious problem in
the body

3. Subtypes of somatoform disorder
(1) Somatization disorder: characterized by many physical
complaints affecting many organ systems
(2) Conversion disorder: characterized by one or two
neurological complaints
(3) Hypochondriasis: characterized less by a focus on
symptoms than by patients' beliefs that they have a specific
disease
(4) Body dysmorphic disorder: characterized by a false belief
or exaggerated perception that a body part is defective

4. Cont...
(5) Pain disorder: characterized by symptoms of pain that
are either exclusively related to, or significantly
exacerbated by, psychological factors
(6) Undifferentiated somatoform disorder: which includes
somatoform disorders not otherwise described that
have been present for 6 months or longer
(7) Somatoform disorder not otherwise specified:
symptoms do not meet any of the somatoform disorder
diagnoses mentioned above

5. 1.Somatization disorder
Somatization:
is the tendency to experience,
communicate, and amplify psychological
and interpersonal distress in the form of
somatic distress and medically
unexplained symptoms.

6. 
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Somatization disorder:
is an illness of multiple somatic complaints
involves multiple organ systems
occurs over a period of several years
The disorder is chronic and is associated with
significant psychological distress
impaired social and occupational functioning
and excessive medical-help-seeking behaviour.

7. Epidemiology

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The lifetime prevalence in the general population is estimated
to be 0.2 %- 2% in women and 0.2 % in men
Female-to-male ratio 5:1
occurs most often among patients who have little education
and low incomes.
begins before age 30
it usually begins during a person's teenage years.
About two thirds of all patients have identifiable psychiatric
symptoms

8.
Etiology
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The cause of somatization disorder is unknown
Psychosocial Factors
the cause involve interpretations 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),
or to symbolize a feeling or a belief (e.g., a
pain in the gut).

9. Cont…
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Genetics
Twin studies: Concordance rate of 29 % in
monozygotic twins and 10 % in dizygotic twins
run in families and occurs in 10 to 20 percent of
the first-degree female relatives of probands of
patients with somatization disorder
The male relatives of women with somatization
disorder show an increased risk of antisocial
personality disorder and substance-related disorder

10. DSM-V-TR Diagnostic Criteria
A.
B.
A history of many physical complaints
beginning before age 30 years occur over a
period of several years and result in treatment
being sought(required or wanted)or significant
impairment in social, occupational, or other
important areas of functioning
Each of the following criteria must have been
met, with individual symptoms occurring at any
time during the course of the disturbance:

11. 1.
2.
3.
four pain symptoms:
a history of pain related to at least four different
sites or functions (e.g., head, abdomen, back,
joints, extremities, chest, rectum, during
menstruation, during sexual intercourse, or during
urination)
two gastrointestinal symptoms:
a history of at least two gastrointestinal symptoms
other than pain (e.g., nausea, bloating, vomiting
other than during pregnancy, diarrhoea, or
intolerance of several different foods)
one sexual symptom:
a history of at least one sexual or reproductive
symptom other than pain (e.g., sexual
indifference(lack of interest), erectile or ejaculatory
dysfunction, irregular menses, excessive menstrual
bleeding, vomiting throughout pregnancy)

12. C.
D.
4.one pseudoneurological symptom:
a history of at least one symptom or deficit suggesting
a neurological condition not limited to pain
(conversion symptoms such as impaired coordination
or balance, paralysis or localized weakness, difficulty
swallowing or lump(swelling) in throat, aphonia(Loss
of voice), ....)
Despite appropriate investigation, each of
the symptoms in Criterion B cannot be fully
explained by a known general medical
condition or the direct effects of a
substance (e.g., a drug of abuse, a
medication)
The symptoms are not intentionally
produced or feigned(pretend) (as in
factitious disorder or malingering)

13. Clinical Features
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Most common symptoms
Nausea and vomiting (other than during
pregnancy)
difficulty swallowing
pain in the arms and legs
Shortness of breath unrelated to exertion,
Amnesia/ loss of memory/, and complications
of pregnancy and menstruation

14. Cont…
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Patients frequently believe that they have been sickly
most of their lives.
commonly associated with
major depressive disorder,
personality disorders,
substance-related disorders,
generalized anxiety disorder and phobias
Suicide threats are common, but actual suicide is rare
symptoms results in an increased incidence of marital,
occupational and social problems.

