Transcript SOMATOFORM DISORDERS

SOMATOFORM DISORDERS
Group of disorders that includes
physical symptoms for which an
adequate medical explanation cannot
be found
 Psychological factors --> symptom’s
onset, severity, duration
 Not malingering or factitious disorder
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5 Specific somatoform disorders:
Somatization DO
Conversion DO
Hypochondriasis
Body Dysmorphic DO
Pain DO
SOMATIZATION DISORDER
Hysteria, Briquet’s Syndrome
 Many somatic symptoms
 Multiple complaints and organ systems
affected
 Chronic
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Epidemiology
Lifetime prevalence = 0.1-0.2%
 F > M (5-20X) = 5:1
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Etiology
1.
2.
Psychosocial factors - social
communication
Biological factors - attention and
cognitive impairments
Diagnosis
Onset before the age of 30 years
 Complain of at least 4 pain sxs, 2 GI
sxs, 1 sexual sx, 1 pseudoneurological
sx
 No physical or laboratory explanation
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Clinical Features
Many somatic complaints; long
complicated medical history
 Psychological distress: anxiety,
depression
 Common suicidal threats
 Medical history is circumstantial, vague,
imprecise, inconsistent, disorganized
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Patients are dependent, self-centered,
hungry for admiration or praise
 Common associated mental DO - MDD,
PD, SRD, GAD, phobias
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Differential Diagnosis
1.
2.
3.
Non-psychiatric medical condition
Mental DO - MDD, GAD,
schizophrenia
Other somatization DO
Course and Prognosis
Chronic, debilitating
 Onset before age 30 years
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Treatment
Single identified MD
 Visits: regular, avoid additional
lab/diagnostic procedures
 Somatic symptoms - emotional
expressions
 Psychotherapy: individual, group
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CONVERSION DISORDER
One or more neurological symptoms
(paralysis, blindness, paresthesias)
 Psychological factors --> onset,
exacerbation
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Epidemiology
F:M = 2:1 - 5:1
 Onset is any age (common during
adolescence and young adults)
 Rural population, little educated, low IQ,
low SE group, military personel
 Comorbid with MDD, anxiety,
schizophrenia
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Etiology
1.
1.
Psychoanalytic - repression of
unconscious conflict/anxiety -->
physical sx
Nonverbal means of controlling and
manipulating
Biological factors - hypomentabolism
of dominant hemisphere
impaired hemispheric
communication
Diagnosis
Symptoms or deficits affecting
neurological functions
 Psychological factors --> onset,
exacerbations
 Not intentionally feigned or produced
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Clinical Features
Most common symptoms: paralysis,
blindness, mutism
 Most commonly associated with
passive-aggressive, dependent,
antisocial and histrionic PDs
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1.
Sensory Sxs: anesthesia and paresthesia,
esp extremities
distribution usually inconsistent with
central or peripheral neuro dse
characteristic stocking and glove
anesthesia or hemianesthesia (along the
midline)
organs of special senses - deafness,
blindness, tunnel vision --> N neuro exam
2. Motor Sxs: abnormal movements, gait
disturbance, weakness, paralysis
generally worsen by attention
3. Seizure Sxs: pseudoseizure
4. Mixed presentation
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Other associated features:
 Primary
gain: represent an unconscious
psychological conflict
 Secondary gain: accrue tangible
advantages & benefits
 Le belle indifference: unconcerned about
what appears to be a major impairment
 Identification: unconsciously model their
sxs on those someone important to them
Differential Diagnosis
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2.
Rule out medical disorder: thorough medical
and neuro work-up
25-50% diagnosed with conversion DO -->
neuro or non-psychiatric medical DO
Neuro DO - dementia, brain tumors,
degenerative dse, basal ganglia dse
Psychiatric DO - schiz, deprssive DO, other
somatoform, malingering, factitious DO
Course and Prognosis
90-100% resolve in few days to less
than a month
 Good prognosis: sudden onset, easily
identifiable stressor, good premorbid
adjustment, no comorbid psychiatric or
medical DO
 25-50% --> neuro or non-psychiatric DO
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Treatment
Spontaneously resolve
 Insight-oriented supportive or behavioral
therapy
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HYPOCHONDRIASIS
Unrealistic or inaccurate interpretations
of physical symptoms or sensations -->
preoccupation and fear that they have
serious disease
 Significant distress; impaired function
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Epidemiology
F=M
 Onset at any age
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Etiology
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Misinterpretation of bodily symptoms
Social learning model
Variant form of other mental disorder depression and anxiety DO (80%)
Aggressive and hostile wishes
Diagnosis
Preoccupied with false belief based
misinterpretation of physical s/sxs
 At least 6 months
 Not a delusion or restricted to distress
of appearance
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Clinical Features
Believe that they have a serious
disease not yet detected
 Conviction persist despite negative lab
results, benign course, reassurances
 Usually with depression and anxiety
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Differential Diagnosis
1.
