Transcript Somatoform Disorders

Somatoform Disorders
Dr. Okine
Somatoform Disorders
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Have you ever used or faked Sx to get
out of having to perform important
activities (exams, classes, work, social
functions)?
Have you ever used tactics to gain
attention and sympathy?
Characteristics of the
Somatoform Disorders
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Somatization: the expression of psychological
pain through physical sx or concerns
Unexplained physical symptoms or bodily
preoccupations
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Somatization Disorder, Conversion Disorder, Pain
Disorder, Undifferentiated Somatoform Disorder:
experiencing pain with no apparent medical basis
Hypochondriasis: preoccupation with having a
serious medical condition or disease
Body Dysmorphic Disorder: preoccupation with a
perceived serious defect in appearance
Characteristics of the
Somatoform Disorders
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Psychological factors are associated with the
initiation or exacerbation of Sx
Diagnoses of exclusion – Dx requires you to rule
out:
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Underlying general medical causes
Other psychological disorders, e.g. an Anxiety or
Mood Disorder
Intentional feigning or production of Sx, as in
Factitious Disorder (motivated by a desire to assume
the sick role), or Malingering (motivated by external
incentives for behavior, e.g. economic gain, avoiding
legal responsibility)
Somatization Disorder:
Diagnostic Criteria
A. History of physical symptoms:
 beginning before 30
 occurring over several years
 resulting in TX being sought or significant
impairment in functioning
Somatization Disorder:
Diagnostic Criteria
B. Must meet each of the following criteria during the course of the
disorder:
 4 Pain Sx: a Hx of pain related to at least 4 different sites (e.g.
head, abdomen, back, joints, chest) or functions (e.g.
menstruation, sexual intercourse, urination)
 2 Gastrointestinal Sx: a Hx of at least 2 GI Sx other than pain
(e.g. nausea, bloating, vomiting, diarrhea, intolerance of several
foods)
 1 Sexual Sx: a Hx of at least 1 sexual or reproductive Sx other
than pain (e.g. sexual indifference, erectile or ejaculatory
dysfunction, irregular menses, excessive menstrual bleeding,
vomiting throughout pregnancy)
 1 Pseudoneurological Sx: a Hx of at least 1 Sx or deficit
suggesting a neurological condition without pain (e.g. impaired
coordination or balance, paralysis, localized weakness, difficulty
swallowing, lump in throat, loss of touch or pain sensation, double
vision, blindness, deafness, seizures, urinary retention)
Somatization Disorder:
Diagnostic Criteria
C. Either (1) or (2):
(1) Symptoms not fully accounted for by a
general medical condition or the effects of a
substance
(2) When there is a related medical condition,
the complaints and resulting social or
occupational impairment exceed what would be
expected
D. Symptoms are not intentionally feigned or
produced, as in Factitious Disorder or
Malingering
Somatization Disorder:
General Characteristics
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a complex medical history
inconsistencies between subjective
complaints and objective findings
colorful, dramatic quality to complaints
– exaggerating and elaborating on
physical and psychiatric Sx
respond to psychological/social
problems with physical symptoms
Somatization Disorder:
Facts & Figures
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Prevalence: 0.2-2% among women; less
than 0.2% among men.
Course: chronic, fluctuating disorder;
rarely remits completely
Onset: adolescence; before 25 years old
Most common among those who are:
unmarried, female, & from lower SES
groups
Somatization Disorder: Causes
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Hx of family illness or injury during
childhood
Neurobiologically-based disinhibition
syndrome characterized by impulsive
behavior and pleasure-seeking
Short-term gain of immediate attention
and sympathy
Dependence
Somatization Disorder:
Treatment Considerations
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No well-established treatment.
Most crucial issue is to “do no harm.” Harm can be done by
not considering a possible medical basis for Sx, by
unnecessary medical tests & Tx, & by inadequate Tx for
valid medical conditions
Comprehensive assessment:
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medical history – illnesses, surgeries, pain, fatigue, distress
produced by Sx
current medications
abused substances
psychiatric symptoms – comorbid disorders that could account
for Sx
Stressors – past, present, typical response to stress
Use additional informants & review medical records
Somatization Disorder:
Treatment Considerations
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Long term supportive psychotherapy:
therapist can provide an important,
reassuring, sympathetic relationship; use
brief, widely-spaced sessions
Antidepressants
Use of a “gate-keeper” physician
Work in tandem with a primary care
physician & psychiatrist
Undifferentiated Somatoform Disorder:
Diagnostic Criteria
A. One or more physical complaints (fatigue, loss of
appetite, GI Sx, urinary complaints) which:
 cause significant distress or impairment
 warrant medical attention
 last for at least 6 months
B. R/O alternative explanations for sx:
 General medical conditions
 Effects of a substance
 Factitious Disorder or Malingering
 Other psychological disorders
Conversion Disorder:
Diagnostic Criteria
A.
