Chapter 21: Somatic Symptom and Related Disorders PDF

Universidad Autónoma de Guadalajara AC Access Provided by: Current Diagnosis & Treatment: Psychiatry, 3e Chapter 21: Somatic Symptom and Related Disorders Charles V. Ford; Louis...

Universidad Autónoma de Guadalajara AC Access Provided by: Current Diagnosis & Treatment: Psychiatry, 3e Chapter 21: Somatic Symptom and Related Disorders Charles V. Ford; Louis Trevisan INTRODUCTION Diagnostic criteria for somatic symptom disorder includes one or more symptoms that are distressing or result in significant disruption of daily life, such as excessive thoughts, feelings, behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: (1) disproportionate and persistent thoughts about the seriousness of one's symptoms; (2) persistently high level of anxiety about health or symptoms; and (3) excessive time and energy devoted to these symptoms or health concerns. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). Specifiers include the following: With predominant pain (previously pain disorder); this specifier is for individuals whose somatic symptoms predominantly involve pain. Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months). Current severity is also a specifier: Mild—Only one of the symptoms specified in criterion B is fulfilled. Moderate—Two or more of the symptoms specified in Criterion B are fulfilled. Severe—Two or more of the symptoms in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom) (DSM­5). Patients who somatize psychosocial distress commonly present in medical clinical settings. Approximately 25% of patients in primary care demonstrate some degree of somatization, and at least 10% of medical or surgical patients have no evidence of a disease process. Somatizing patients use a disproportionately large amount of medical services and frustrate their physicians, who often do not recognize the true nature of these patients' underlying problems. Somatizing patients rarely seek help from psychiatrists at their own initiative, and they may resent any implication that their physical distress is related to psychological problems. Despite the psychogenic etiology of their illnesses, these patients continue to seek medical care in nonpsychiatric settings where their somatization is often unrecognized. Somatization is not an either–or proposition. Rather, many patients have some evidence of biological disease but overrespond to their symptoms or believe themselves to be more disabled than objective evidence would indicate. Medical or surgical patients who have concurrent anxiety or depressive disorders use medical services at a rate two to three times greater than that of persons with the same diseases who do not have a comorbid psychiatric disorder. Despite the illusion that somatic symptom and related disorders are specific entities, as is implied by the use of specific diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM­5), the symptoms most of these patients experience fail to meet the diagnostic criteria of the formal somatic symptom disorder. Further, over time, patients' symptoms tend to be fluid, and patients may be best described as having one disorder at one time and another disorder at some other time. Somatization is caused or facilitated by numerous interrelated factors, and for an individual patient a particular symptom may have multiple etiologies. In other words, these disorders are heterogeneous both in clinical presentation and in etiology. Somatic symptom and related disorders are generally multidetermined, and because they represent final common symptomatic pathways of many etiologic factors, each patient must be evaluated carefully so that an individualized treatment plan can be developed (see Table 21–1). Table 21–1 Causes of Somatization Illness allows a socially isolated person access to an auxiliary social support system. The sick role can be used as a rationalization of failures in occupation, social, or sexual roles. Illness can be a means of obtaining nurturance. Illness can be used as a source of power to manipulate other people or social situations. Somatic symptoms may be used as a communication or as a cry for help. Downloaded 2024­10­28 The somatic symptoms11:16 A Your of certain IP is psychological disorders (e.g., major depression and panic disorder) may be incorrectly attributed to physical disease. Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 1 / 17 Because physical illness is less stigmatizing than psychiatric illness, many patients prefer to attribute psychological symptoms to physical causes. ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Some individuals may be hypersensitive to somatic symptoms and amplify them. Such hypersensitivity is often related to concurrent emotions such as depression and anxiety. factors, and for an individual patient a particular symptom may have multiple etiologies. In other words, these disorders are heterogeneous both in clinical presentation and in etiology. Universidad Autónoma de Guadalajara AC Access Provided by: Somatic symptom and related disorders are generally multidetermined, and because they represent final common symptomatic pathways of many etiologic factors, each patient must be evaluated carefully so that an individualized treatment plan can be developed (see Table 21–1). Table 21–1 Causes of Somatization Illness allows a socially isolated person access to an auxiliary social support system. The sick role can be used as a rationalization of failures in occupation, social, or sexual roles. Illness can be a means of obtaining nurturance. Illness can be used as a source of power to manipulate other people or social situations. Somatic symptoms may be used as a communication or as a cry for help. The somatic symptoms of certain psychological disorders (e.g., major depression and panic disorder) may be incorrectly attributed to physical disease. Because physical illness is less stigmatizing than psychiatric illness, many patients prefer to attribute psychological symptoms to physical causes. Some individuals may be hypersensitive to somatic symptoms and amplify them. Such hypersensitivity is often related to concurrent emotions such as depression and anxiety. Somatic symptoms can represent behavior learned in childhood, in that some parenting styles may emphasize attention to illness. The sick role can provide incentives such as disability payments, the avoidance of social responsibilities, and solutions to intrapsychic conflicts. Trauma, particularly childhood physical or sexual abuse, appears to predispose individuals to the use of somatic symptoms as a communication of psychosocial distress. Physicians can inadvertently reinforce the concept of physical disease by symptomatic treatment or through so­called fashionable diagnoses, such as multiple chemical sensitivities or reactive hypoglycemia. Barsky AJ, Ettner SL, Horsky J, et al. Resource utilization of patients with hypochondriacal health anxiety and somatization. Med Care. 2001;39:705– 715. [PubMed: 11458135] Ford C. Somatization and fashionable diagnoses: Illness as a way of life. Scand J Work Environ Health. 1997;3(23 suppl):7–16. FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER The diagnostic criteria for conversion disorder (functional neurological symptom disorder) include: One or more symptoms of altered voluntary motor or sensory function. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. The symptom or deficit is not better explained by another medical or mental disorder. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. Specify symptom type: With weakness or paralysis, with abnormal movement, with swallowing symptoms, with speech symptoms, with attacks or seizures, with anesthesia or sensory symptoms. One also needs to specify: Acute episode or persistent. With psychological stressor or without psychological stressor (DSM­5). General Considerations Functional neurological symptom disorder, previously known as conversion disorder and prior to that known as hysteria or hysterical conversion reaction, is an ancient medical diagnosis, described in both the Egyptian and Greek medical literature. Although often thought to have disappeared with the Victorian age, these disorders continue to the present, but often with more subtlety and sophisticated mimicry than characterized by the dramatic symptoms of the past. A. Epidemiology The reported incidence of conversion symptoms varies widely depending on the populations studied. The lifetime incidence of conversion disorder in women is approximately 33%; however, most of these symptoms remit spontaneously, and the incidence in tertiary­care settings is considerably lower. The incidence in men is unknown. Patients with conversion symptoms comprise 1–3% of patients seen by neurologists. Functional neurologic symptom disorder is diagnosed in 5–10% of hospitalized medical or surgical patients who are referred for psychiatric consultation. Functional neurologic symptom disorder symptoms occur in all age ranges from early childhood to advanced age. The disorder occurs with an approximately equal frequency in prepubertal boys and girls, but it is diagnosed much more frequently in adult women than in men. Downloaded 2024­10­28 11:16 A Your IP is Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 2 / 17 Functional neurologic symptom disorder symptoms appear to occur more frequently in people of lower intelligence, in those with less education or ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility less social sophistication, and in those with any condition or situation in which verbal communication may be impeded. The reported incidence of conversion symptoms varies widely depending on the populations studied. The lifetime incidence of conversion disorder in women is approximately 33%; however, most of these symptoms remit spontaneously, and the