بسم الله الرحمن الرحیم

بسم الله الرحمن الرحیم

Somatoform Disorders

Somatoform Disorders The term somatoform derives from

the Greek soma for body and the somatoform disorders are a broad group of illnesses that have bodily signs and symptoms as a major component.

Somatoform Disorders These disorders encompass mind-body

interaction in which the brain, in ways still not well understood, sends various signals that impinge on the patient's awareness, indicating a serious problem in the body.

DSM-IV-TR recognizes five specific somatoform disorders: Somatization disorder Conversion disorder Hypochondriasis Body dysmorphic disorder Pain disorder

Two residual diagnostic categories for somatoform disorder:

Undifferentiated somatoform disorder Somatoform disorder NOS

Somatization disorder Somatization disorder is characterized

by many somatic symptoms that can not be explained adequately on the basic of physical and laboratory examinations.

Somatization disorder Epidemiology:

the prevalence of somatization disorder in the general population is estimated to be 0.2% to 2% in women and 0.2%in men.

The disorder occurs among patient who have little education and low incomes.

Somatization disorder Epidemiology Somatization disorder is defined as

beginning before age 30. it usually begins during a person's teenage years.

Somatization disorder commonly coexists with other mental disorders.

About 2/3 of all patients with somatization disorder have identifiable psychiatric symptoms.

Psychosocial factors : Psychoanalytic interpretation of symptoms

rest on the hypothesis that the symptoms substitute for dystonic thoughts.

The symptoms as social communication whose result is to avoid obligations.

Some patients come from unstable homes and have been physically abused.

Etiology

EtiologyBiological factors A limited number of brain imaging studies

have reported decreased metabolism in the frontal lobe and the nondominant hemisphere.

Somatization disorder tends to run in families and occurs in 10-20% of the first-degree female relatives of patients with somatization disorder

Etiology Within these families, first degree male relatives

are prone to substance abuse and antisocial personality disorder.

Concordant rates are 29% in monozygotic twins and 10% in dizygotic twins.

Cytokines may help cause some of the nonspecific symptoms of disease such as hypersomnia, anorexia, fatigue and depression.

Somatization disorder Comorbidity: somatization disorder is commonly

associated with other mental disorders, including major depressive disorder, personality disorder, substance-related disorder, generalized anxiety disorder and phobias.

Anxiety and depression are the most prevalent psychiatric conditions.

Diagnostic criteria for somatization disorder A) A history of many physical complaints

beginning before age 30 years that occur over a period of several years.

B) Each of the following criteria must have been met :

1) Four pain symptoms, e.g., head, abdomen, back, joints, extremities, chest, rectum, during sexual intercourse or during urination.

Diagnostic criteria for somatization disorder2) Two gastrointestinal symptoms: two

gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting, diarrhea)

3) One sexual symptoms e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding.

Diagnostic criteria for somatization disorder4) One pseudo neurological symptom e.g.,

impaired coordination or balance, paralysis, difficulty swallowing or lump in throat, aphonia, loss of touch or pain sensation, double vision, blindness, deafness,…

c) There isn't any known general medical condition or direct effects of a substance.

D) The symptoms are not intentionally produced or feigned

Treatment Primary physician should see patients

usually at monthly interval.

Additional laboratory and diagnostic procedures should generally be avoided.

Long- range strategy for patient with somatization disorder is to increase the patient's awareness of the possibility that psychological factors are involved in the symptoms until the patient is willing to see a mental health clinician.

Treatment Psychotherapy, both individual and group,

decreases these patients’ personal health care expenditures by 50% , largely by decreasing their rate of hospitalization.

In psychotherapy settings, patients are helped to cope with their symptoms, to express underlying emotions, and to develop alternative strategies for expressing their feelings.

Tretment Psychopharmacological treatment of the

coexisting disorder, mood or anxiety disorder, is indicated.

Medication must be monitored, because patients with somatic disorder tend to use drugs erratically and unreliably .

Conversion disorder A conversion disorder is a disturbance of bodily

functioning that does not conform to current concepts of the anatomy and physiology of the CNS or the PNS.

It typically occur in a setting of stress and produces considerable dysfunction.

Conversion disorder DSM-IV-TR defines conversion as characterized

by the presence of one or more neurological symptoms that can not be explained by a known neurological or medical disorder.

The diagnosis requires association of psychological factors with the initiation or exacerbation of the symptoms.

Conversion disorder Epidemiology:

some symptoms of conversion disorder that are not severe enough to warrant the diagnosis, may occur in up to 1/3 of the general population.

The ratio of w/m among adult patients is at least 2/1 and as mush as 10/1 among children.

Conversion disorder Conversation disorder can have its onset at

any time from childhood to old age but it is most common in adolescents and young adults.

Data include that conversion disorder is most among rural populations, person with little education, those in low socioeconomic groups and military personnel who have been exposed to combat situations.

Conversion disorder Comorbidity

Conversion disorder is commonly associated with diagnoses of major depressive disorder, anxiety disorders, and schizophrenia and shows an increased frequency in relatives of probands with conversion disorder.

