Somatoform disorders.pptx definition, pathophysiology

This slide contains information on the somatoform disorders

1. Somatoform disorders

2. Definition and overview The term somatoform derives from the Greek word soma for body, and the somatoform disorders are a broad group of illnesses that have bodily signs and symptoms as a major component which are influenced by a disorder of the mind. Physical and laboratory examinations persistently fail to show significant substantiating data about the patient's complaints, which, nevertheless, are vigorous and sincere. Patients believe that they have some kind of undetected and untreated bodily derangement. The complaints are not imaginary and modern physician who dismisses his patient with the statement that the complaint is imaginary does a disservice to both the patient and the profession.

3. Somatoform Disorders Somatoform disorders are Somatization disorder , characterized by many physical complaints affecting many organ systems; Conversion disorder , characterized by one or more neurological complaints; Hypochondriasis , characterized less by a focus on symptoms than by patients' beliefs that they have a specific disease; Body dysmorphic disorder , characterized by a false belief or exaggerated perception that a body part is defective; Pain disorder , characterized by symptoms of pain that are either solely related to, or significantly exacerbated by, psychological factors;

4. Somatization Disorder Somatization disorder is an illness of multiple somatic complaints in multiple organ systems that occurs over a period of several years and results in significant impairment or treatment seeking, or both. The disorder is chronic and is associated with significant psychological distress, impaired social and occupational functioning, and excessive medical-help-seeking behavior. Somatization disorder has been 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.)

5. Epidemiology The lifetime prevalence of somatization disorder in the general population is estimated to be 0.2 percent to 2 percent in women and 0.2 percent in men. Women with somatization disorder outnumber men 5 to 20 times. The disorder is inversely related to social position and occurs most often among patients who have little education and low incomes. Somatization disorder is defined as beginning before age 30; it usually begins during a person's teenage years.

6. Etiology Psychosocial Factors Biological Factors Genetics

7. Psychosocial Factors The symptoms substitute for repressed instinctual impulses : to avoid obligations (e.g., going to a job a person does not like), to express emotions (e.g., anger at a spouse) Parental teaching, parental example, and ethnic mores may teach some children to somatize more than others. Unstable homes/physically abused.

8. Biological Factors These patients have characteristic attention and cognitive impairments that result in the faulty perception and assessment of somatosensory inputs that includes excessive distractibility, inability to habituate to repetitive stimuli, and lack of selectivity A limited number of brain-imaging studies have reported decreased metabolism in the frontal lobes and the nondominant hemisphere.

9. Genetics Somatization disorder tends to run in families and occurs in 10 to 20 percent of the first-degree female relatives of patients with somatization disorder.

10. diagnosis A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought 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: 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 symptom s : a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, 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, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy) one pseudo neurological 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 in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)

11. Either (1) or (2): after 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) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).

12. Clinical vignette A 34-year-old female temporary clerk presented with chronic and intermittent dizziness, parasthesias, pain in multiple areas of her body, and intermittent nausea and diarrhea. On further history, the patient said that the symptoms had been present most of the time, although they had been undulating since she was approximately 24 years of age. In addition to the symptoms previously mentioned, she had mild depression, was disinterested in many things in life, including sexual activity, and had been to many doctors to try to find out what was wrong with her. Even though she had seen many doctors and had many tests, she stated that no one can find out what's wrong with her. She wanted another opinion. She commented that she had been sick a lot since childhood and had been on various medications on and off. Physical examination revealed a normotensive, slightly overweight female in no acute distress. She had diffuse and mild abdominal tenderness, without true guarding or rebound tenderness. Her neurological examination was normal. She winced when physical examination was conducted on various parts of her body, although this wincing went away when the physician was speaking with her while conducting the examination

13. Clinical features Patients with somatization disorder have many somatic complaints and long, complicated medical histories. Nausea and vomiting (other than during pregnancy), difficulty swallowing, pain in the arms and legs, shortness of breath unrelated to exertion, amnesia, and complications of pregnancy and menstruation are among the most common symptoms. Patients frequently believe that they have been sickly most of their lives. Pseudoneurological symptoms suggest, but are not pathognomonic of, a neurological disorder these include impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures, or loss of consciousness other than fainting.

14. Clinical features Psychological distress and interpersonal problems are prominent; anxiety and depression are the most prevalent psychiatric conditions. Suicide threats are common, but actual suicide is rare. Patients classically (but not always) describe their complaints in a dramatic, emotional, and exaggerated fashion, with vivid and colourful language; Female patients with somatization disorder may dress in an exhibitionistic manner. Patients may be perceived as dependent, self-centred, hungry for admiration or praise, and manipulative.

