Transcript Somatoform Disorders:

Somatoform Disorders
Somatization Disorder
Conversion Disorder
Pain Disorder
Hypochondriasis
Factitious Disorder
Annabelle Winne,
LCSW
Introduction to
Psychiatry
April 16, 2010
[email protected], 332-2046
Somatoform Disorders: Introduction
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Somatic: (Gk soma body) of, relating to, or
affecting the body
Assessment tools: medical tests, DSM,
defensive structures, attitudes and beliefs,
childhood experiences
–
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Person-as-a-whole/person’s story
Spectrum of intensity & duration
–
Mild intensity, time-limited experiences/symptoms
are normal
Theories of Etiology: Stress-Diathesis Model
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DIATHESIS/PREDISPOSITION
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PLUS exposure to STRESS
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biological: genetics, IQ, personality
environmental: poverty, family dynamics
biological: brain damage, biotoxins
environmental: injury, trauma, developmental expectation
RESULTS IN Dysfunction
Multi-deterministic origin of symptoms/disorder
–
Must have both diathesis and stress to have dysfunction
Theories of Etiology: Psychodynamic Model
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External stressor triggers an emotional conflict which
is manifested within a physical symptom
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Primary gain (intra-psychic)
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–
Does the symptom in some way resolve the precipitating
conflict/stressor? (Avoidance of social role or upcoming
change/transition….)
Secondary gain (inter-psychic)
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Reinforcement beyond primary gain, something achieved
through taking on sick role (attention, nurturance)
Ego Psychology

Ego regulates the self
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Mediates between ID, superego and reality
Ego functions: self-esteem, reality testing, affect regulation,
cognition, mastery
Defenses
 Largely out of awareness (unconscious)
 Protect against anxiety or knowledge of stressors
 Protect against socially/morally unacceptable
feelings/wishes
 AKA coping mechanisms, process of coping, managing or
modulating affect
 Baseline vs. situational stressors
Defenses
Ego defenses have a
protective function, “automatically and
unconsciously modify the individual’s perception of and/or
reaction to danger” (Schamess, 1996.)
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–
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Mature: sublimation, altruism, humor, suppression
Borderline neurotic: intellectualization, repression, externalization
(somatization), reaction formation,
Immature: hypochondriasis, splitting, denial, projection,
dissociation
Symptoms as psychological defense
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–
Defense can be adaptive or maladaptive
Compromise formation: symptom as expressed wish (ID) in
disguised form (influence of superego) that can be tolerated
Regression in service of the ego
–
Temporary lower functioning during stressful periods can be
adaptive
Somatoforms: General Information
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Avoid being overly attached to DSM – tendency for
Somatoform Disorders to morph over time
Very common co-morbid occurrence with
depression, anxiety, personality disorders
Internalize psychological pain
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Internalize vs. externalize
Locus of control is external
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VS. balance of internal/external locus of control
Somatoforms: General Information II
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Telling someone “it’s all in your head” not productive
in developing therapeutic alliance or helping client
cope or resolve symptoms
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High use of medical care, “doctor shoppers”
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Experience of pain and discomfort is real
25% patients in primary care some somatization
10% patients in med/surg have no evidence of disease process
Expensive if not appropriately treated
Multidisciplinary team is best practice
If acute onset, asses for precipitating stressors, such
as combat or sexual abuse or developmental change
Substance abuse as iatrogenic risk of treatment
–
Benzodiazepines, opiates
Somatization Disorder: DSM
A. History of many physical complaints combined with
decreased functioning
B. Symptoms:
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(1) four pain symptoms in at least 4 sites
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(2) two gastrointestinal symptoms
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(3) one sexual symptom
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(4) one pseudoneurological symptom
C. Symptoms cannot be explained by medical
condition, OR complaints or impairment in excess
D. Not faked (malingering or factitious)
Somatization Disorder: Prevalence
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Up to 2.0% of the general population
Up to 6.0% of patients in primary care
– Similar to prevalence rates of UTIs
Up to 9% of patients in general hospital wards
12 - 28% of patients seen by a specialist
10 x more common in women than in men
Somatization Disorder: Assessment
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Many complaints about pain
Significant impairment in functioning (social or occupational)
Not fully explained by a medical condition or substance. Or, if
related to a medical condition, impairment and/or pain greater
than expected
Linked with hx of child abuse, especially sexual abuse
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Assess for history of abuse and trauma
Simultaneously help-seeking and help-rejecting
Typically less concerned with etiology of symptoms and more
focused on symptoms themselves
How is Somatization different from fibromyalgia and CFS?