incidence inUniversidad tertiary­careAutónoma settings is de Guadalajara considerably AC lower. The incidence in men is unknown. Patients with conversion symptoms comprise 1–3% of patients seen by neurologists. Functional neurologic Access Provided by: symptom disorder is diagnosed in 5–10% of hospitalized medical or surgical patients who are referred for psychiatric consultation. Functional neurologic symptom disorder symptoms occur in all age ranges from early childhood to advanced age. The disorder occurs with an approximately equal frequency in prepubertal boys and girls, but it is diagnosed much more frequently in adult women than in men. Functional neurologic symptom disorder symptoms appear to occur more frequently in people of lower intelligence, in those with less education or less social sophistication, and in those with any condition or situation in which verbal communication may be impeded. B. Etiology Some authors have viewed conversion as more of a symptom than a diagnosis, with the implication that another underlying psychiatric disorder is usually present. It is likely that conversion is heterogeneous and that for some patients there is more than one cause. Among proposed etiologies are suggestions that the symptoms resolve an intrapsychic conflict expressed symbolically through a somatic symptom. For example, a person with a conflict over anger may experience paralysis of the right arm. Interpersonal issues have also been implicated. That is, the symptom may manipulate the behavior of other persons and elicit attention, sympathy, and nurturance. Functional neurologic symptom disorder often follows a traumatic event and may be a psychological mechanism evoked to cope with acute stress. Conversion or functional neurologic symptom disorder symptoms are frequently found in patients receiving treatment on neurologic services and in patients with cerebral dysfunction. It seems likely that underlying neurologic dysfunction facilitates the emergence of conversion symptoms, perhaps as a result of impairment in the patient's ability to articulate distress. Functional neurologic symptom disorder may also be viewed as a learned behavior. For example, a person who has genuine epileptic convulsions may learn that seizures have a profound effect on others and may develop pseudoseizures. In this case, the individual may have both genuine epileptic seizures and pseudoseizures, and distinguishing between the two may be difficult. Current theories about the etiology of conversion emphasize the role of communication. People who have difficulty in verbally articulating psychosocial distress, for any reason, may use conversion symptoms as a way of communicating their distress. C. Genetics According to one nonreplicated Scandinavian study, relatives of patients with conversion disorder were at much higher risk for conversion symptoms. Polygenic transmission was proposed. Clinical Findings A. Signs & Symptoms A functional neurologic symptom disorder symptom, by definition, mimics dysfunction in the voluntary motor or sensory system. Common symptoms include pseudoseizures, vocal cord dysfunction (e.g., aphonia), blindness, tunnel vision, deafness, and a variety of anesthesias and paralyses. On careful clinical examination and with the aid of laboratory investigations, these symptoms prove to be nonphysiologic. A clinical example is the presence of normal deep tendon reflexes in a person with a "paralyzed" arm. Contrary to popular belief, patients with functional neurologic symptom disorder may be depressed or anxious about the symptom. Some phenomena that have traditionally been associated with conversion, such as symbolism, la belle indifference (an inappropriate lack of concern for the disability), and histrionic personality, do not reliably differentiate conversion from physical disease. B. Psychological Testing Psychological tests often demonstrate comorbid psychiatric illness associated with tendencies to deny or repress psychological distress. A characteristic finding on the Minnesota Multiphasic Personality Inventory­2 (MMPI­2) is the presence of the "conversion V," in which the hypochondriasis and hysteria scales are elevated above the depression scale, forming a "V" in the profile. However, such a finding is not pathognomonic for conversion. C. Laboratory Findings Most functional neurologic symptom disorder symptoms are, by definition, pseudoneurologic. Laboratory examinations, such as nerve conduction speed, electromyograms, and visual and auditory evoked potentials, demonstrate that the sensory and nervous system is intact despite the clinical symptoms. Simultaneous Downloaded 2024­10­28 electromyographic 11:16 A Your IP isand video recording of a patient with pseudoseizures can be diagnostic when the patient has epileptic­ like movements Chapter while Symptom 21: Somatic the simultaneous electroencephalogram and Related (EEG) Disorders, Charles tracing V. Ford; demonstrates Louis Trevisan normal electrical activity in the brain. Page 3 / 17 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility D. Neuroimaging pathognomonic for conversion. Universidad Autónoma de Guadalajara AC C. Laboratory Findings Access Provided by: Most functional neurologic symptom disorder symptoms are, by definition, pseudoneurologic. Laboratory examinations, such as nerve conduction speed, electromyograms, and visual and auditory evoked potentials, demonstrate that the sensory and nervous system is intact despite the clinical symptoms. Simultaneous electromyographic and video recording of a patient with pseudoseizures can be diagnostic when the patient has epileptic­ like movements while the simultaneous electroencephalogram (EEG) tracing demonstrates normal electrical activity in the brain. D. Neuroimaging Consistent with observations that conversion symptoms are more likely to involve the nondominant side of the body is the finding that the majority of functional neurologic symptom disorder patients have unilateral right hemisphere structural or physiological abnormalities demonstrated by neuroimaging. Functional neuroimaging has demonstrated decreased activity in cortex and subcortical circuits, reflecting cerebral representation of peripheral symptoms (e.g., decreased activation of visual cortex during "hysterical" blindness). These decreases have been frequently shown to be associated with concurrent activation in limbic regions such as the cingulate or orbitofrontal cortex. In general, there appears to be similarity of functional neuroimaging findings of conversion disorder and hypnosis. E. Course of Illness Most functional neurologic symptom disorder symptoms remit quickly, often spontaneously. They are frequently transient reactions to acute psychosocial stressors. Prolonged symptoms are generally associated with environmental reinforcers (e.g., the symptom provides a solution to a chronic family conflict and/or disability payments). Conversion symptoms, either similar to the original symptoms or a new symptom, may occur with recurrence of stressors. This is particularly true with pseudoseizures. Differential Diagnosis (Including Comorbidity) The differential diagnosis of conversion disorder always involves the possibility of physical disease. Even when conversion is obvious, the patient may have underlying neurologic or other disease that he or she has unconsciously amplified or elaborated. Malingering must also be considered. The primary difference between malingering and conversion is that the degree of conscious motivation is higher in malingering. Systematic studies of conversion disorder suggest that it is often accompanied by other psychiatric disorders. Depression is common; and schizophrenia has also been reported, though rarely. Patients with functional neurologic symptom disorder may be responding to overwhelming environmental stressors that they cannot articulate, such as concurrent sexual or physical abuse or the feeling of being overwhelmed with responsibilities. Dissociative syndromes are also often associated with conversion, particularly pseudoseizures (which are regarded by some clinicians as dissociative episodes). Some clinicians have proposed that dissociative disorders and conversion disorders involve the same mechanisms: dissociation reflects mental symptoms and conversion represents somatic symptoms. Functional neurologic symptom disorder is grouped with the dissociative disorders in International Classification of Disease, 10th edition (ICD­10). Treatment The treatment of functional neurologic symptom disorder is often multimodal and varies according to the acuteness of the symptom. If the symptom is acute, symptom relief often occurs spontaneously or with suggestive techniques. If the symptom is chronic, it is often being reinforced by factors in the patient's environment; therefore, behavioral modification techniques are necessary. A. Psychopharmacologic Interventions There are no specific psychopharmacologic interventions for functional neurologic symptom disorder. However, when comorbid conditions are identified (e.g., depression), these conditions must be treated with the appropriate medications. B. Psychotherapeutic Interventions Acute conversion symptoms may, on occasion, respond to insight­oriented psychotherapy techniques. On the whole, insight­oriented therapies have not been effective for chronic conversion symptoms, which generally require behavioral modification for symptom relief. Behavioral therapy can be offered in the context of physical or speech therapy, and this offers the patient a face­saving mechanism by which he or she can gradually discard the symptoms. Patients also receive positive reinforcement for symptomatic improvement and are ignored, to avoid reinforcement, at times of symptom expression. C. Other Interventions Downloaded 2024­10­28 11:16 A Your IP is Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 