15. Course and Prognosis Somatization disorder is a chronic, undulating, and relapsing disorder that 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. Patients with this disorder consider themselves to be medically ill, good evidence is that they are no more likely to develop another medical illness than people without somatization disorder.

16. Treatment Somatization disorder is best treated when the patient has a single identified physician as primary caretaker. When more than one clinician is involved, patients have increased opportunities to express somatic complaints. Primary physicians should conduct a partial physical examination and should respond to each new somatic complaint. Additional laboratory and diagnostic procedures should generally be avoided.

17. treatment Once somatization disorder has been diagnosed, the treating physician should listen to the somatic complaints as emotional expressions rather than as medical complaints. Nevertheless, patients with somatization disorder can also have bona fide physical illnesses; therefore, physicians must always use their judgment about what symptoms to work up and to what extent. Increase the patient's awareness of the possibility that psychological factors are involved in the symptoms until the patient is willing to see a mental health clinician.

18. treatment Psychotherapy, both individual and group, decreases these patients' personal health care expenditures by 50 percent, largely by decreasing their rates of hospitalization. In psychotherapy settings, patients are helped to cope with their symptoms, to express underlying emotions, and to develop alternative strategies for expressing their feelings. Medication if indicated must be monitored, because patients with somatization disorder tend to use drugs erratically and unreliably.

19. Conversion Disorder The term conversion was introduced by Sigmund Freud, who, hypothesized that the symptoms of conversion disorder reflect unconscious conflicts. Conversion disorder is an illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors because the illness is preceded by conflicts or other stressors. The symptoms or deficits of conversion disorder are not intentionally produced, are not caused by substance use, are not limited to pain or sexual symptoms, and the gain is primarily psychological and not social, monetary, or legal.

20. Common symptoms Motor Symptoms Involuntary movements Tics Blepharospasm Torticollis Opisthotonos Seizures Abnormal gait Falling Astasia-abasia Paralysis Weakness Aphonia Sensory Deficits Anesthesia, especially of extremities Midline anesthesia Blindness Tunnel vision Deafness Visceral Symptoms Psychogenic vomiting Pseudocyesis Globus hystericus Swooning or syncope Urinary retention Diarrhea

21. Epidemiology 5 to 15 percent of psychiatric consultations and 25 to 30 percent of admissions to general hospital involve patients with conversion disorder diagnoses. The ratio of women to men among adult patients is at least 2 to 1 and as much as 10 to 1; among children, an even higher predominance is seen in girls. Symptoms are more common on the left than on the right side of the body in women. Men with conversion disorder have often been involved in occupational or military accidents. The onset of conversion disorder is generally from late childhood to early adulthood and is rare before 10 years of age or after 35 years of age, but onset as late as the ninth decade of life has been reported. Conversion disorder is most common among rural populations, persons with little education, those with low intelligence quotients, those in low socioeconomic groups, and military personnel who have been exposed to combat situations.

22. Comorbidity Medical and, especially, neurological disorders occur frequently among patients with conversion disorders. Among the Axis I psychiatric conditions, depressive disorders, anxiety disorders, and somatization disorders are especially noted for their association with conversion disorder. Patients admitted to a psychiatric hospital for conversion disorder reveal that one quarter to one half have a clinically significant mood disorder or schizophrenia.

23. Etiology Psychoanalytic Factors According to psychoanalytic theory, conversion disorder is caused by repression of unconscious intrapsychic conflict and conversion of anxiety into a physical symptom. The conflict is between an instinctual impulse and the prohibitions against its expression. The symptoms allow partial expression of the forbidden wish or urge but disguise it, so that patients can avoid consciously confronting their unacceptable impulses; that is, the conversion disorder symptom has a symbolic relation to the unconscious conflict for example, vaginismus protects the patient from expressing unacceptable sexual wishes. Conversion disorder symptoms also allow patients to communicate that they need special consideration and special treatment. Such symptoms may function as a nonverbal means of controlling or manipulating others.

24. Etiology Learning Theory In terms of conditioned learning theory, a conversion symptom can be seen as a piece of classically conditioned learned behavior; symptoms of illness, learned in childhood, are called forth as a means of coping with an otherwise impossible situation. Biological Factors Preliminary brain-imaging studies have found hypometabolism of the dominant hemisphere and hypermetabolism of the nondominant hemisphere and have implicated impaired hemispheric communication in the cause of conversion disorder.