15. Differential Diagnosis
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General medical condition
Major depressive disorder
schizophrenia or delusional disorder
Panic disorder

16. Course and Prognosis

Course and Prognosis

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chronic, undulating(rising and falling)
relapsing disorder
rarely remits completely
It is unusual for the individual with somatization
disorder to be free of symptoms
for greater than 1 year, during which time they
may see a doctor several times.

17. Psychiatric evaluation of a patient referred for
somatization
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Allowing the patient to report a detailed history of his or
her physical symptoms provides reassurance that the
symptoms are being taken seriously,
Complete a physical examination:
Perform an objective physical and laboratory
examination of the patient
Conduct relevant portions of a physical and
neurological examination, which is likely to improve the
alliance with the patient.

18. Treatment
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Somatization disorder is best treated when the patient has
a single identified physician as primary caretaker
See patients during regularly scheduled visits
Respond to each new somatic complaint with conducting
partial physical examination
Additional laboratory and diagnostic procedures should
generally be avoided
Physicians must always use their judgment about what
symptoms to work up and to what extent to rule out
physical illness

19. Cont…
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Psychotherapy:
Individual and group psychotherapy decreases
these patients' personal health care
expenditures by 50 percent
patients are helped to cope with their symptoms,
to express underlying emotions, and to develop
alternative strategies for expressing their
feelings

20. 2. Conversion
Disorder

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symptoms or deficits affect voluntary motor
or sensory functions, which suggest another
medical condition
caused by psychological factors because the
illness is preceded/ come first/ by conflicts
or other stressors.
symptoms are not intentionally produced
are not caused by substance use
are not limited to pain or sexual symptoms
the gain is primarily psychological and not
social, monetary(financial), or legal.

22. Epidemiology

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general hospital psychiatric consultations in 5 to
15 %
Women to male adults 2:1 as much as 10:1
among children, an even higher predominance is
seen in girls.
Women are more likely subsequently to develop
somatization disorder
onset from late adolescence to early adulthood

23. Cont…
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rare before 10 years of age or after 35 years
Conversion symptoms in middle or old age highly
suggests the probability of occult neurological or
other medical condition.
Men with conversion disorder have often been
involved in occupational or military accidents
An association exists between conversion disorder
and antisocial personality disorder

24. DSM-V-TR Diagnostic Criteria
A.
B.
C.
D.
One or more symptoms or deficits affecting voluntary
motor or sensory function that suggest a neurological or
other general medical condition.
Psychological factors are judged to be associated with
the symptom or deficit
the symptom or deficit is not intentionally produced or feigned
(as in factitious disorder or malingering).
the symptom or deficit cannot, after appropriate investigation, be
fully explained by a general medical condition, or by the direct
effects of a substance, or as a culturally sanctioned behaviour or
experience

25. Cont…
E.
F.
The symptom or deficit causes clinically
significant distress or impairment or
warrant(permit) medical evaluation
The symptom or deficit is not limited to pain
or sexual dysfunction, does not occur
exclusively during the course of somatization
disorder, and is not better accounted for by
another mental disorder.

26. Clinical Features
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The most common conversion disorder symptoms:
gait disturbance, weakness, and paralysis, tics, and
jerks
Patients with the symptoms rarely fall; if they do,
they are generally not injured.
Hemi anesthesia of the body beginning
precisely along the midline. symptoms may
involve the organs of special sense and can
produce deafness, blindness, and tunnel vision.