Somatization DO: Differential Dx
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Lifelong pattern of multiple, unexplained complaints
– Different from somatic symptoms related to
anxiety or depression like muscle tension, mild
abdominal pain, shortness of breath
Different also from somatic symptoms of Panic
Disorder (panic attacks)
Somatization DO: Course of Illness
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Chronic with changes in acuity over time
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Typical episode 6-9 months, remission for 9-12 months
Full remission is rare
One study showed 95% of patients with somatization disorder
had been to health care provider in past 6 months vs. 56% of
other community residents
Typically episodes of illness are secondary to period of stress
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New symptoms
Or seeking health care more frequently
Accurate diagnosis is key
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Otherwise pt is referred to multiple doctors and specialists with
many unnecessary, expensive diagnostic procedures and without
appropriate treatment
Somatization DO: Common Characteristics
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“Sicker than the sick”
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Pattern of many, many unexplained physical somatic
complaints
Current DSM
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Poor physical, social and mental health when compared to people
with chronic health problems
Appear in adolescence and meet full criteria by 30 y.o., can also
develop in late 30’s
“Chaotic” social lives
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Many losses
Unstable work hx
Somatization Disorder: Treatment
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Lead provider for primary care, collaborate with necessary specialists
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R/O underlying physical etiology (cardiac, gastro, neurological etc.)
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Very important specialist know about Somatization DO diagnosis
Do repeatedly over time as physical disease can develop in future
Not either/or (mental or physical)
Order additional procedures/tests based on objective data (signs), not
subjective data (symptoms) – “conservative management” of comorbid
medical conditions
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Very important to refrain from unnecessary testing – counter indicated with
this population because it avoids the recommended treatment
Also, pts tend to be very sensitive to invasive procedures
Risk of iatrogenic injury
Somatization Disorder: Treatment II
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Brief, regular appointments every 4-6 weeks
– Conduct “partial exam of organ system” that pt is complaining
about
– More frequent during initial stage of treatment and flare ups
Engage, develop trust, refer pt to mental health and continue to treat
– Not a dump, pts will sense this and seek out a “better” health care
provider
– Important how you frame referral – someone who can see pt more
frequently to help with stress of symptoms, to help with cooccurring depression or anxiety, to help cope with the discomfort
and difficulty of the symptoms
Help pt validate and contain their feelings - anxiety, pain,
disappointment, wish for relief
– Rx for reassurance, validation and empathy
Psychoeducation about how stress effects chronic pain
Somatization Disorder: Treatment III
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Consult with psychiatric provider ASAP to lessen your
anxiety/frustration and result in better tx for pt
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Team-based is preferable, may be necessary for pt to f/u with
medications for co-morbid disorders
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Avoid waiting until your frustration mounts, pt has (yet another)
negative relationship with a provider
Benefit of in-house psychiatric providers, can bring provider into
your office at appointment time
Phone calls from team members prompting meds
Referral to therapy – individual and/or group
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Biofeedback
Mindfulness-Based Stress Reduction
CBT groups
Somatization Disorder: Treatment IV
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Treat comorbid psychiatric disorders
– 83-100% of pts had comorbid conditions
– 55% major depression
– 34% anxiety disorder
– 26% panic disorder
– 61% with 1+ personality disorder – avoidant, paranoid and
obsessive compulsive
Predict difficulties with medications
– Pt may somaticize normative side effects – “I stopped using
it on the second day because I got a headache”
– May have poor follow through
– May change dosage without consulting you
Somatization Disorder: Treatment V
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Motivational interviewing with goal of referral to mental health
provider
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Be open to very small steps forward; these can be easy to miss,
openings for “change talk,” if provider is mired in attitude of
hopelessness
Metaphor of tennis
‣ If you can’t see progress, look for smaller, more detailed
footwork.