25. Clinical Features Paralysis, blindness, and mutism are the most common conversion disorder symptoms. Sensory Symptoms In conversion disorder, anesthesia and paresthesia are common, especially of the extremities e.g. characteristic stocking-and-glove anesthesia of the hands or feet or the hemianesthesia of the body beginning precisely along the midline. Conversion disorder symptoms may involve the organs of special sense and can produce deafness, blindness, and tunnel vision. In conversion disorder blindness, for example, patients walk around without collisions or self-injury, their pupils react to light.

26. Clinical features Motor Symptoms Abnormal movements, gait disturbance, weakness, and paralysis. The movements generally worsen when attention is called to them. Patients with the symptoms rarely fall; if they do, they are generally not injured. Other common motor disturbances are paralysis and paresis involving one, two, or all four limbs, although the distribution of the involved muscles does not conform to the neural pathways. Reflexes remain normal; the patients have no fasciculations or muscle atrophy (except after long-standing conversion paralysis); electromyography findings are normal.

27. Clinical features Seizure Symptoms Pseudoseizures are another symptom in conversion disorder. Clinicians may find it difficult to differentiate a pseudoseizure from an actual seizure by clinical observation alone. Tongue-biting, urinary incontinence, and injuries after falling are generally not present. Pupillary and gag reflexes are retained after pseudoseizure, and patients have no postseizure increase in prolactin concentrations.

28. Other Associated Features Primary Gain Patients achieve primary gain by keeping internal conflicts outside their awareness. Symptoms have symbolic value; they represent an unconscious psychological conflict. Secondary Gain Patients accrue tangible advantages and benefits as a result of being sick; for example, being excused from obligations and difficult life situations, receiving support and assistance that might not otherwise be forthcoming, and controlling other persons' behavior. La Belle Indifference La belle indifference is a patient's inappropriately cavalier attitude toward serious symptoms; that is, the patient seems to be unconcerned about what appears to be a major impairment. Identification Patients with conversion disorder may unconsciously model their symptoms on those of someone important to them. For example, a parent or a person who has recently died may serve as a model for conversion disorder.

29. Course and Prognosis The onset of conversion disorder is usually acute and symptoms or deficits are usually of short duration, and approximately 95 percent of acute cases remit spontaneously, usually within 2 weeks in hospitalized patients. If symptoms have been present for 6 months or longer, the prognosis for symptom resolution is less than 50 percent and diminishes further the longer that conversion is present. Recurrence occurs in one fifth to one fourth of people within 1 year of the first episode. A good prognosis features are acute onset, presence of clearly identifiable stressors at the time of onset, a short interval between onset and the institution of treatment, and above average intelligence. Paralysis, aphonia, and blindness are associated with a good prognosis, whereas tremor and seizures are poor prognostic factors.

30. Treatment The most important feature of the therapy is a relationship with a caring and confident therapist. Insight-oriented psychotherapy, in which patients explore intrapsychic conflicts and the symbolism of the conversion disorder symptoms. With patients who are resistant to the idea of psychotherapy, physicians can suggest that the psychotherapy will focus on issues of stress and coping. Telling such patients that their symptoms are imaginary often makes them worse. Parenteral amobarbital or lorazepam may be helpful in obtaining additional historic information, especially when a patient has recently experienced a traumatic event. The longer the duration of these patients' sick role and the more they have regressed, the more difficult the treatment.

31. Hypochondriasis Hypochondriasis is characterized by 6 months or more of a general and nondelusional preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms. This preoccupation causes significant distress and impairment in one's life; The term hypochondriasis is derived from the old medical term hypochondrium, (below the ribs) and reflects the common abdominal complaints of many patients with the disorder, but they may occur in any part of the body.

32. Epidemiology 4 to 6 percent of a general medical clinic population. Men and women are equally affected by hypochondriasis. The disorder most commonly appears in persons 20 to 30 years of age. Some evidence indicates that the diagnosis is more common among blacks than among whites, but social position, education level, and marital status do not appear to affect the diagnosis. HypochondriacaI complaints reportedly occur in about 3 percent of medical students, usually in the first 2 years, but they are generally transient.

33. Etiology Misinterpretation of bodily symptoms. Persons with hypochondriasis augment and amplify their somatic sensations; they have low thresholds for, and low tolerance of, physical discomfort. For example, what persons normally perceive as abdominal pressure, persons with hypochondriasis experience as abdominal pain. The symptoms of hypochondriasis are viewed as a request for admission to the sick role made by a person facing seemingly insurmountable and insolvable problems. The sick role offers an escape that allows a patient to avoid noxious obligations, to postpone unwelcome challenges, and to be excused from usual duties and obligations.