2.
3.
Non-psychiatric medical condition
Other somatoform disorders
MDD, anxiety DO, schiz, other
psychotic DO
Course and Prognosis
Episodic, months to years
 Good prognosis: high SE class,
treatment-responsive anxiety or
depression, sudden onset, (-) PD, (-)
related non-psychiatric medical
condition
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Treatment
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Usually resistant to psychiatric
treatment
 Focus
on stress reduction and education in
coping with chronic illness
Group psychotherapy
 Regular scheduled PE
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BODY DYSMORPHIC DO
Preoccupation with an imagined bodily
defect or an exaggerated distortion of a
minimal or minor defect
 Causes significant distress; impaired
function
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Epidemiology
Rare; poorly studied
 Most common age of onset: 15-30 yo
 F > M, unmarried
 Commonly coexists with other mental
DO (MDD, anxiety, psychotic DOs)
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Etiology
Serotonin
 Cultural and social effects
 Psychodynamic models
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Diagnosis
Preoccupied with an imagined defect in
appearance or an overemphasis of a
slight defect
 Significant emotional distress; impaired
functioning
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Clinical Features
Most common concerns: facial flaws
 Common associated symptoms: ideas
of reference, attempts to hide deformity,
excessive mirror checking or avoidance
 Avoid social or occupational exposure
 Housebound; attempt suicide
 Traits: O-C, schizoid, narcissistic PD
 Comorbid: depression, anxiety DO
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Differential Diagnosis
Anorexia nervosa, gender identity DO,
brain damage
 Delusional DO, somatic type
 Narcissistic PD, depressive DO, OCD,
schizophrenia
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Course and Prognosis
Gradual onset
 Usually chronic
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Treatment
Serotonin-specific drugs - clomipramine,
fluoxetine
 Treat coexisting mental DO
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PAIN DISORDER
Psychogenic pain DO
 Pain in one or more sites --> no nonpsychiatric medical or neurological
condition
 Emotional distress; functional
impairment
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Epidemiology
F>M
 Peak onset on 4th to 5th decades
 Blue-collar occupation, 1st degree
relatives
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Etiology
1.
Psychodynamic: expression of
intrapsychic conflict
defense mechanism-displacement,
substitution, repression
2.
3.
4.
Behavioral: reinforced with reward and
inhibited when ignored/punished
Interpersonal: manipulation and
gaining advantages
Biological: 5HT and endorphins
Diagnosis
Significant complaints of pain
 Emotional distress and functional
impairment
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Clinical Features
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Collection of different histories of various
pains
Pain maybe post-traumatic, neuropathic,
neurological, iatrogenic, musculoskeletal
(+) psychological factor
Long history of medical and surgical care,
visits many MDs, requests many meds
Complicated by SRD
MDD: 25-50% of patients
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Dysthymic or depressive DO sxs - 60-100%
Differential Diagnosis
1.
Physical pain VS Psychogenic pain
Physical Pain: fluctuates in intensity,
highly sensitive to emotional, cognitive,
attentional and situational influence
2. Psychogenic Pain: does not vary,
insensitive to any of above factors, does
not wax or wane, not temporarily relieved
by distraction
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2.
Other somatoform DO
Course and Prognosis
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Abrupt onset and increases in severity
Treatment
Address rehabilitation
 PAIN IS REAL
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 Pharmacotherapy
- antidepressant
 Behavioral therapy
 Psychotherapy
 Pain control program
UNDIFFERENTIATED
SOMATOFORM DO
One or more physical complaints that
can’t be explained by known medical
condition
 Doesn’t meet the diagnostic criteria for
any somatoform DO
 At least 6 months
 Significant emotional distress and
impaired functioning
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2 types of somatoform pattern:
Involving ANS: CV, GI, urogenital, derma
sxs
2. Involving sensations of fatigue or
weakness (neurasthenia): mental or
physical fatigue, physical weakness and
exhaustion
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