27. Course and Prognosis
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Onset usually acute
usually of short duration
Spontaneous remission 95% usually within 2 weeks
The prognosis is less than 50% if symptoms have been
present for 6 months or longer
Recurrence occurs in one fifth to one fourth of people
within 1 year of the first episode
tremor and seizures are poor prognostic factors.
good prognosis
acute onset,
presence of clearly identifiable stressors
a short interval between onset and the institution
of treatment
Paralysis, aphonia, and blindness

28. Treatment
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most important is a relationship with a caring
and confident therapist
Psychotherapy
Insight-oriented supportive or behavior therapy
behavioral relaxation exercises
Direct confrontation(disagreement) has no real
benefit
Focus on coping stress

29. 3.
Hypochondriasis

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hypochondriasis is derived from the old medical
term hypochondrium (below the ribs )
characterized by 6 months or more of a general
and non delusional preoccupation with
fears of contracting
or the idea that one has, a serious disease based
on the person's misinterpretation of bodily
symptoms
Epidemiology
6-month prevalence in a general medical clinic
population is 4 to 6 %, but it may be as high as 15
%.
Men and women are equally affected
most commonly appears in persons 20 to 30 years
of age
social position, education level, and marital status
do not appear to affect the diagnosis.

31. DSM-V-TR Diagnostic Criteria
A.
B.
C.
D.
E.
F.
Preoccupation with fears of having, or the idea
that one has, a serious disease based on the
person's misinterpretation of bodily symptoms.
The preoccupation persists despite appropriate
medical evaluation and reassurance.
The belief in Criterion A is not of delusional
intensity & not restricted to a circumscribed
concern about appearance
The preoccupation causes clinically significant
distress or impairment
duration of the disturbance is at least 6 months.
The preoccupation is not better accounted for
by mental illness

32. Clinical Features

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Believe that they have a serious disease that
has not yet been detected, and they cannot
be persuaded(convinced) to the
contrary(differen)
Their convictions persist despite negative
laboratory results,
the benign course of the alleged disease
over time, and appropriate reassurances
from physicians.

33. Course and Prognosis
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one third to one half of all patients with
hypochondriasis eventually improve significantly
Good prognosis:
sudden onset of symptoms, brief episode
the absence of a personality disorder
the absence of a related non psychiatric
medical condition.
treatment-responsive anxiety or depression
Most children with hypochondriasis recover by late
adolescence or early adulthood.

34. Treatment

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office visits
Frequent, regularly scheduled physical examinations
Physicians are not abandoning them
That their complaints are being taken seriously
Pharmacotherapy: comorbidities with anxiety disorder or major
depressive disorder.
Psychotherapy
Group psychotherapy:
provides the social support and social interaction that seem to reduce their anxiety.
Individual insight-oriented psychotherapy, behavioural therapy, cognitive
therapy, may be useful.

35. 4. Body Dysmorphic4. Body Dysmorphic
DisorderDisorder
4. Body Dysmorphic
Disorder
4. Body Dysmorphic
Disorder

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Preoccupation with an imagined defect in
appearance
causes clinically significant distress or
impairment in important areas of
functioning.

37. Epidemiology

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poorly studied condition
patients are more likely to go to
dermatologists
internists
plastic surgeons
The most common age of onset is
between 15 and 30 years
women are affected somewhat more
often than men
likely to be unmarried.

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Cont...
Body dysmorphic disorder commonly coexists
with other mental disorders
One study found that more than 90 percent of
patients with body dysmorphic disorder had
experienced a major depressive episode in their
lifetimes
about 70 percent had experienced an anxiety
disorder; and
about 30 percent had experienced a psychotic
disorder

39. DSM-V-TR Diagnostic Criteria
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Preoccupation with an imagined defect in
appearance excessive concern in the presence
of slight physical abnormality
clinically significant distress or impairment in
social, occupational, or other important areas of
functioning.
The preoccupation is not better accounted for
by another mental disorder (e.g., dissatisfaction
with body shape and size in anorexia nervosa).

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The most common concerns
involve facial flaws, particularly those involving
specific parts (e.g., the nose).
Other body parts are hair, breasts, and genitalia

Common comorbid diagnoses
depressive disorders and anxiety disorders
patients may also have traits of OCD, schizoid, and
narcissistic personality disorders

41. Differential diagnosis
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Anorexia nervosa
Major depressive episode
OCD
Avoidant personality disorder or social
phobia
Delusional disorder somatic type

42. Course and Prognosis

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Begins during adolescence
The onset can be gradual or abrupt.
The disorder usually has a long and undulating
course with few symptom-free intervals.