34. Clinical Features Patients with hypochondriasis believe that they have a serious disease that has not yet been detected, and they cannot be persuaded to the contrary. Their convictions persist despite negative laboratory results, the benign course of the alleged disease over time, and appropriate reassurances from physicians. Transient HypochondriacaI states can occur after major stresses, most commonly the death or serious illness of someone important to the patient, or A serious (perhaps life-threatening) illness that has been resolved can leave the patient temporarily hypochondriacal.

35. Course and Prognosis The course of hypochondriasis is usually episodic; the episodes last from months to years and are separated by equally long quiescent periods. There may be an obvious association between exacerbations of hypochondriacal symptoms and psychosocial stressors. One third to one half of all patients with hypochondriasis eventually improve significantly. A good prognosis is associated with high socioeconomic status, treatment-responsive anxiety or depression, sudden onset of symptoms, the absence of a personality disorder, and the absence of a related nonpsychiatric medical condition. Most children with hypochondriasis recover by late adolescence or early adulthood.

36. Treatment Group psychotherapy often benefits such patients, in part because it provides the social support and social interaction that seem to reduce their anxiety. Other forms of psychotherapy, such as individual insight-oriented psychotherapy, behavior therapy, cognitive therapy, and hypnosis may be useful. Frequent, regularly scheduled physical examinations help to reassure patients that their physicians are not abandoning them and that their complaints are being taken seriously. Invasive diagnostic and therapeutic procedures should only be undertaken, however, when objective evidence calls for them.

37. Body Dysmorphic Disorder Body dysmorphic disorder is characterized by a preoccupation with an imagined defect in appearance that causes clinically significant distress or impairment in important areas of functioning. If a slight physical anomaly is actually present, the person's concern with the anomaly is excessive and bothersome.

38. Epidemiology Body dysmorphic disorder is a poorly studied condition, partly because patients are more likely to go to dermatologists, internists, or plastic surgeons than to psychiatrists. One study of a group of college students found that more than 50 percent had at least some preoccupation with a particular aspect of their appearance Available data indicate that the most common age of onset is between 15 and 30 years and that women are affected somewhat more often than men. Affected patients are also likely to be unmarried. 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. Etiology Many studies have indicated that low serotonin levels may be responsible for Body Dysmorphic Disorder. Stereotyped concepts of beauty emphasized in certain families and within the culture at large may significantly affect patients with body dysmorphic disorder.

40. Clinical Features The most common concerns involve facial flaws, particularly those involving specific parts Hair, Nose, Skin and eyes. Other body parts of concern are lips, chin, waist and stomach, breasts, and genitalia and breasts. A proposed variant of dysmorphic disorder among men is the desire to “bulk up” and develop large muscle mass, which can interfere with ordinary living, holding a job, or staying healthy. The specific body part may change during the time a patient is affected with the disorder. Common associated symptoms include ideas or frank delusions of reference (usually about persons' noticing the alleged body flaw), either excessive mirror checking or avoidance of reflective surfaces, and attempts to hide the presumed deformity (with makeup or clothing).

41. Clinical features The effects on a person's life can be significant; almost all affected patients avoid social and occupational exposure. As many as one third of the patients may be housebound because of worry about being ridiculed for the alleged deformities, and approximately one fifth attempt suicide. As discussed, comorbid diagnoses of depressive disorders and anxiety disorders are common, and patients may also have traits of OCD, schizoid, and narcissistic personality disorders

42. Course and Prognosis Body dysmorphic disorder usually begins during adolescence. The disorder usually has a long and undulating course with few symptom-free intervals. The part of the body on which concern is focused may remain the same or may change over time.

43. Treatment Treatment of patients with body dysmorphic disorder with surgical, dermatological, dental, and other medical procedures to address the alleged defects is almost invariably unsuccessful. Tricyclic anti-depressants and selective serotonin reuptake inhibitor drugs, have reportedly been useful and may reduce symptoms in at least 50 percent of patients.

44. Pain Disorder A pain disorder is characterized by the presence of, and focus on, pain in one or more body sites and is sufficiently severe to come to clinical attention. Psychological factors are necessary in the genesis, severity, or maintenance of the pain, which causes significant distress or impairment, or both.

