Transcript SOMATOFORM DISORDERS - New York Medical College

SOMATOFORM DISORDERS
Maria L.A. Tiamson, MD
Asst. Professor, Psychiatry
New York Medical College
SOMATIZATION, the concept
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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
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Asthma
Ulcerative colitis
Rheumatoid arthritis
Eczematous disorders
Irritable bowel syndrome
Forms of Somatization
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Medically unexplained symptoms
Hypochondriacal somatization
Somatic presentation of psychiatric
disorders (ie., depressive equivalents)
Most common presenting
symptoms
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Abdominal pain
chest pain
dyspnea
headache
fatigue
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Cough
back pain
nervousness
dizziness
Infectious Diseases
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Lyme disease
AIDS
Infectious mononucleosis
Syphilis
Chronic Fatigue Syndrome
Post-infection syndromes
SOMATIZATION, the cost
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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
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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
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Physiological Mechanisms
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autonomic arousal
muscle tension
hyperventilation
vascular changes
cerebral information processing
physiological effects of inactivity
sleep disturbance
Pathophysiological Mechanisms
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Psychological Mechanisms
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perceptual factors
beliefs
mood
personality factors
Interpersonal Mechanisms
• reinforcing actions of relatives and friends
• health care system
• disability system
DSM-IV Somatoform Disorders
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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
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Somatization Disorder
Conversion Disorder
Hypochondriasis
Body Dysmorphic Disorder
Somatoform Pain Disorder
Undifferentiated Somatoform Disorder
Somatoform Disorder, NOS
Somatization Disorder
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“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
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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
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Four pain symptoms
One sexual symptom
One pseudoneurological symptom
Two GI symptoms
Somatization Disorder
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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
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Monosymptomatic (one or more
neurological symptoms)
Most common in
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adolescents, young adults
rural populations
low education and low IQ
low socioeconomic group
military personnel exposed to combat
Conversion Disorder
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Symptom has a symbolic relation to the
unconscious conflict
“la belle indifference”
Conversion Disorder
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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
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Symptoms do not conform to known
anatomical pathways and physiological
mechanisms
often inconsistent
DDX: multiple sclerosis, myasthenia gravis,
dystonias
Conversion Disorder
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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
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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
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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
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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
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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
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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
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Undifferentiated somatoform disorder
• unexplained physical effects that last for at least
six months
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Somatoform Disorder, NOS
• residual category
Relation of Depression and
Somatization
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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
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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
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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...
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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
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Total fabrications
Exaggerations
Simulations of the disease
Self-induced disease
A Physical Diagnosis is more
likely if….
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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
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Emphasize explanation
Arrange for regular follow-up
Treat mood/anxiety disorder
Minimize polypharmacy and multiple
diagnostic tests
Provide specific treatment when indicated
Remember….
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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...
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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
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Intentional fabrication of symptoms to
achieve a secondary gain, usually material
benefits