4 / 17 An acute conversion symptom may remit with suggestions through hypnosis or by the use of an Amytal (or lorazepam) interview that creates an altered ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility state of consciousness. Such techniques may be useful in determining underlying psychological stressors, but caution must be exercised so that patients do not incorporate the interviewer's suggestions as a part of their own history. not been effective for chronic conversion symptoms, which generally require behavioral modification for symptom relief. Behavioral therapy can be Universidad Autónoma de Guadalajara AC offered in the context of physical or speech therapy, and this offers the patient a face­saving mechanism by which he or she can gradually discard the Access Provided by: symptoms. Patients also receive positive reinforcement for symptomatic improvement and are ignored, to avoid reinforcement, at times of symptom expression. C. Other Interventions An acute conversion symptom may remit with suggestions through hypnosis or by the use of an Amytal (or lorazepam) interview that creates an altered state of consciousness. Such techniques may be useful in determining underlying psychological stressors, but caution must be exercised so that patients do not incorporate the interviewer's suggestions as a part of their own history. D. Environmental Manipulation When the conversion symptom represents "a cry for help" because of environmental pressures, it may be necessary to manipulate these stressors in order to produce symptomatic relief. For example, the pseudoseizures of a teenage girl might be a cry for help because she is involved in an incestuous relationship with her stepfather. Obviously, symptom relief will require attention to the sexual abuse. E. Treatment of Comorbid Disorders When identified, comorbid disorders must be treated concurrently. Conversion symptoms may respond, for example, to treatment for an underlying depression. Complications/Adverse Outcomes of Treatment Remission, with treatment of a conversion symptom, does not rule out the possibility that the patient has an underlying physical disease to which he or she was reacting with exaggeration or elaboration. Thus each patient must receive a careful medical evaluation. Conversely, a failure to consider conversion disorder and to continue to provide treatment as though the patient has a physical disease reinforces the symptom and can lead to permanent invalidism. Prognosis Most conversion symptoms remit quickly; those that persist are often associated with environmental reinforcers and are more resistant to treatment. Factors associated with a good prognosis are symptoms precipitated by stressful events, good premorbid psychological health, and the absence of comorbid neurologic or psychiatric disorders. In the past, an underlying neurologic disease would later emerge in about 25% of patients. However, at the present, with more sophisticated neurologic diagnostic tests, the subsequent emergence of previously undetected neurologic disease is uncommon. Ford CV. Conversion disorder and somatoform disorder not otherwise specified. In: Gabbard GO, ed. Treatment of Psychiatric Disorders. 3rd ed. Washington, DC: American Psychiatric Press; 2001:1755–1776. Varilleunier P. Hysterical conversion and brain function. In: Laureys S, ed. Progress in Brain Research , Vol 150. Amsterdam: Elsevier; 2005;309–329. SOMATIC SYMPTOM DISORDER The DSM­5 diagnostic criteria for somatic symptom disorder are listed at the beginning of this chapter. The majority (about 75%) of patients previously diagnosed with hypochondriasis as well as somatization disorder would now be diagnosed under this grouping. The rest of the grouping makes up the DSM­5 illness anxiety disorder (see next section). General Considerations The syndrome of multiple unexplained physical symptoms was traditionally known as "hysteria" or "grand hysteria." It also received the eponym "Briquet's syndrome" for a brief time before being defined and renamed Somatization Disorder by the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM­III) in 1980. There have been repeated efforts to refine diagnostic criteria, but recent phenomenological studies indicate that there is considerable overlap with hypochondriasis. A. Epidemiology Downloaded 2024­10­28 11:16 A Your IP is Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 5 / 17 Reports of the incidence ©2024 McGraw of somatic Hill. All Rights symptomTerms Reserved. disorder in the of Use generalPolicy Privacy population vary Accessibility Notice widely, depending on the populations studied and the techniques used. According to the Epidemiologic Catchment Area (ECA) studies, the incidence of somatization disorder is 0.1–0.4%. However, in one investigation of an academic family practice, 5% of patients met criteria for somatization disorder. A similarly high incidence has been demonstrated The syndrome of multiple unexplained physical symptoms was traditionally known as "hysteria" or "grand hysteria." It also received the eponym Universidad Autónoma de Guadalajara AC "Briquet's syndrome" for a brief time before being defined and renamed Somatization Disorder by the Diagnostic and Statistical Manual of Mental Access Provided by: Disorders, third edition (DSM­III) in 1980. There have been repeated efforts to refine diagnostic criteria, but recent phenomenological studies indicate that there is considerable overlap with hypochondriasis. A. Epidemiology Reports of the incidence of somatic symptom disorder in the general population vary widely, depending on the populations studied and the techniques used. According to the Epidemiologic Catchment Area (ECA) studies, the incidence of somatization disorder is 0.1–0.4%. However, in one investigation of an academic family practice, 5% of patients met criteria for somatization disorder. A similarly high incidence has been demonstrated for hospitalized medical or surgical patients. Of note, most patients with somatization disorder are not diagnosed as such, and because of their "doctor­shopping" behavior they see multiple physicians, often simultaneously. The prevalence of undifferentiated somatoform disorder (the subsyndromal form of the disorder) is much higher than that of somatization disorder and may affect as much as 4–11% of the general population. Individuals who meet the full criteria for somatization disorder tend to be female, unmarried, nonwhite, poorly educated, and from rural areas. B. Etiology There are no well­accepted theories as to the etiology of somatization disorder. Patients with this disorder often come from chaotic, unstable, and dysfunctional families in which alcohol was abused. These patients often use physical symptoms as a coping mechanism. The high rate of psychiatric comorbidity associated with somatization disorder suggests that the disorder may represent a common final symptomatic pathway for different psychiatric problems, particularly major depression and personality disorder. C. Genetics The evidence for a genetic influence in the development of somatization disorder is limited but suggestive of a common genetic tendency associated with criminality. Women are more likely to express this genetic tendency as somatization disorder, and men more likely to express it as antisocial personality disorder. It is difficult to delineate precise genetic mechanisms in the face of massive environmental influences. Clinical Findings A. Signs & Symptoms Patients with somatic symptom disorder, by definition, present to physicians with multiple unexplained physical symptoms. These presentations are often accompanied by a sense of urgency. Thus, these patients are subjected to numerous invasive diagnostic or treatment procedures. Symptoms are multisystemic in nature and frequently involve chronic pelvic pain, atypical facial pain, and nonspecific subjective complaints such as dizziness. Medical care costs for these patients may run as high as two to eight times that of age­matched control subjects. Patients with somatization disorder also have a number of psychological symptoms, including depression, anxiety, suicidal gestures, and substance abuse. They may be addicted to prescribed medications, and at times they may exhibit drug­seeking behaviors. B. Psychological Testing There are no specific psychological tests for somatization disorder, but patients with this disorder usually score high on MMPI­2 scales 1 (hypochondriasis) and 3 (hysteria) and on the somatization scale of the Symptom Check List­90, revised version. Because of high comorbidity (see later discussion), psychological testing is not consistent for the group as a whole. C. Laboratory Findings There are no specific laboratory findings for somatization disorder. The diagnosis is based on a lack of objective evidence to substantiate physical disease. D. Neuroimaging Studies reporting neuroimaging results in patients with somatic symptom disorder have been inconsistent, suggesting that somatic symptom disorder is a poorly defined disorder that may be the final common symptomatic pathway of several different underlying psychiatric disorders. E. Course of Illness These patients, by definition, develop multiple unexplained physical symptoms beginning in adolescence or early adulthood. Symptomatic Downloaded presentation, 2024­10­28 which can be11:16 quiteAdramatic, Your IP is is frequently associated with concurrent psychosocial stressors. The number and intensity of symptoms Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 6 / 17 may wax and wane over time, but rarely does a year or two pass without some symptomatic complaints. These patients characteristically undergo ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility numerous invasive diagnostic and therapeutic procedures that, in retrospect, had vague