43. Treatment
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Treatment of patients with body dysmorphic
disorder with
Surgical,
Dermatological and
Dental, to address the alleged defects is almost
invariably unsuccessful
Serotonin-specific drugs
Fluoxetine reduce symptoms in at least 50 percent
of patients
Treat coexisting disorder with the appropriate
pharmacotherapy and psychotherapy

44. Pain Disorder
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Formerly called
somatoform pain disorder
psychogenic pain disorder
idiopathic pain disorder
atypical pain disorder

45. Epidemiology

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Prevalence
lifetime prevalence 12 percent
Pain disorder can begin at any age, peak onset is
on 4
th-5
th decade
The gender ratio is unknown
Chronic pain appears to be most frequently
associated with depressive disorders
acute pain appears to be more commonly
associated with anxiety disorders

46. Etiology
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Psychodynamic Factors
Symbolically expressing an intrapsychic conflict through the
body
Pain can function as a method of obtaining love or a
punishment for wrong doing
Behavioral Factors
Pain behaviors are
reinforced when rewarded
inhibited when ignored or punished
symptoms may become intense

47. DSM V criterion
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Pain in one or more anatomical sites
Pain cause significant distress/ suffering/
Pain cause impairment in social or occupational
functioning
Inability to work
Absence from work
Frequent use of health care system
Disruption of family normal life

48. Clinical manifestation
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Common localization of pain

Head, back, abdomen, pelvic, facial, chest

Not better accounted by other psychiatric disorder

Duration
Chronic – 6 months or longer
Acute – less than 6 months

49. Treatment
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May not be possible to cure the pain
The treatment approach must address rehabilitation
Discuss the issue of psychological factors
Therapists must understand that the patient's
experiences of pain are real
Psychotherapy
Individual psychotherapy
Family therapy
Behavioral – operant conditioning

50. 6. Undifferentiated
Somatoform Disorder
6. Undifferentiated
Somatoform Disorder

51. •
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Undifferentiated somatoform disorder is
characterized by
one or more unexplained physical symptoms of at least
6 months' duration
which are below the threshold for a diagnosis of
somatization disorder
Two types of symptom patterns:
1. those involving the autonomic nervous system
2.and those involving sensations of fatigue or weakness

52. DSM-V-TR Diagnostic Criteria
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One or more physical symptom
e.g. fatigue, loss appetite, gastrointestinal or
urinary complaints
Can not be explained by general medical illness
or direct effect of a substance
Significant distress or functional impairment
Symptoms are not intentionally produced or
feigned
Duration at least 6 months

53. 7.Somatoform
Disorder NOS

54. DSM-V-TR Diagnostic Criteria
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do not meet the criteria for any specific somatoform disorder.
E.g.,
Pseudocyesis/Development of pregnancy symptoms in a
nonpregnant woman (e.g.,menstrual abnormalities,
abdominal enlargement, and breast changes/
A disorder involving nonpsychotic hypochondriacal
symptoms of less than 6 months' duration.
A disorder involving unexplained physical complaints
(e.g., fatigue or body weakness) of less than 6 months'
duration that are not due to another mental disorder

55. Case study one
•A middle-aged man is chronically preoccupied
with his health. For many years he feared that his
irregular bowel functions meant he had cancer.
Now he is very preoccupied about having a
serious heart disease, despite his physician’s
assurance that the occasional “extra beats” he
detects when he checks his pulse are completely
benign. What is his most likely diagnosis?

56. Case study two
•A 20-year-old student is very distressed by a
small deviation of her nasal septum. She is
convinced that this minor imperfection is
disfiguring, although others can barely notice it.

57. Case study three
•For the past three years, a 24- year-old college
student has suffered from chronic headaches,
fatigue, shortness of breath, dizziness, ringing
ears, and constipation. He is incensed when
his primary physician recommends a
psychiatric evaluation since no organic cause
for his symptoms could be found.

58. THANKTHANK
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