B.
C.
D.
E.
F.
One or more Sx or deficits affecting voluntary motor or sensory
functioning and indicative of a neurological or other medical
condition
Psychological factors are associated with the Sx – the initiation
or exacerbation of Sx is preceded by conflicts or stressors
The Sx is not intentionally feigned or produced, as in Factitious
Disorder or Malingering
The Sx cannot be fully explained by a general medical
condition, the effects of a substance, or a culturally sanctioned
behavior or experience
Sx cause significant distress or impairment in functioning or
warrant medical attention
The Sx is not limited to pain or sexual dysfunction, does not
occur exclusively in the course of Somatization Disorder, and is
not better accounted for by another mental disorder
Conversion Disorder:
Specifiers
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Specifiers:
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With Motor Sx or Deficits – e.g. impaired
coordination or balance, paralysis, localized
weakness, difficulty swallowing, lump in throat,
urinary retention
With Sensory Sx or Deficits – loss of touch or
pain sensation, double vision, blindness,
deafness, hallucinations
With Seizures or Convulsions
With Mixed Presentation
Conversion Disorder:
Facts & Figures
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More common in:
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rural populations
lower SES
less medically/psychologically sophisticated
women than men (2-10x)
In women, sx are much more common on the left than
right side of the body
11-500 out of 100,000 in general population meet criteria
for conversion disorder
3% of outpatient referrals to mental health clinics
1-14% of medical/surgical inpatients
Onset: late childhood through early adulthood; rarely
before 10 or after 35
Conversion Disorder:
Assessment
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Assess the following:
 physical sx, medical conditions, medications, abused
substances, psychiatric symptoms, and stressors and
conflicts
 the person’s level of medical knowledge
 whether the person may be intentionally feigning
symptoms
 manner of presenting symptoms – dramatic and
histrionic or la belle indifference
 R/O underlying neurological or general medical
conditions by referral for a thorough neuorological
examination: 5-10% have real medical problems
Conversion Disorder: Theory
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Psychoanalytic:
 The person experiences a traumatic event, which produces anxiety
and psychological conflict
 Anxiety and unconscious psychological conflict are converted to
somatic symptoms
 Sx provide primary gain (reduce anxiety and keep the conflict out of
awareness)
 Sx provide secondary gain (the person obtains external benefits,
such as attention or sympathy, or evades noxious duties and
responsibilities)
Getting sick provides the person an escape from a traumatic situation
Hx of significant stress
Over-involved and over-protective parents
Prior experience with real physical problems
Underlying psychopathology
Conversion Disorder:
Treatment Considerations
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Role of suggestibility – patients can be suggested into & out of Sx
Identify and attend to the traumatic or stressful life event
Address current psychosocial stressors with environmental
manipulation, support, advice, and coping skills
Reduce any reinforcing or supportive consequences from the
conversion Sx
Insight-oriented therapies usually aren’t indicated or helpful
For acute Sx: positive expectation for recovery; a face-saving way
for the patient to recover, e.g. physical therapy
For chronic Sx: physical rehabilitation, suggestion, &
psychotherapy
Work closely with a medical doctor and psychiatrist
Pain Disorder:
Diagnostic Criteria
A. Pain in one or more anatomical sites is the
predominant focus of clinical presentation and is of
sufficient severity to warrant clinical attention.
B. Psychological factors are judged to have an
important role in the onset, severity, exacerbation, or
maintenance of the pain.
C. Pain causes clinically significant distress or
impairment in important areas or functioning or
warrants medical attention.
D. Pain is not intentionally feigned or produced, as in
Factitious Disorder or Malingering.
E. Pain is not better accounted for by a Mood, Anxiety,
or Psychotic Disorder.