indications. Somatization disorder frequently persists into late life. Studies reporting neuroimaging results in patients with somatic symptom disorder have been inconsistent, suggesting that somatic symptom disorder Universidad Autónoma de Guadalajara AC is a poorly defined disorder that may be the final common symptomatic pathway of several different underlying psychiatric disorders. Access Provided by: E. Course of Illness These patients, by definition, develop multiple unexplained physical symptoms beginning in adolescence or early adulthood. Symptomatic presentation, which can be quite dramatic, is frequently associated with concurrent psychosocial stressors. The number and intensity of symptoms may wax and wane over time, but rarely does a year or two pass without some symptomatic complaints. These patients characteristically undergo numerous invasive diagnostic and therapeutic procedures that, in retrospect, had vague indications. Somatization disorder frequently persists into late life. Differential Diagnosis (Including Comorbidity) Organic physical disease is always part of the differential diagnosis for these multisymptomatic patients who often carry poorly documented diagnoses of systemic diseases (e.g., systemic lupus erythematosus). Many of these patients have received one or more "fashionable diagnoses" such as fibromyalgia, dysautonomia, chronic fatigue syndrome, or total allergy syndrome. Few physicians have the means or the energy to make complete reviews of these patients' medical records, but such reviews generally fail to demonstrate objective evidence for any of these diagnoses. Patients with somatic symptom disorder almost always have one or more comorbid Axis I psychiatric diagnoses and almost always meet criteria for at least one personality disorder. Despite the multiplicity of psychiatric signs and symptoms, and a medical history of multiple unexplained physical complaints, patients with somatic symptom disorder are often unrecognized. Treatment Patients with somatic symptom disorder perceive themselves as being medically ill and are unlikely to seek psychiatric care for their distress. They may resent any implication that their problems are psychogenic and may reject referrals for psychiatric treatment. Thus the primary management of these patients falls on the primary care physician and his or her capability to coordinate care with multiple medical specialists. A. Psychopharmacologic Interventions There is no specific psychopharmacologic treatment for somatic symptom disorder. These patients do, however, frequently suffer from comorbid psychiatric disorders such as panic disorder or depression, which should be appropriately treated (see Chapters 17 and 18). B. Psychotherapeutic Interventions The provision of group experiences, particularly those that are supportive rather than insight­oriented, may significantly reduce medical care utilization. Group support allows these patients to feel socially connected and reduces their need to reach out to the medical system for assistance. C. Management Principles Primary care physicians can use several simple management techniques to significantly lower medical care utilization by patients with somatization disorder. These principles include the following: (1) schedule frequent appointments without requiring development of a new symptom, (2) avoid statements that the symptoms are "all in your head," (3) undertake invasive diagnostic or therapeutic procedures only if objective signs or symptoms are present, and (4) prescribe all medications and coordinate medical care. Complications/Adverse Outcomes of Treatment Patients with somatic symptom disorder are at risk for iatrogenic complications of invasive or therapeutic procedures (e.g., peritoneal adhesions resulting from multiple abdominal operations). Habituation to prescribed analgesics or anxiolytics also occurs frequently. Clinicians must exercise caution when prescribing any potentially lethal medication for these patients because they are prone to impulsive acting­out behaviors including suicide attempts. Conversely, an approach that is too confrontational about the basic psychological issues underlying the medical care–seeking behaviors may motivate these patients to find a physician who is less psychologically minded and more accommodating to requests for medications and operations. Prognosis Somatic symptom disorder is a chronic problem that continues throughout the patient's life. Management principles are aimed at reducing symptoms and containing medical care costs, not at cure. These patients frequently experience iatrogenic complications from medications and surgical Downloaded 2024­10­28 procedures. However, one11:16 A Your long­term IP found study is no evidence of reduced longevity, which suggests that these patients do not have any underlying Chapter 21: Somatic biological disease. Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 7 / 17 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Fink P, Rosendal M, Toft T. Assessment and treatment of functional disorders in general practice: The extended reattribution and management and operations. Universidad Autónoma de Guadalajara AC Access Provided by: Prognosis Somatic symptom disorder is a chronic problem that continues throughout the patient's life. Management principles are aimed at reducing symptoms and containing medical care costs, not at cure. These patients frequently experience iatrogenic complications from medications and surgical procedures. However, one long­term study found no evidence of reduced longevity, which suggests that these patients do not have any underlying biological disease. Fink P, Rosendal M, Toft T. Assessment and treatment of functional disorders in general practice: The extended reattribution and management model—an advanced educational program for non­psychiatric doctors. Psychosomatics. 2002;43:93–131. [PubMed: 11998587] Mai F. Somatization disorder: A practical review. Can J Psychiatry. 2004;49:652–662. [PubMed: 15560311] ILLNESS ANXIETY DISORDER The diagnostic criteria for illness anxiety disorder (as a minority of hypochondriasis cases are now classified) include a preoccupation with having or acquiring a serious illness. The somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or if there is a high risk for developing a medical condition (e.g., if a strong family history is present), the preoccupation is clearly excessive or disproportionate. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. The individual performs excessive health­related behaviors (e.g., repeatedly checks self for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor's appointments and hospitals). Illness­related preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time. The illness­related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive–compulsive disorder, or delusional disorder, somatic type. Specifiers include care­seeking type and care­avoidant type. General Considerations Hypochondriasis, which literally means "below the cartilage," reflects the abdominal symptoms and concerns of these patients. Hypochondriasis was once considered to be the male equivalent of "hysteria," but it is now recognized as having equal gender distribution. Recent phenomenological research suggests that there is considerable overlap between somatic symptom disorder and illness anxiety disorder. A. Epidemiology The incidence of illness anxiety disorder in the general population is not known. The typical age at onset is young adulthood, and the disorder occurs with an approximately equal frequency in men and women. Contrary to popular belief, it is not more prevalent among the elderly. Transient hypochondriasis frequently follows acute illness or injury and may be viewed as a normal hypervigilant scanning of bodily functions for detection of further injury. B. Etiology Illness anxiety disorder has been interpreted from a psychodynamic perspective as the turning inward of unacceptable feelings of anger. An alternative explanation is that hypochondriasis is learned behavior resulting from a childhood in which family members were excessively preoccupied with illness and bodily functions. Other proposed etiologies include the view that hypochondriasis is a form of depression or obsessive–compulsive disorder (OCD), with a symptomatic focus on bodily function. Illness anxiety disorder is likely a multi­determined disorder. C. Genetics Illness anxiety disorder is a familial disorder, but there is no direct evidence of genetic input. The increased incidence in family members can be explained on the basis of learned behavior or the indirect influence of psychiatric disorders that do have genetic input (e.g., major depression) and that occur in both the patient and family members. Clinical Findings A. Signs & Symptoms Downloaded 2024­10­28 The illness anxiety 11:16 disordered A Your patient IP is presents with fear and concern about disease rather than with dramatic symptoms. The fears may typically Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 8 / 17 emanate from the ©2024 McGraw misinterpretation Hill. of normal All Rights Reserved. bodily Terms sensations. of Use Sensations Privacy regarded Policy Notice as normal aches and pains by most people are interpreted by Accessibility the hypochondriacal patient as evidence of serious disease. The Illness anxiety disordered patient characteristically relates his or her history in an obsessively detailed manner, often with relatively little affect. These patients tend to be emotionally constricted and are limited in their social, that occur in both the patient and family members. Universidad Autónoma de Guadalajara AC Clinical Findings Access Provided by: A. Signs & Symptoms The illness anxiety disordered patient typically presents with fear and concern about disease rather than with dramatic symptoms. The