What might “change talk” look like for people who somatize?
Somatization Disorder: Case Studies
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ER patient transferred from Brighton for SI statement when
wanting assessment for exacerbation in chronic pain
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Family with somatic tendencies
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Insisted on invasive procedure
Mom, dad, daughter
Meds for daughter
Mom hx of cancer, also pain. Initially no PCP. Suboxone.
Adolescent girl with hx of sexual abuse dx with connective
tissue disease, pain in other systems (pelvic, gastro, neuro)
who had addiction to Percoset
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Stress (abuse, parental response to it) + predisposition (family
coping styles, genetic load)
Question of primary and secondary gain
Conversion Disorder: Introduction
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Also known as “hysteria”
Term “conversion” was coined by Freud who
developed hypothesis that anxiety was
unconsciously “converted” into physical symptom
Psychoanalytic approach – the symptom
simultaneously represents the conflict and provides a
solution to it – a “symbolic condensation of the
unconscious conflict” (Ford, 2001)
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A man anxious about his rage has a paralyzed arm. Thus,
he can’t hit anyone.
Conversion Disorder: DSM
A. Loss of function of a voluntary motor system or
sense organ
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–
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B.
C.
D.
E.
Not accounted for by medical or neurological condition
Causes significant functional impairment
Excludes culturally sanctioned behavior
Examples: paralysis, pregnancy in non-pregnant woman,
vocal cord dysfunction, pseudoseizures
Symptom preceded by stressor
Not faked (malingering or factitious)
Symptom not limited to pain or sexual dysfunction
Symptom/deficit: motor, sensory, seizures
Conversion Disorder: Prevalence
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All ages – children, adolescents, adults, geriatric
In children, occurs equally between boys and girls
In adults diagnosed much more in women
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Except in predominately male settings (military)
5-10% of hospital patients referred for psychiatric
consultation
Up to 14% of Med/Surgical Inpts
Up to 3% of neurology patients
Conversion Disorder: Assessment
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Loss of function of a voluntary motor system or sense organ
Rule out underlying physical illness
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Very important to consider underlying neurological disorder at present
time of conversion disorder and also in future
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Does pt have conscious control of symptom? (Malingering, Factitous DO)
Is start of symptom associated with stressor or psychological conflict?
Sometimes recent contact with someone who modeled symptom
Often associated with depression
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Apparent tie between Conversion DO and Neurological Dysfunction
Requires a subjective decision on the part of the provider
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Reflexes in paralyzed limb, EEG is normal, nerve conduction speed WNL
Occasionally occurs in people diagnosed with schizophrenia
May or may not have personality disorder
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If yes, common in dependent and histrionic PDO
Conversion Disorder: Treatment
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“Three P’s” to aid with formulation and treatment plan
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Predisposition
 Tendency to somatize and rigid personality structure
 Impaired ability or cultural norm against explicit verbal communication
 Underlying psychiatric or neurological disorders
Precipitating stressor
 Psychological conflicts
 Traumatic events (combat, sexual abuse)
Perpetuating factors
 Primary gain (intra-psychic) - does the symptom in some way resolve
the precipitating conflict/stressor?
 Secondary gain (inter-psychic) - reinforcement for taking on sick role
Treatment consists of symptom relief and also consideration of
factors/stressors/conflict which was a precipitant
–
Some consider Conversion Disorder a symptom of another disorder
Acute Conversion Disorder: Treatment II
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Good prognosis in people with good health prior to
disorder, clear precipitating stressor and no cooccurring psychiatric disorder – symptom can stop
quickly
Reassurance that symptom is not a sign of serious
medical disease/problem
Acute Conversion Disorder: Treatment III
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Suggestion/Psychoeducation
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Gentle and supportive suggestion/interpretation/confrontation
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Symptom as response to stressor
– Message from brain to body part is not working properly
– Give words to repressed affect/conflict/cognition
– Regain use of organ/limb through physical therapy
– Validate discomfort of precipitating stressor
Lorazepam
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Repressed affect may emerge
Gain historical information
May have reduction in symptom
Medical risks (compromised cardiac status)
Contraindicated in patients who are opposed to procedure and with
people who have psychosis
Chronic Conversion Disorder: Treatment IV
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Chronic
– Worse prognosis related to symptom lasting
longer than 6 months, older age and significant
secondary gain
– Behavior modification
– Family therapy
– Physical therapy, occupational therapy, speech
therapy
 Disuse atrophy
Case Study:
Conversion DO (drpeck.com)
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January 22, 1995
Patient is a 52-year-old woman whose husband is president of a local union.
