SOMATOFORM DISORDERS

Maria L.A. Tiamson, MD Asst. Professor, Psychiatry New York Medical College

SOMATIZATION, the concept

 Poorly understood…”crocks”..”turkeys”.. “hysterics”..”worried well”   the tendency to express and communicate psychological distress in the form of somatic symptoms for which they seek medical help “one of medicine’s blind spots”

Psychosomatic Illnesses

 Asthma  Ulcerative colitis  Rheumatoid arthritis  Eczematous disorders  Irritable bowel syndrome

Forms of Somatization

 Medically unexplained symptoms  Hypochondriacal somatization  Somatic presentation of psychiatric disorders (ie., depressive equivalents)

Most common presenting symptoms

 Abdominal pain  chest pain  dyspnea  headache  fatigue  Cough  back pain  nervousness  dizziness

Infectious Diseases

 Lyme disease  AIDS  Infectious mononucleosis  Syphilis  Chronic Fatigue Syndrome  Post-infection syndromes

SOMATIZATION, the cost

 10% of total direct healthcare costs with the potential to bankrupt the healthcare financing system  Somatizers have 9x more total charges, 6x more hospital charges, 14x more MD services  Somatizers are sick in bed an average of 7 days a month vs. 0.48 days for the general population

SOMATIC COMPLAINTS

 Patients who experience their symptoms but do not deliberately produce them (SOMATOFORM DISORDERS)  Patients who knowingly create symptoms in themselves, either for material gain (MALINGERING), or for more subtle benefits, such as gratification of the patient role (FACTITIOUS DISORDERS)

Pathophysiological Mechanisms

 Physiological Mechanisms • autonomic arousal • • muscle tension hyperventilation • • vascular changes cerebral information processing • • physiological effects of inactivity sleep disturbance

Pathophysiological Mechanisms

 Psychological Mechanisms • perceptual factors • • beliefs mood • personality factors  Interpersonal Mechanisms • reinforcing actions of relatives and friends • • health care system disability system

DSM-IV Somatoform Disorders

 A group of disorders that include medical symptoms and complaints FOR WHICH AN ADEQUATE MEDICAL EXPLANATION CANNOT BE FOUND.

 Not intentionally produced  Onset, severity and duration of symptoms are strongly linked to psychological factors

DSM-IV Somatoform Disorders

 Somatization Disorder  Conversion Disorder  Hypochondriasis  Body Dysmorphic Disorder  Somatoform Pain Disorder  Undifferentiated Somatoform Disorder  Somatoform Disorder, NOS

Somatization Disorder



“hysteria”,

Briquet’s Syndrome  multiplicity of somatic complaints involving multiple organ systems  female predominance  before age 30  chronic  excessive medical help-seeking behavior

Somatization Disorder

 Cannot be fully explained by any known GMC or substance use  if GMC is present, physical complaints or impairment are in excess of what could be expected  significant impairment in functioning

Somatization Disorder

 F our pain symptoms  O ne sexual symptom  O ne pseudoneurological symptom  T wo GI symptoms

Somatization Disorder

 Complaints described in colorfiul, exaggerated terms but lack specific factual information  prominent anxiety and depressive symptoms  10-20% female 1st degree relatives of SD women, increased ASPD and SUD in male rrelatives

Conversion Disorder

 Monosymptomatic (one or more neurological symptoms)  Most common in • adolescents, young adults • • rural populations low education and low IQ • • low socioeconomic group military personnel exposed to combat

Conversion Disorder

  Symptom has a symbolic relation to the unconscious conflict

“la belle indifference”

Conversion Disorder

 Impaired coordination, balance  paralysis, weakness  aphonia, difficulty swallowing, lump in the throat  urinary retention  loss of touch/pain, double vision, blindness  deafness, seizures

Conversion Disorder

 Symptoms do not conform to known anatomical pathways and physiological mechanisms  often inconsistent  DDX: multiple sclerosis, myasthenia gravis, dystonias

Conversion Disorder

 Dramatic or histrionic  suggestible  sx are self-limited and do not lead to physical changes/disability  associated with dissociative disorders, MDD, histrionic, antisocial and dependent personality disorders

Hypochondriasis

 Preoccupation with the fear of contracting, or the belief of having, a serious disease  Usually with co-morbid depression, anxiety   Misinterpretation of physical symptoms and sensations Request for admission to the “sick role”, which offers an escape

Hypochondriasis

 Preoccupation is with any of the ff: bodily functions, minor physical abnormalities, vague and ambiguous physical sensations   medical history is presented in great detail and length “doctor shopping”  associated with serious illness in childhood, past experience with disease in a family member

Body Dysmorphic Disorder

 Preoccupation with an imagined defect or an exaggerated distortion of a minimal or minor defect in physical appearance 

dysmorphophobia

 Comorbid with major depression (90%), anxiety disorder (70%), psychotic disorder (30%)

Body Dysmorphic Disorder

 Marked distress over supposed deformity  frequent mirror checking and checking in other reflecting surfaces  excessive grooming behavior  use of special lighting or magnifying glasses  avoidance of usual activities

Somatoform Pain Disorder

 Presence of pain that is the “predominant focus of clinical attention”  Not fully accounted by a nonpsychiatric medical or neurological condition  The symbolic meaning of body disturbances relate to atonement for perceived sin, to expiation of guilt, or to suppressed aggression

Nonspecific Somatoform Disorders

 Undifferentiated somatoform disorder • unexplained physical effects that last for at least six months  Somatoform Disorder, NOS • residual category

Relation of Depression and Somatization

 Patients with SD have a high prevalence of depression (48-94%)  Patients with MDD have substantial levels of somatization (63-84%)  Depression can be treated successfully when it coexists with SD Smith, 1992

Relation of Depression and Pain

 Patients with chronic pain have a significant current prevalence of depressive disorders  More than half of patients with MDD complain of pain  Pain is reduced with the treatment of depression Smith, 1992

Baron Karl Friedrich Hieronymus von Munchausen

Factitious Disorders

 Psychological symptoms   Physical symptoms

Munchausen’s syndrome

,

pseudologica fantastica, peregrination

 usually co-morbid with psychiatric conditions  intentional production of symptoms but goal is

intangible

and psychologically complex

ALERT…ALERT…ALERT...

 Numerous surgical scars, usually in the abdominal area  Patient is truculent and evasive  Personal and medical history were fraught with acute and harrowing adventures  History of many hospitalizations, malpractice claims, insurance claims  Involved in the healthcare profession

Symptom Types

 Total fabrications  Exaggerations  Simulations of the disease  Self-induced disease

A Physical Diagnosis is more

likely if….

 Symptoms do not meet DSM-IV criteria.

 Premorbid social history is unremarkable.

 There is an ABRUPT change in personality, mood, or ability to function.

 There are RAPID fluctuations in mental status.

 There is lack of response to usual biologic or psychologic interventions.

Principles of Management

 Emphasize explanation  Arrange for regular follow-up  Treat mood/anxiety disorder  Minimize polypharmacy and multiple diagnostic tests  Provide specific treatment when indicated

Remember….

 Reassurance that “nothing is wrong” does NOT help.

  The patient does not want symptom relief but rather a RELATIONSHIP and understanding.

Little is to be gained by saying that “it’s all in your head”.

Remember...

 You should acknowledge the patient’s plight, avoid challenging the patient.

 A positive organic diagnosis will not cure the patient.

 SOMATIZATION MAY CO-EXIST WITH ANY PHYSICAL ILLNESS AND MAY INITIALLY MASK THE ILLNESS.

Malingering

 Intentional fabrication of symptoms to achieve a secondary gain, usually material benefits