fears may emanate from the misinterpretation of normal bodily sensations. Sensations regarded as normal aches and pains by most people are interpreted by the hypochondriacal patient as evidence of serious disease. The Illness anxiety disordered patient characteristically relates his or her history in an obsessively detailed manner, often with relatively little affect. These patients tend to be emotionally constricted and are limited in their social, occupational, and sexual functions. Many hypochondriacal patients keep their own personal medical records. They often own the Physicians' Desk Reference or the Merck Manual. They feel transient relief when reassured that they do not have serious disease but, within hours or days, begin to obsessively doubt that assurance and may return for another visit. B. Psychological Testing Psychological testing (e.g., the MMPI­2) generally demonstrates a preoccupation with somatic symptoms in association with underlying depression and anxiety. C. Laboratory Findings No laboratory findings are diagnostic of illness anxiety disorder. The diagnosis is often made by exclusion when all tests for physical diseases are normal. D. Neuroimaging There are no reported studies of neuroimaging of patients with illness anxiety disorder. E. Course of Illness Illness anxiety disorder is a condition that characteristically begins in early adulthood and continues to late life. Symptoms wax and wane and symptomatic exacerbation may occur at times of occupational or interpersonal stress, with learning about an acquaintance's illness, or reading about a disease in a magazine. Worry or concern about relatively minor symptoms such as those associated with irritable bowel syndrome may escalate into an obsessional conviction of having a malignancy. At times, the patient may become so preoccupied with disease fears/conviction that interpersonal relationships are adversely effected. Interestingly, these patients often handle genuine physical disease in an appropriate and realistic manner. Differential Diagnosis (Including Comorbidity) The hypochondriacal patient must be reevaluated continually for the possibility that physical disease may underlie each new symptomatic complaint. Hypochondriacal patients may have concurrent relatively benign polysymptomatic illnesses that they interpret as evidence of more severe disease. They also have a higher prevalence of major depression, panic disorder, and OCD than is expected for the general population. These patients may interpret the physiologic symptoms of major depression or panic disorder as evidence of disease. Treatment Treatment of illness anxiety disorder falls predominantly to the primary care physician to whom these patients repeatedly return; hypochondriacal patients see their problems as medical, not psychiatric. Although some patients ultimately accept referral to a psychiatrist, premature referral may destroy rapport and make management more difficult. A. Psychopharmacologic Interventions Symptomatic improvements of hypochondriacal symptoms have been demonstrated after administration of selective serotonin reuptake inhibitors (SSRIs). This is independent of the effects of treating comorbid psychiatric illness and suggests the possibility that, at least for some patients, hypochondriasis may be a subtype of OCD. B. Psychotherapeutic Interventions Illness anxiety disorder patients are usually not good candidates for traditional insight­oriented psychotherapy because they tend to be alexithymic (unable to express feelings in words). However, a recently developed psychotherapeutic intervention based on the principles of cognitive–behavioral Downloaded 2024­10­28 11:16 A Your IP is therapy (CBT) Chapter appearsSymptom 21: Somatic to hold promise. The approach and Related Disorders, is based CharlesonV. theFord; provision Louisof new information, discussion, and exercises intended to Page Trevisan modulate 9 / 17 ©2024 the McGraw sensations ofHill. All Rights benign bodily Reserved. Terms discomfort that are of dueUseto normal Privacy Policy Notice physiology and to help Accessibility patients reattribute these sensations to their appropriate cause rather than to fears of serious illness. This combined behavioral intervention can be used by the primary care physician or by staff working within the medical setting. hypochondriasis may be a subtype of OCD. Universidad Autónoma de Guadalajara AC Access Provided by: B. Psychotherapeutic Interventions Illness anxiety disorder patients are usually not good candidates for traditional insight­oriented psychotherapy because they tend to be alexithymic (unable to express feelings in words). However, a recently developed psychotherapeutic intervention based on the principles of cognitive–behavioral therapy (CBT) appears to hold promise. The approach is based on the provision of new information, discussion, and exercises intended to modulate the sensations of benign bodily discomfort that are due to normal physiology and to help patients reattribute these sensations to their appropriate cause rather than to fears of serious illness. This combined behavioral intervention can be used by the primary care physician or by staff working within the medical setting. Group therapy techniques can also meet these patients' needs for relationships and can be a vehicle by which cognitive–behavioral approaches are used to modify these patients' illness behavior. C. Treatment of Comorbid Disorders Illness anxiety disorder is often accompanied by depression, anxiety, or OCD. When one or more of these disorders are present, appropriate treatment should be initiated. Hypochondriacal patients tend to be inordinately sensitive to medication side effects. They continually scan their bodies in a hypervigilant fashion for bodily sensations. It is often necessary to initiate pharmacologic treatment with very low dosages—while encouraging the patient to tolerate side effects—and then to gradually increase the dosage into the therapeutic range as tolerated. D. Management Principles Within the primary care setting, patients should be seen at regularly scheduled intervals. Each new complaint or worry should be accompanied by a limited evaluation to ensure that it does not represent the development of organic disease. Invasive procedures should not be undertaken without clear indication. The doctor–patient relationship should be warm, trusting, and empathetic and should gradually enable these patients to express their emotional feelings more openly. Complications/Adverse Outcomes of Treatment Failure to recognize illness anxiety disorder may result in needless expense due to exhaustive medical evaluation. Purely medical management may reinforce the symptoms, and iatrogenic complications may result from unneeded invasive procedures. Prognosis Illness anxiety disorder is characterized by a chronic fluctuating course. With few exceptions, cure is not to be anticipated for these long­term patients. Patients whose illness anxiety disorder is related to a defined depressive episode or to panic disorder often experience a significant relief of hypochondriacal symptoms when the comorbid condition is treated effectively. A few patients with more severe chronic comorbid depression or OCD will deteriorate; some become invalids for life. Patients with good premorbid psychological health who demonstrate transient hypochondriasis in response to acute illness or life stress have a good prognosis and may show complete remission of symptoms. Barsky AJ, Ahern DK. Cognitive behavioral therapy for hypochondriasis: A randomized controlled trial. JAMA. 2004;291:1464–1470. [PubMed: 15039413] Creed F, Barsky F. A systematic review of the epidemiology of somatization disorder and hypochondriasis. J Psychosom Res. 2004;56:391–408. [PubMed: 15094023] Margariños M, Zafar U, Nessenson K, Blanco C. Epidemiology and treatment of hypochondriasis. CNS Drugs. 2002;16:9–22. [PubMed: 11772116] BODY DYSMORPHIC DISORDER Body dysmorphic disorder is now listed in DSM­5 under Obsessive–Compulsive and Related Disorders. The diagnostic criteria include the following: Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that or others) in response to the appearance concerns. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The appearance Downloaded 2024­10­28 11:16 A Your IP is preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for anPage eating Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan 10 / 17 disorder. Specifiers include the following: With muscle dysmorphia : The individual is preoccupied ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case. Also specify: With good insight or fair insight, With poor insight, or With absent insight/delusional beliefs. Body dysmorphic disorder is now listed in DSM­5 under Obsessive–Compulsive and Related Disorders. TheUniversidad Autónoma diagnostic criteria de the include Guadalajara following:AC Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. At some point Access Provided by: during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that or others) in response to the appearance concerns. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder. Specifiers include the following: With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case. Also specify: With good insight or fair insight, With poor insight, or With absent insight/delusional beliefs. General Considerations Dysmorphophobia was originally described in the nineteenth century and has been regarded as closely related to other monosymptomatic hypochondriacal disorders (e.g., delusions of bromosis). It was first included in the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM­III­R) in 1987. Patients with body dysmorphic disorders (BDD) are characterized by their preoccupations with perceived defects in appearance—"imagined ugliness" (a term coined by K. A. Phillips in 1991). A. Epidemiology Studies in the general population have found an incidence of BDD in the range of 1–5%. However, there are higher rates among dermatology and cosmetic surgery patients. There is probably a dimensional rather than a categorical quality to BDD that ranges from relatively normal concern with one's body (in a society preoccupied with appearance) to a delusional intensity to the preoccupation that becomes totally incapacitating. Of those individuals who present for clinical attention, there is a roughly equal distribution between men and women. Most patients are 20–40 years old. A high percentage of these patients have never married or are unemployed. B. Etiology Theories of the etiology of body BDD are closely tied to issues of comorbidity (see later section). Many clinicians believe that BDD is a part of obsessive– compulsive spectrum of disorders but it is also closely related to social anxiety disorder and major depression. Cultural values that emphasize personal appearance may also contribute to the development of BDD. C. Genetics No studies have reported evidence for a genetic influence in the development of BDD. Clinical Findings A. Signs & Symptoms Patients with BDD are most commonly preoccupied with hair or facial features such as the shape of the nose. Other parts of the body such as breasts or genitalia can also be the source of preoccupation. For example, a man may become preoccupied with the size of his penis. Patients may spend hours each day gazing in a mirror or other reflective surfaces. Fears of humiliation, because of the imagined defect, may cause these patients to become housebound, unable to use public transportation or attend social functions or work. These patients may visit physicians multiple times seeking treatment, particularly surgical intervention to correct defects that are imperceptible to the normal observer. Most patients with BDD spend considerable time, hours per day, in repetitive behaviors attempting to improve or hide the perceived defect. These behaviors may include attempts to camouflage the defect such as engaging in excessive grooming or behaviors such as picking at the skin. Patients with BDD, on the whole, have little insight into their condition, and a considerable proportion can be described as delusional. B. Psychological Testing One simple screening question, "Are you concerned about your appearance?" may lead to other questions that confirm the diagnosis. Psychological testing such as the MMPI­2 or projective testing can help determine the presence of comorbid disorders. Tests may indicate depression, OCD, social phobia, or an underlying psychotic process. C. Laboratory Findings No specific laboratory Downloaded findings 2024­10­28 11:16establish A Your aIPdiagnosis is of BDD. Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 11 / 17 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility D. Neuroimaging One study using single­photon emission computed tomography (SPECT) demonstrated a broad range of findings that did not support the view of BDD One simple screening question, "Are you concerned about your appearance?" may lead to other questions that confirm the diagnosis. Psychological testing such as the MMPI­2 or projective testing can help determine the presence of comorbid disorders. Tests may indicate Universidad depression, Autónoma OCD, social AC de Guadalajara phobia, or an underlying psychotic process. Access Provided by: C. Laboratory Findings No specific laboratory findings establish a diagnosis of BDD. D. Neuroimaging One study using single­photon emission computed tomography (SPECT) demonstrated a broad range of findings that did not support the view of BDD as being in either the obsessive–compulsive disorder (OCD) or major depressive disorder (MDD) spectrum of disorders. It did, however, suggest some involvement of parietal regions, consistent with cerebral areas involved in facial recognition. E. Course of Illness Patients generally have the onset of BDD in adolescence. In the more extreme forms it is associated with complete social withdrawal and a high incidence of suicide. Because of the pain from their imagined ugliness, persons with BDD are highly impaired in interpersonal relationships and their occupations; often unable to work because they are housebound. They frequently seek multiple consultations from dermatologists or plastic surgeons. The course of BDD is chronic with low rates of remission even with treatment. Differential Diagnosis (Including Comorbidity) The differential diagnosis of BDD includes delusional disorder, somatic type, in which the patient has a clear­cut noninsightful distortion of reality; anorexia nervosa, in which the patient has a distorted body image and refuses to maintain body weight at or above a minimally normal weight for age and height; and gender identity disorder, in the which the patient is preoccupied with his or her body, thinking that it reflects the wrong gender (i.e., transsexualism). The large majority of patients with BDD have a comorbid psychiatric disorder, most commonly major depressive disorder, social phobia, psychotic disorders, OCD, substance use disorders, and personality disorders (most commonly cluster C). Persons with BDD have high rates of suicidal ideation and attempts. Treatment BDD can best be conceptualized as a syndrome of heterogeneous etiology rather than as a specific entity. As such, one must keep in mind the high incidence of psychiatric comorbidity and the various underlying psychiatric disorders that are manifested as a preoccupation with appearance. Many of these patients seek surgery, and the psychiatrist may be asked to render an opinion as to whether surgery is contraindicated (see later discussion). Physicians must remain alert to the increased risk of suicide in patients with BDD. A. Psychopharmacologic Interventions A serotonin reuptake inhibitor (SRI) should be the first choice as an antidepressant medication. The SRIs are of proven efficacy in treating BDD but are, as yet, an "off­label" prescription; there are no FDA­approved medications for BDD. Positive responses to SSRIs have been reported in patients, whose symptoms have a delusional intensity, lending further credence to the opinion that BDD is in the OCD spectrum of disorders. Similar to the treatment of OCD patients being treated with SRIs, treatment response for BDD may require 10–12 weeks, at relatively high dosages. B. Psychotherapeutic Interventions Cognitive–behavioral therapy (CBT) provided in either individual or group format has been demonstrated to be an effective treatment for BDD. Techniques emphasize cognitive restructuring, exposure with response prevention (e.g., exposing the perceived defect in social situations and preventing avoidance behaviors), and behavioral experiments such as empirically testing hypotheses involving dysfunctional thoughts and beliefs. There are no reports concerning psychodynamic psychotherapy, but it is unlikely that this modality would be helpful in patients with so little insight about these disorders. C. Nonpsychiatric Medical Interventions Although the majority of BDD patients seek nonpsychiatric treatment from dermatologists and cosmetic surgeons, these treatments are rarely effective and at times may worsen the disorder. Downloaded 2024­10­28 11:16 A Your IP is Chapter 21: Somatic D. Treatment SymptomConditions of Comorbid and Related Disorders, Charles V. Ford; Louis Trevisan Page 12 / 17 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Comorbid psychiatric conditions such as major depression and social phobia should be treated. about these disorders. Universidad Autónoma de Guadalajara AC Access Provided by: C. Nonpsychiatric Medical Interventions Although the majority of BDD patients seek nonpsychiatric treatment from dermatologists and cosmetic surgeons, these treatments are rarely effective and at times may worsen the disorder. D. Treatment of Comorbid Conditions Comorbid psychiatric conditions such as major depression and social phobia should be treated. Complications/Adverse Outcomes of Treatment It is important to recognize the intensity of the BDD patient's distress. These patients are at risk for suicide or the development of psychosis. Patients who receive surgical interventions are frequently displeased with the result and continue to seek further operations. Prognosis The long­term outcome of BDD is unknown. Diagnostic criteria for the disorder have been formulated relatively recently, and data are preliminary. Earlier reports on dysmorphophobia (an earlier described syndrome similar to BDD) suggest that a significant proportion of these patients develop psychotic processes and that most are severely disabled from their disorder. Suicide rates are markedly elevated. Recent reports of success in treating BDD with SSRIs may portend a more favorable long­term prognosis. Grant JE, Phillips KA. Recognizing and treating body dysmorphic disorder. Ann Clin Psychiatry. 2005;17:205–210. [PubMed: 16402752] Looper KJ, Kirmayer LJ. Behavioral medicine approaches to somatoform disorders. J Consult Clin Psychol. 2002;70:810–827. [PubMed: 12090385] Phillips KA, Pagano ME, Menaid W, Stout RL. A 12­month follow­up study on the course of body dysmorphic disorder. Am J Psychiatry. 