She has become increasingly weak and has been unable to functionparticularly with her hands. She has also has difficulty walking, and has lost
weight and become lethargic. She has been hospitalized, and biopsies have
shown a change in the musculature- particularly of the thenar area (the muscle
between the thumb and forefinger). A diagnosis of amyotrophic lateral sclerosis,
or Lou Gerhig's Disease, has been made.
Patient gives a history of being very unhappy and isolated. She feels that the
marriage to her husband of 27 years deteriorated. He spends very little time
with her and she feels quite alone, particularly since the children have grown.
She has done some private duty nursing, and her last case was a man who had
Lou Gerhig's disease and recently died.
Patient will be seen on a regular basis. She was placed on an antidepressant,
Prozac, 20 mg. once a day.
Case Study:
Conversion DO (drpeck.com) II
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March 15, 1995
Patient continues to do poorly. Her husband, who is concerned
that she will be deteriorating from this disease and won't have
long to live, has decided to terminate his presidency of the
union.
April 16, 1995
Patient was referred to me by a local neurologist, who after
careful evaluation, wrote a report stating that he did not believe
that she was suffering from Lou Gerhig's disease. He felt that
the atrophy was actually the result of disuse- meaning that she
was simply not using her musculature. Microscopically, this
atrophy is not that different from what can be found in A.L.S.
and may mimic it.
Case Study:
Conversion DO (drpeck.com) III
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June 6, 1995
Patient seems to be getting stronger. She is
beginning to ambulate more without a cane,
particularly with the support of her husband who is
now with her full time.
September 11, 1995
Patient is much more active. She has even been
able to drive a car. She and her husband have
decided to retire and move south to Florida.
Conversion Disorder: Case Study
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Anna O. (Breuer and Freud)
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Bright woman with limited options (Victorian
Vienna, 1882), question of sexual abuse
Cared for fa through his illness
After fa’s death – paralysis, muteness, anorexia,
difficulty swallowing
“The talking cure,” hypnosis, free association
Ended in “hysterical pregnancy” when Breuer
terminated tx
Conversion Disorder: Case Study
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Pt transferred to ED due to paralysis
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Medical work-up negative
Worked on ladders, chin strap stuck on ladder
and pt was immobilized for approx. 3 minutes
Conversion Disorder: Case Study
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Adolescent girl with hx of sexual abuse by
relative
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“Pseudoseizures” started after initial psychiatric
hospitalization
Self-harm became severe and multi-faceted
Episodes became ritualized daily event at
arranged time
Question of Conversion DO vs. Dissociative DO
Pain Disorder: DSM
A. Pain is severe and prominent
B. It results in functional impairment
C. Psychological factors have significant role in
pain
D. Not faked (malingering or factitious)
Pain Disorder : DSM II
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Associated with Psychological Factors
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Associated with both Psychological Factors and
General Medical Condition
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Psych. factors have major role in onset, severity,
exacerbation or maintenance of pain (not dx if criteria for
Somatization DO are met)
Both psych. factors and med. condition have important roles
Associated with a General Medical Condition
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Med. condition has major role (low back, sciatic, headache)
Pain Disorder: Prevalence
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Pain Disorder with Psychological Factors is rare
Pain Disorder with Medical Factors and Med/Psych
Factors more common, especially in Pain Clinics
– US, 10 – 15% of adults/year have some type of
back-related work injuries
– Most people with acute back injuries recover
Pain Disorder: Course of Illness
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Acute pain stems from tissue damage (ED, PCP)
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Chronic pain continues after tissue damage is repaired
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Most people recover
Neurological system dysfunctions
Occurs in very small portion of people with acute pain
Depression strongly associated with chronic pain (not clear
which came first) – over than 50% in most studies (Sullivan,
2001)
Pain Disorder: Treatment
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Pain is real
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Common for there to be a discrepancy between subjective
report of pain and physical findings
Important to attend medically to physical c/o pain
Provide psychoeducation when/if patient focuses on “cure”
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Some people are drug-seeking, but not common
Complicated if person has chronic pain and also has an opioid
addiction
More a question of resuming functioning in light of pain
“Doctor shopping” is common. The relationship with health care
provider is key.