Comorbidity Studies of patients admitted to a

psychiatric hospital for conversion disorder reveal that on further study, one quarter to one half have a clinically significant mood disorder or schizophrenia.

Etiology Psychoanalytic factors:

conversation disorder is caused by unconscious intrapsychic conflict and conversation of anxiety into a physical symptom.

The symptoms allow partial expression of the forbidden, so that patients can avoid consciously confronting their unacceptable impulses.

Etiology The conversion disorder symptom has a

symbolic relation to the unconscious conflict.

Symptoms may function as a nonverbal means of controlling others.

Learning theory: a conversion symptom can be seen as a piece of classically conditioned learned behavior.

Etiology Biological factors

Preliminary brain- imaging studies have found hypometabolism of the dominant hemisphere and hypermetabolism of the no dominant hemisphere and have implicated impaired hemispheric communication in the cause of conversion disorder.

Diagnosis criteria for conversion disorder

A) One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.

B) The initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

C) The symptom or deficit is not intentionally produced or feigned.

Diagnosis criteria for conversion disorderD) The symptom or deficit cannot be fully

explained by a general medical condition or by the direct effects of a substance.

E) The symptom or deficit cause clinically significant distress or impairment in social, occupational,….

F) The symptoms or deficit is not better accounted for by another mental disorder.

Conversion disorder Symptoms

Motor symptoms: involuntary movements, tics, blepharospasm, torticolli, opisthotones, seizure, abnormal gait, falling , astasia- abasia, paralysis, weakness, aphonia

Sensory deficits: anesthesia(exteremities), blindness, tunnel vision, deafness

Symptoms Visceral symptoms: psychogenic vomiting,

pseudocyesis, globus hystericus, swooning or syncope, urinary retention, diarrhea.

Seizure symptoms: 1/3 of the patient’s pseudoseizure also have a coexisting epileptic disorder.

Treatment Resolution of the conversion disorder

symptom is usually spontaneous, although probably facilitated by therapy.

The most important feature of the therapy is a relationship with a caring and confident therapist.

Treatment Telling such patients that their symptoms are

imaginary often makes them worse.

Anxiolytics and behavioral relaxation exercises are effective in some cases.

Treatment Parenteral amobarbital or lorazepam maybe

helpful in obtaining additional historic information, especially when a patient has recently experienced a traumatic event.

The longer the duration of these patient’s sick role, the more difficult the treatment.

Hypochondriasis Hypochondriasis is defined as a person's

preoccupation with the fear of contracting, or the belief of having, a serious disorder.

This fear or belief arises when a person misinterprets bodily symptoms or functions.

Patient's preoccupations result in significant distress to them and impair their ability to function.

Hypochondriasis Epidemiology: Men and woman are equally affected

hypochondriasis.

Although the onset of symptom can occur at any age, the disorder most commonly appears in persons 20- 30 years of age.

Social position, education level and marital status do not appear to affect the diagnosis.

Etiology A reasonable body of data indicates that

persons with hypochondriasis augment and amplify their somatic sensation.

They have low threshold and low tolerance of physical discomfort.

They may focus on bodily sensation, misinterpret them and become alarmed by them because of a faulty cognitive scheme.

Etiology The second theory is that hypochondriasis is

understandable in terms of a social learning model.

A third theory suggests that hypochondriasis is a variant form of other mental disorders.

80 % of patients with hypochondriasis may have coexisting depressive or anxiety disorders.

Diagnostic criteria for hypochondriasisA) Preoccupation with fears of having, or the

idea that one has a serious disease based on the person’s misinterpretation of bodily symptoms.

B) The preoccupation persist despite appropriate medical evaluation and reassurance.

C) The belief in criterion A is not of delusional intensity.

D) The preoccupation causes clinically significant distress or impairment in social, occupational or other functions.

E) The duration of the disturbance is at least 6 months.

F) The preoccupation is not better accounted for by other psychiatric disorders.

Diagnostic criteria for hypochondriasis

Treatment Patients with hypochondriasis usually resist

psychiatric treatment although some accept this treatment if it takes place in medical setting and focuses on stress reaction in coping with chronic illness.

Group psychotherapy often benefits such patients,, in part because it provide the social support and social interaction that reduce their anxiety.

Treatment Regularly scheduled physical examinations

help to reassure patients that their physicians are not abandoning them.

Pharmacotherapy alleviates hypochondriacal symptoms only when a patient has an underlying drug- responsive condition such as an anxiety disorder or major depressive disorder.

Body dysmorphic disorder Patient with body dysmorphic disorder have a

pervasive subjective feeling of ugliness despite a normal or nearly normal appearance.

The core of the disorder is the person's strong belief or fear that he or she is unattractive.

This fear is rarely assuaged by reassurance even though the typical patient with this disorder is quite normal in appearance.

Body dysmorphic disorderEpidemiology:

body dysmorphic disorder is a poorly studied condition, partly because patients are more likely to go to dermatologist, internist or plastic surgeon than to psychiatrists.

Available data indicate that the most common age of onset is between 15 and 30 years and that women are affected somewhat more often than men.