2006;163:907– 912. [PubMed: 16648334] SOMATIC SYMPTOM DISORDER: WITH PREDOMINANT PAIN Pain disorder is no longer a separate diagnostic heading in DSM­5. It is now located under Somatic Symptom Disorder with the specifier of with predominant pain. General Considerations Somatic symptom disorder with predominant pain syndromes are categorized based on whether they are associated primarily with (1) psychological factors, (2) a general medical condition, or (3) psychological factors and a general medical condition. The second categorization is not considered to be a mental disorder but is related to the differential diagnosis. This classification of pain appears to be superior to previous systems because it takes into account underlying physical disease to which the patient may be reacting in an exaggerated form. Thus the clinician can avoid the either–or dualism that prevailed earlier. Most patients probably have some degree of physical disease that initiates painful sensations, and it is the response to these sensations that constitutes abnormal illness behavior. A. Epidemiology Pain is the most common complaint with which patients present to physicians. It is estimated that the cost to the U.S. economy (direct and indirect costs) for pain­related disability is in the range of $100 billion. A well­constructed European epidemiologic study found that pain disorder is the most common of the somatoform disorders; the incidence over 1 year was 8.1%, and lifetime incidence was 12.7%. According to one U.S. study, 14% of internal medicine private patients had chronic pain. Those who seek medical care for chronic pain may be a subgroup of those who experience it. B. Etiology Pain is a heterogeneous disorder. No single etiologic factor is likely to apply to all patients. Among the proposed etiologies are psychodynamic formulations that pain represents an unconsciously determined punishment to expiate guilt or for aggressive feelings or an effort to maintain a relationship with a lost object. Consistent with psychodynamic theories, some patients with pain syndromes demonstrate masochistic, self­defeating personality characteristics. Downloaded 2024­10­28 11:16 A Your IP is Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 13 / 17 AnotherMcGraw ©2024 etiologicHill. theory proposes All Rights that pain Terms Reserved. represents learned of Use behavior. Privacy PolicyIt isNotice hypothesized that the patient's previous experiences of personal pain Accessibility have led to changes in other persons' behavior, thereby reinforcing the experience of pain and pain behaviors. Consistent with this theory are observations that some pain patients have experienced medical illnesses or injuries associated with pain or lived in childhood homes where disease, B. Etiology Universidad Autónoma de Guadalajara AC Access Provided by: Pain is a heterogeneous disorder. No single etiologic factor is likely to apply to all patients. Among the proposed etiologies are psychodynamic formulations that pain represents an unconsciously determined punishment to expiate guilt or for aggressive feelings or an effort to maintain a relationship with a lost object. Consistent with psychodynamic theories, some patients with pain syndromes demonstrate masochistic, self­defeating personality characteristics. Another etiologic theory proposes that pain represents learned behavior. It is hypothesized that the patient's previous experiences of personal pain have led to changes in other persons' behavior, thereby reinforcing the experience of pain and pain behaviors. Consistent with this theory are observations that some pain patients have experienced medical illnesses or injuries associated with pain or lived in childhood homes where disease, illness, and pain were present. It has also been proposed that pain represents a somatic expression of depression. There is a high incidence of depression in pain patients and among their family members, and depression often precedes pain symptoms. Another important dysphoric affect is anger, which often precedes the onset of chronic pain symptoms and/or is an important factor in maintaining the pain complaints. Because pain is a subjective symptom, it is easy to simulate. A substantial percentage of litigants who claim pain have been shown to exaggerate or outright feign the symptom. C. Genetics No studies have related genetic factors to pain disorder. Clinical Findings A. Signs & Symptoms Patients who repetitively seek treatment for pain may represent a subset of individuals with pain who have certain patterns of illness behavior, rather than reflecting psychological characteristics of all persons who have pain per se. Pain syndromes include fibromyalgia, atypical facial pain, chronic pelvic pain, chronic low back pain, recurrent or persistent headaches, and so on. These patients' descriptions of pain are often dramatic and include vivid descriptions such as "stabbing back pain" or "a fire in my belly." B. Psychological Testing Psychological tests such as the MMPI are often used to evaluate pain patients. Common findings include somatic preoccupation, underlying depression or anxiety, and a tendency to deny psychological symptoms. The McGill Pain Questionnaire, a patient self­report test, frequently discloses that the patient uses idiosyncratic and colorful words to describe his or her pain experience. C. Laboratory Findings In experimental settings, pain disorder patients often have a lower threshold for pain than do normal subjects. It is difficult to determine if this greater sensitivity is the result of physiologic or psychological differences. D. Neuroimaging Elucidation of brain mechanisms involved in pain is evolving rapidly through techniques of functional neuroimaging. Interpretations of findings remain at the investigational stage, but there is promise for future clinical applications. Available information, to date, implies that the anterior cingulate cortex plays a critical role in the emotional component of pain. Chronic pain syndromes have been associated with increased activity in the somatosensory cortices, anterior cingulate cortex, and prefrontal cortex and decreased activity in the thalamus. E. Course of Illness No common symptoms or psychological features describe all pain patients. Despite this heterogeneity, pain patients share some features. Pain patients tend to focus on their pain as an explanation for all their problems; they deny psychological problems and interpersonal problems, except as they relate to pain. These patients frequently describe themselves as independent, yet observations of them suggest that they are dependent on others. They frequently demand that the doctor remove the pain, and they are willing to accept surgical procedures in their search for pain relief. "Doctor shopping" is common. Family dynamics are altered in a manner that makes the pain patient the focus of the family's life. Pain patients often see themselves as disabled and unable to work or perform usual self­care activities. They demand, and often receive, a large number of medications, particularly habituating sedatives and analgesics. The pain persists despite chronic and often excessive use of these medications, on Downloaded which these 2024­10­28 patients 11:16 mayIPbecome A Your is both psychologically and physiologically dependent. Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 14 / 17 ©2024 McGrawDiagnosis Differential Hill. All Rights(Including Comorbidity) Reserved. Terms of Use Privacy Policy Notice Accessibility The differential diagnosis of pain disorder inevitably involves underlying disease processes that may cause the pain. The coexistence, however, of such they relate to pain. These patients frequently describe themselves as independent, yet observations of them suggest that they are dependent on others. They frequently demand that the doctor remove the pain, and they are willing to accept surgical procedures Universidad in their search for Autónoma de pain relief. AC Guadalajara "Doctor shopping" is common. Family dynamics are altered in a manner that makes the pain patient the focus of the family's Access Provided by: life. Pain patients often see themselves as disabled and unable to work or perform usual self­care activities. They demand, and often receive, a large number of medications, particularly habituating sedatives and analgesics. The pain persists despite chronic and often excessive use of these medications, on which these patients may become both psychologically and physiologically dependent. Differential Diagnosis (Including Comorbidity) The differential diagnosis of pain disorder inevitably involves underlying disease processes that may cause the pain. The coexistence, however, of such disease does not rule out the diagnosis of pain disorder if psychological factors are believed to exacerbate or intensify the pain experience. Patients with chronic pain have a high frequency of comorbid psychiatric disorders, including depressive spectrum disorders, anxiety disorders, conversion disorder, and substance abuse disorders. Many of these patients meet diagnostic criteria for a personality disorder, most commonly dependent, passive­aggressive, or histrionic personality disorders. Treatment The treatment of acute pain disorder is generally aimed at reducing the patient's underlying anxiety and the acute environmental stressors that exacerbate the patient's personal distress. Psychiatrists are much more likely to be involved in the evaluation than in the treatment of chronic pain syndromes. Psychiatrists may see patients with these syndromes on referral or as a part of a multidisciplinary pain treatment team. Because patients with chronic pain often resent implications that their pain has psychological causes, psychiatrists are usually most effective when serving as consultants to other health care providers. Chronic pain characteristically leads to changes in behavior that are reinforced by environmental factors. These patients have often assumed an identity as a chronically disabled person and have taken a passive stance toward life. The major objectives for treatment must be to make the patient an active participant in the rehabilitation process, to reduce the patient's doctor shopping, and to identify and reduce reinforcers of the patient's pain behaviors. A. Psychopharmacologic Interventions Patients with chronic pain have generally received prescriptions for multiple