3 Types of Pain Disorder
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Pain Disorder Associated with Psychological
Factors: psychological factors have a major role
in the onset, severity, exacerbation, or
maintenance of pain
Pain Disorder Associated with a General Medical
Condition: GMC or site of pain is coded on Axis
III, e.g. low back, sciatic, pelvic, headache,
chest, joint, abdominal, throat, urinary
Pain Disorder Associated with Both Psychological
Factors and a General Medical Condition: most
common
Pain Disorder: Specifiers
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Acute: duration less than 6 months
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Chronic: duration 6 months or longer
Pain Disorder:
Treatment Considerations
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Collect info regarding physical Sx, medical
conditions, medications, abused substances,
psychiatric symptoms, stressors and conflicts
Distinguish from Factitious Disorder or
Malingering
Target both the physical and psychological
aspects of chronic pain
Validate the person’s pain, rather than
challenging or insight
Enlist the person’s cooperation in developing
strategies for dealing with pain
Pain Disorder:
Treatment Considerations
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Pain management: teach techniques for coping with pain;
use of analgesic, anti-inflammatory, and antidepressant
medications
Cognitive behavioral techniques: distraction, stress
management, cognitive restructuring, activity pacing, sleep
management, logging activities attempted and level of pain
associated with each
Attend to factors that influence recovery: acknowledging
pain; giving up unproductive efforts to control pain;
participating in regularly scheduled activities despite pain;
recognizing and treating comorbid disorders; adapting to a
potentially chronic condition; not allowing the pain to
become the determining factor in one’s lifestyle
Hypochondriasis:
Diagnostic Criteria
A. Preoccupation with fear of having or belief that one has a
serious illness, based on misinterpretation of bodily Sx or
functions
B. Preoccupation persists despite appropriate medical
evaluation, reassurance, and the person’s not developing
the feared disease
C. Preoccupation lasts at least 6 months
D. Preoccupation causes clinically significant distress or
impairment in important areas of functioning
E. Preoccupation is not better accounted for by other
disorders, such as GAD, OCD, Panic Disorder, Major
Depression, Separation Anxiety, or another Somatoform
Disorder
Hypochondriasis
Specifier:
 With Poor Insight: person doesn’t
recognize the preoccupation is
excessive or unreasonable
Prevalence:
 1-5% in general population
Gender Differences:
 Sex ratio is 50-50
Hypochondriasis: Causes
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Faulty interpretation of bodily cues and
sensations as evidence of physical illness
Enhanced sensitivity to, & over-focusing on,
physical sensations and illness cues
Stressful life events
Disproportionate incidence of disease in family
during childhood
Secondary gains associated with the sick role:
decreased responsibility and increased attention
Hypochondriasis: Treatments
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Cognitive behavioral treatment: identifying
& challenging illness-related
misinterpretations of bodily sensations;
showing patients how to create Sx by
focusing attention on certain body areas
Stress management
Explanatory therapy: reassurance &
education regarding the source and
origins of Sx
Body Dysmorphic Disorder:
Diagnostic Considerations
A. Preoccupation with an imagined defect in
appearance or markedly excessive concern
about a slight physical anomaly
B. The preoccupation causes clinically
significant distress or impairment in important
areas or functioning
C. The preoccupation is not better accounted
for by another mental disorder, such as
distorted body image in Anorexia Nervosa
Body Dysmorphic Disorder:
Common Features
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Constant and excessive use of mirrors
Avoidance of mirrors
Lots of time spent grooming
Lots of grooming rituals
Attempts to hide parts of body
Constantly seeking reassurance about looks, while
discounting feedback
Anxiety or depression about one’s appearance
Body Dysmorphic Disorder:
Facts & Figures
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People with BDD often seek help from
dermatologists and plastic surgeons (rates of
BDD in these settings is 6-15%)
BDD is under-recognized & under-diagnosed
in nonpsychiatric settings
BDD is infrequent in mental health settings
Onset: adolescence and young adulthood
Body Dysmorphic Disorder:
Causes
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Defense mechanism of displacement:
displacing underlying psychological
conflict and anxiety onto a body part
Variant of OCD
Body Dysmorphic Disorder:
Treatment
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There is little to no research on treatments for BDD
Distinguish BDD from normal concerns about
appearance or overvaluing of appearance (resistant to
reality testing and reassurance; cause significant
distress or impairment; delusional)
Pharmacotherapy: SSRI’s at higher doses & for longer
duration
CBT strategies: exposure and response prevention,
self-esteem building, modifying distorted thinking, and
coping strategies