Pain Clinics are best practice
–
Multidisciplinary team of medical, mental health, vocational
services, OP, PT, Neuro
Pain Disorder:
Medical Treatments (Sullivan, 2001)
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Avoid unnecessary invasive procedures, risk of iatrogenic injury
Medications
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Antidepressants
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Anticonvulsants/Mood stabilizers
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SSRIs when co-morbid depression
Tricyclics when no concurrent depression
More chance of side effects (vs. SSRIs)
Opiates
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Last resort
Fixed-schedule
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Not as-needed as this draws attention to pain as oppose to focus being on
increasing function
Better analgesic effect
Pain Disorder: Therapy
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Regressive treatments less efficacious
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Person is already in a regressed, “sick,” dependent role
Focus on increasing function, as oppose to
decreasing pain
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CBT
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Attitudes and thoughts as drivers of emotion and bx and pain
experience, small and manageable steps, coping skills (as
oppose to “cure”), social skills, relaxation, homework and role
plays
Biofeedback
Physical therapy
Family/Couples Therapy
Hypochondriasis : DSM
A. Misinterpretation of body symptoms which lead to
preoccupation with belief that one has disease
B. The preoccupation persists despite appropriate medical
evaluation and reassurance
C. The belief in Criterion A is not of delusional intensity (as in
Delusional Disorder, Somatic Type) and is not restricted to a
circumscribed concern about appearance (as in Body
Dysmorphic Disorder).
D. Clinically significant impairment in functioning
E. At least 6 months in duration
F. R/O Generalized Anxiety Disorder, Obsessive-Compulsive
Disorder, Panic Disorder, a Major Depressive Episode,
Separation Anxiety, or another Somatoform Disorder.
Hypochondriasis: Prevalence
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1 – 5% of general pop
2 – 7% of primary care OPD
Hypochondriasis: Course of Illness
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Appears to depend on the time person has spent in the medical
system
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Seen many doctors, attitude of mistrust and betrayal – less
responsive to reassurance
May be more responsive to structured treatment (combination of
CBT and psychodynamic approaches)
Newly emerging symptoms and/or no personality disorder –
may be responsive to reassurance and education about
symptoms/bodily sensations
Appears to co-occur frequently with anxiety (pre-symptomatic)
and depression (post-symptomatic)
Question if it is a type of personality disorder or a type of OCD
(obsessive thoughts and compulsive attempts at self-soothing
which are generally ineffective)
Hypochondriasis: Treatment
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Approaches borrowed from treatment of anxiety and OCD
(education, CBT, phobia exposure)
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Misinterpretation of bodily sensations
Misinterpretation of medical information
100 patients referred for psychiatric assessment – 77 patients
treated with CBT – 62 (81%) showed marked to moderate
improvement (House, 1989)
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Discontinue medical contacts/investigation
Misconceptions challenged
Provocation test (hyperventilation, muscle tension) to change
understanding of bodily sensations
Relaxation
Education
Hypochondriasis: Treatment II
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Genuine reassurance person doesn’t have disease
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Most effective with people without personality disorders
Do not dismiss patients without follow-up as depression and
schizophrenia can be fatal
Do not over-treat patients out of fear. Excessive labs usually treat the
provider’s anxiety.
Explore the context in which the patient's symptoms began. Clues to
losses, disappointments, helplessness, and isolation may be found.
Do not be too quick to translate somatic complaints into
psychological explanations.
Do not respond to patients' wishes to be "rescued" with an air of
omnipotence.
Be restrained with the prescription pad. Return appointment often
more productive.
When patients expand their conversation beyond symptom
complaints, they are improving. Do not rush to ask "What happened
to the (headache, backache, sore arm, and so on)?"
Factitious Disorders : DSM
A.
Intentional production or feigning of physical or psychological
signs or symptoms.