45. Epidemiology The prevalence of pain disorder appears to be common. It has been estimated that 10 to 15 percent of adults have some form of work disability because of back pain alone. Approximately 3 percent of people in a general practice have persistent pain, with at least 1 day per month of activity restriction because of the pain. Pain disorder can begin at any age. The gender ratio is unknown. Pain disorder is associated with other psychiatric disorders, especially mood and anxiety disorders.

46. epidemiology Chronic pain appears to be most frequently associated with depressive disorders, and acute pain appears to be more commonly associated with anxiety disorders. The associated psychiatric disorders may precede the pain disorder, may co-occur with it, or may result from it. Depressive disorders, alcohol dependence, and chronic pain may be more common in relatives of individuals with chronic pain disorder. Individuals whose pain is associated with severe depression and those whose pain is related to a terminal illness, such as cancer, are at increased risk for suicide.

47. Etiology Patients who experience bodily aches and pains without identifiable and adequate physical causes may be symbolically expressing an intrapsychic conflict through the body. By displacing the problem to the body, they may feel that they have a legitimate claim to the fulfilment of their dependency needs. Many patients have intractable and unresponsive pain because they are convinced that they deserve to suffer. Pain can function as a method of obtaining love, a punishment for wrongdoing, and a way of expiating guilt and atoning for an innate sense of badness.

48. ETIOLOGY Pain behaviors are reinforced when rewarded and are inhibited when ignored or punished. For example, moderate pain symptoms may become intense when followed by the considerate and attentive behavior of others, by monetary gain, or by the successful avoidance of distasteful activities Intractable pain has been conceptualized as a means for manipulation and gaining advantage in interpersonal relationships, for example, to ensure the devotion of a family member or to stabilize a fragile marriage. Such secondary gain is most important to patients with pain disorder.

49. Clinical Features Patients present with low back pain, headache, atypical facial pain, chronic pelvic pain, and other kinds of pain. A patient's pain may be posttraumatic, neuropathic, neurological, iatrogenic, or musculoskeletal; to meet a diagnosis of pain disorder, however, the disorder must have a psychological factor judged to be significantly involved in the pain symptoms and their ramifications. Patients with pain disorder often have long histories of medical and surgical care. They visit many physicians, request many medications, and may be especially insistent in their desire for surgery.

50. Clinical features Indeed, they can be completely preoccupied with their pain and cite it as the source of all their misery. Such patients often deny any other sources of emotional dysphoria and insist that their lives are blissful except for their pain. Their clinical picture can be complicated by substance-related disorders, because these patients attempt to reduce the pain through the use of alcohol and other substances. Major depressive disorder is present in about 25 to 50 percent of patients with pain disorder, and dysthymic disorder or depressive disorder symptoms are reported in 60 to 100 percent of the patients. The most prominent depressive symptoms in patients with pain disorder are anergia, anhedonia, decreased libido, insomnia, and irritability; diurnal variation, weight loss, and psychomotor retardation appear to be less common.

51. Course and Prognosis The pain in pain disorder generally begins abruptly and increases in severity for a few weeks or months. The prognosis varies, although pain disorder can often be chronic, distressful, and completely disabling. Acute pain disorders have a more favorable prognosis than chronic pain disorders. A wide range of variability is seen in the onset and course of chronic pain disorder. In many cases, the pain has been present for many years by the time the individual comes to psychiatric care, owing to the reluctance of patient and physician to see pain as a psychiatric disorder. People with pain disorder who resume participation in regularly scheduled activities, despite the pain, have a more favorable prognosis than people who allow the pain to become the determining factor in their lifestyle.

52. Treatment Because it may not be possible to reduce the pain, the treatment approach must address rehabilitation. Clinicians should discuss the issue of psychological factors early in treatment and should frankly tell patients that such factors are important in the cause and consequences of both physical and psychogenic pain. Therapists should also explain how various brain circuits that are involved with emotions (e.g., the limbic system) can influence the sensory pain pathways. For example, persons who hit their head while happy at a party can seem to experience less pain than when they hit their head while angry and at work. Nevertheless, therapists must fully understand that the patient's experiences of pain are real.

53. treatment Analgesic medications do not generally benefit most patients with pain disorder. In addition, substance abuse and dependence are often major problems for such patients who receive long-term analgesic treatment. Sedatives and antianxiety agents are not especially beneficial and are also subject to abuse, misuse, and adverse effects. The success of SSRIs supports the hypothesis that serotonin is important in the pathophysiology of the disorder. Clinicians should not confront somatizing patients with comments such as “This is all in your head”. For the patient, the pain is real, and clinicians must acknowledge the reality of the pain, even as they understand that it is largely intrapsychic in origin.