One study found that more than 90% of patient with body dysmorphic disorder had experienced a major depressive episode in their lifetime, about 70% had experienced an anxiety disorder and about 30% had experienced a psychotic disorder.

Etiology• The pathophysiology of the disorder may

involve serotonin because:

1) High co morbidity with depressive disorders

2) Family history of mood disorders

3) Family history of OCD

Etiology

4) Responsiveness to serotonin- specific drugs

• In psychodynamic models , body dysmorphic disorder is seen as reflecting the displacement of a second or emotional conflict onto a no related body part.

Diagnostic criteria for body dysmorphic disorderA) Preoccupation with an imagined defect in

appearance.

B) The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

C) The preoccupation is not better accounted for by another mental disorder.

Body dysmorphic disorder Clinical features:

the most common concern involve facial flaws, particularly those involving specific parts, e.g. the nose.

Other body parts of concern are hair, breast and genitalia.

A proposed variant of dysmorphic disorder among men is the desire to bulk up and develop large muscle mass.

The effects on a person's life can be significant, almost all affected patients avoid social and occupational exposure.

As many as 1/3 of the patient may be house bound because of worry about being ridiculed for deformities and as many as one fifth attempt suiside.

Treatment A large body of data indicates that serotonin-

specific drugs, for example clomimpramine and fluoxetine,reduce symptoms in at least 50% of patients.

The coexisting disorders should be treated with the appropriate pharmacotherapy and psychotherapy.

Pain disorder DSM-IV-TR define pain disorder as the presence of pain

that is the predominate focus of clinical attention.

The primary symptom is pain in one or more sites that is not fully accounted for by a nonpsychiatric medical or neurological condition.

The pain is associated with emotional distress and functional impairment.

The disorder has been called somatoform pain disorder, psychogenic pain disorder, idiopathic pain disorder and atypical pain disorder.

Pain disorderEpidemiology:

Pain disorder is diagnosed twice as frequently in women as in men.

The peak age of onset are in the forth and fifth decades, perhaps because the tolerance for pain decline with age.

First- degree relatives of patients with pain disorder have an increased likelihood of having the same disorder, that genetic inheritance or behavioral mechanism are possibly involved in its transmission.

Depressive disorder, anxiety disorders, and substance abuse are also more common in the families of patients with pain disorder than in the general population.

Etiology Psychoanalytic factors: patients may be

symbolically expressing an intrapsychic conflict through the body.

Patients suffering from alexithymia, who are unable to articulate their internal feeling states in words, express their feelings with their bodies.

Behavioral factors: pain behaviors are reinforced when rewarded and are inhibited when ignored or punished.

Etiology Biological factors: Serotonin is probably the

main neurotransmitters in the descending inhibitory pathway, and endorphins also play a role in the CNS modulation.

Endorphin deficiency seems to correlated with augmentation of incoming sensory stimuli.

Some patients may have pain disorder, because of sensory and limbic structural or chemical abnormalities that predispose them to experience pain.

Diagnostic criteria for pain disorder

A) Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.

B) The pain causes clinically significant distress or impairment in social, occupational or other functioning.

C) Psychological factors are judged to have an important role in the onset, severity, exacerbation or maintenance of the pain.

D) The symptom or deficit is not intentionally produced.

E) The pain is not better accounted for by a mood, anxiety, or psychotic disorder.

Diagnostic criteria for pain disorder

Treatment Pharmacotherapy Analgesic medications do not generally

benefit most patients with pain disorder.

Antidepressant such as TCA & SSRI are the most effective pharmacological agents.

Pharmacotherapy Antidepressants reduce pain through their

antidepressant action or exert an independent, direct analgesic effect.

Amphetamine, which has analgesic effects, may benefit some patients, especially when used as an adjunct to SSRI, but dosage must be monitored carefully.

Psychotherapy The first step is to develop a solid

therapeutic alliance by empathizing with the patient’s suffering.

For the patient, the pain is real and clinicians must acknowledge the reality of the pain even as they understand that it is largely intrapsychic in origin.

Cognitive therapy has been used to alter negative thoughts and to foster a positive attitude.

Diagnosis criteria for undifferentiated somatoform disorder

A) One or more physical complaints (e.g., fatigue, loss of appetite, GI or urinary complaints.)

B) Either 1 or 2 :1- the symptoms cannot be fully explained by a

known general medical condition or the direct effects of a substance.

2- when there is a related general medical condition, the physical complaint or resulting social or occupational impairment is in excess of what would be expected .

Diagnosis criteria for undifferentiated somatoform disorderC) Clinically significant distress or impatient.

D) The duration of the disturbance is at least 6 months.

E) The disturbance is not better accounted for by another mental disorder.

F) The symptoms are not intentionally produced or feigned.

Diagnostic criteria for somatoform disorder NOS This category includes disorders that do not meet

the criteria for any specific somatoform disorder:

1) Pseudocyesis: a false belief of being pregnant that is associated with objective signs of pregnancy.

2) A disorder involving non psychotic hypochondriacal symptoms of less than 6 months duration.

3) A disorder involving unexplained physical complaints (e.g., fatigue or body weakness) of less than 6 months’ duration that are not due to another mental disorder.