B.
The motivation for the behavior is to assume the sick role.
C.
External incentives for the behavior (such as economic gain,
avoiding legal responsibility, or improving physical well-being,
as in Malingering) are absent.
Factitious Disorder: Differential Diagnosis
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
Motivation is internal gain, not external benefits/gains
(Malingering)
Symptoms are produced consciously and with intent,
not unconsciously (Somatoform DO, Conversion DO,
Hypochondria)
Factitious Disorders :Prevalence
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Difficult to measure (disorder involves deception)
1% of mental health consults in large, general
hospital
50% are male
Factitious Disorders : Course of Illness
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Typically has intermittent episodes
Less common is one episode or chronic, ongoing
episode
Factitious Disorder: Course of Illness
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Acute onset secondary to stress (easier to treat)
– Associated with Axis I dx
Munchausen syndrome is at extreme – typically
male, often travels and cons people in order to be an
patient endlessly. Can be very expensive.
– Associated with personality disorder (antisocial
and/or borderline)
Factitious Disorders: Assessment

Possible clues:
– Hx of having worked in medical field or known
others who worked in medical field
– Failure to respond to medical treatment
– Inconsistent medical findings
– Collateral information is very important
‣ Request prior medical records
– Appearance of being socially isolated
‣ Few visitors despite serious medical problem
Factitious Disorder: Etiology
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Mastery/Masochism
– Create illness to master having experienced
illness as a child or being abused
Dependency gratification
– Dependency needs not adequately met during
childhood
Defense against loss
Factitious Disorders : Treatment
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Earlier, illegal strategy
– List circulated to forbid admissions
Confrontation in a non-punitive, validating way
– This is a coping skill for dealing with stress, let’s
see if we can help you develop some healthier
coping skills.
– May be experienced by pt as shameful and pt may
flee to another provider/hospital.
Factitious Disorders : Case Study

Action Team Client
– Factitious vs. Dissociative
Research Criteria for Factitious Disorders by
Proxy or Munchausen Syndrome by Proxy
A. Intentional production or feigning of physical or
psychological signs or symptoms in another person
who is under the individual's care.
B. The motivation for the perpetrator's behavior is to
assume the sick role by proxy.
C. External incentives for the behavior (such as
economic gain) are absent.
D. The behavior is not better accounted for by another
mental disorder.
Malingering: DSM
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False or grossly exaggerated medical or psychiatric
symptoms are intentionally produced
Motivation is some type of external gain
– Avoid work, military service, criminal sentencing
– Obtain drugs, financial gain
May be adaptive in some situations (kidnapped,
abuse)
Malingering: Treatment
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Management, not treatment
Be direct and discuss your assessment with patient
– They may disclose at this point
– Beware your own countertransference. You may
feel angry at having been lied to and conned.
Avoid shame-based retribution.
Rare in people with chronic pain, those who seek
disability
Case Examples
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Woman moved here from another part of the state.
Some confirmation of her story. Homeless.
REPEATED use of ER and psych. hospital.
Precipitous discharges.
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Gentleman recently DC’ed SHH, presents next day
wanting hospitalization and medications. Providers
disagree.
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Factitious vs. malingering vs. dissociative
Factitious vs. malingering vs. psychotic
Increase in late fall of presentation in ER of
homeless folks
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Malingering vs. depression secondary to environmental
change
Sources/More Information
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Treatments of Psychiatric Disorders, 3rd Ed. (2001), Editor
Glen O. Gabbard, M.D.
DSM-IV-TR
The Anxiety & Phobia Workbook (2005) by Edmund J. Bourne
Aaron T. Beck, Cognitive Therapy
Inside Out and Outside In (2000) by Joan Berzoff, Laura
Melano Flanagan, Patricia Hertz
Freud and Beyond: A History of Modern Psychoanalytic
Thought (1996) by Stephen A. Mitchell, Margaret J. Black
Holloway, K.L. and K.J. Zerbe, Simplified approach to
somatization disorder: When less may prove to be more.
Postgraduate Medicine 2000; 108(6): 89-95.
Psychoanalytic Diagnosis: Understanding Personality Structure
in the Clinical Process (1994) by Nancy McWilliams.