analgesics, often including opiate medications. These patients may demand increasing dosages of medication if they have become dependent, and they may exhibit considerable resistance to discontinuing or decreasing medications. Clinicians must explain to these patients that medications have not been successful in relieving pain and that other techniques are indicated. Medications may play a limited role as part of the overall treatment. As a general rule, nonsteroidal anti­inflammatory agents rather than opiates should be the first choice in medication. When more potent analgesics are indicated, they should be prescribed on a fixed­dosage schedule rather than on a variable­dosage schedule. Patients who are prescribed medication on an as­needed basis are much more likely to engage in pain behaviors to indicate the need for medication. The use of a fixed­dosage schedule enables the extinction of pain behaviors as a means of communicating the need for more medication. Patients who have been prescribed opiates either over a long period of time or in high dosages may require a detoxification program rather than abrupt discontinuation. Antidepressant medications are often helpful to pain patients, particularly when symptoms of major depression are present. Clinical experience suggests that dual­reuptake inhibitors (serotonin and norepinephrine) such as duloxetine or venlafaxine are more effective than the serotonin reuptake inhibitors. Tricyclic antidepressants such as nortriptyline continue to have a role in the treatment of chronic pain patients, and patients may have a beneficial response to dosages lower than those used to treat depression. Caution must be used in prescribing potentially habituating medications (e.g., benzodiazepines) for sleep or anxiety because these patients are at high risk for prescription drug abuse/dependency. Anecdotal reports suggest that "off­label" use of the atypical antipsychotic medications (e.g., olanzapine) or antiepileptic medications (e.g., gabapentin) may be useful in some patients. B. Psychotherapeutic Interventions Insight­oriented psychotherapy may be helpful for the few patients who have identified unconscious conflictual issues. However, the vast majority of patients with chronic pain are not psychologically oriented, and insight psychotherapy is not efficacious. Supportive psychotherapy may be helpful in reassuring and encouraging these patients and in improving their compliance with other aspects of the treatment program. As a general rule, behavioral therapy is the most effective type of psychotherapy in the treatment of pain disorders. Both operant conditioning and CBT are widely used (see Chapter 10). Operant conditioning is based on the concept that certain learned behaviors develop in response to environmental cues. Thus the patient has learned a variety of pain behaviors that are elicited in certain situations. Patients often communicate their pain to others (e.g., by grimacing) to elicit responses. Behavioral analysis identifies both the stimuli and the response­altering reinforcements to these behaviors. The behavioral therapist works to Downloaded substitute new 2024­10­28 11:16 behaviors for A Yourlearned previously IP is pain behaviors. Patients are praised for increasing their activity and are not rewarded for pain. Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 15 / 17 Behavioral techniques are most useful when the patient's family is included in the overall treatment program, so that pain behavior is not reinforced ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility when the patient returns home. CBT techniques focus on identifying and correcting the patient's distorted attitudes, beliefs, and expectations. One variety of this treatment involves behavioral therapy is the most effective type of psychotherapy in the treatment of pain disorders. Both operant conditioning and CBT are widely used Universidad Autónoma de Guadalajara AC (see Chapter 10). Access Provided by: Operant conditioning is based on the concept that certain learned behaviors develop in response to environmental cues. Thus the patient has learned a variety of pain behaviors that are elicited in certain situations. Patients often communicate their pain to others (e.g., by grimacing) to elicit responses. Behavioral analysis identifies both the stimuli and the response­altering reinforcements to these behaviors. The behavioral therapist works to substitute new behaviors for previously learned pain behaviors. Patients are praised for increasing their activity and are not rewarded for pain. Behavioral techniques are most useful when the patient's family is included in the overall treatment program, so that pain behavior is not reinforced when the patient returns home. CBT techniques focus on identifying and correcting the patient's distorted attitudes, beliefs, and expectations. One variety of this treatment involves teaching the patient how to relax or refocus thinking and behavior away from the preoccupation of pain. C. Pain Clinics & Centers Chronic pain patients are often disabled and receive fragmented medical care from multiple specialists. A pain clinic provides comprehensive integrated medical care. These clinics seem to work best when a strong behavioral therapy component is associated with a comprehensive evaluation and when treatment interventions include the patient's spouse, family, and, when applicable, employer. The therapeutic focus of pain clinics is to transfer the patient's sense of responsibility for treatment from physicians and medications to the patient himself or herself and to work actively within a rehabilitation program to restore self­care and social and occupational functioning. The focus is on rehabilitation more than it is on pain relief. The message provided is that the patient must learn how to "play hurt." These techniques are often useful for short­term improvement in function. Limited data are available regarding long­term outcome. D. Treatment of Comorbid Disorders Treatment of the symptom of pain often involves attention to coexisting or secondary psychiatric disorders. Major depression should be treated pharmacologically, and anxiety disorders should be treated as indicated with relaxation techniques, behavioral therapy, or pharmacotherapy. Substance abuse problems frequently require detoxification and appropriate rehabilitation techniques to maintain abstinence. Patients whose pain appears to be related to symptoms of posttraumatic stress disorder may require treatment for that disorder; specialized treatment programs for the survivors of violent crimes or sexual abuse may be indicated. Complications/Adverse Outcomes of Treatment Pain disorder patients are at risk for iatrogenic addiction to opiate compounds or benzodiazepines. These patients often sabotage their treatment programs, proclaim that psychiatric treatment was not successful, and then use this as proof that their pain has a physical cause. Prognosis Surprisingly little information is available concerning prognosis for chronic pain patients. Clinicians may see patients who have complained of chronic pain for many years, even decades, and who, in the interim, have been subjected to multiple surgical procedures and have experienced iatrogenic complications. Factors known to be of poor prognostic significance include ongoing litigation related to the pain (e.g., when the illness or accident that caused the pain was associated with a potentially compensable injury), unemployment, loss of sexual interest, or a history of somatization prior to the onset of chronic pain. deLeeuw R., Albuquerque R., Okeson J., Carlson C. The contribution of neuroimaging techniques to the understanding of supraspinal pain circuits: Implications for orofacial pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:308–314. [PubMed: 16122658] Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathology: research findings and theoretical considerations. Psychosom Med. 2002;64:773– 786. [PubMed: 12271108] Eisendrath SJ. Psychiatric aspects of chronic pain. Neurology. 1995;45(Suppl A):S26. [PubMed: 8538883] Fallon BA. Pharmacotherapy of somatoform disorders. J Psychosom Res. 2004;56:455–460. [PubMed: 15094032] Fishbain DA et al. Chronic pain­associated depression: Antecedent or consequences of chronic pain? A review. Clin J Pain. 1997;13:116. [PubMed: 9186019] Downloaded 2024­10­28 11:16 A Your IP is Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 16 / 17 OTHER SPECIFIED ©2024 McGraw Hill. All RightsSOMATIC SYMPTOM Reserved. Terms AND of Use Privacy RELATED Policy DISORDER Notice Accessibility This category applies to patients whose somatic symptom causes significant distress or impairment in social, occupational, or other important areas of Fallon BA. Pharmacotherapy of somatoform disorders. J Psychosom Res. 2004;56:455–460. [PubMed: 15094032] Universidad Autónoma de Guadalajara AC Access Provided by: Fishbain DA et al. Chronic pain­associated depression: Antecedent or consequences of chronic pain? A review. Clin J Pain. 1997;13:116. [PubMed: 9186019] OTHER SPECIFIED SOMATIC SYMPTOM AND RELATED DISORDER This category applies to patients whose somatic symptom causes significant distress or impairment in social, occupational, or other important areas of function, and they predominate but do not meet the full criteria for any of the disorders in the somatic symptom and related disorders diagnostic class. Some examples of presentations that can be specified using "other specified" include the following: (1) Brief somatic symptom disorder: duration less than six months. (2) Brief illness anxiety disorder. (3) Illness anxiety disorder without excessive health­related behaviors: Criterion D for illness anxiety disorder is not met. (4) Pseudocyesis: A false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy. UNSPECIFIED SOMATIC SYMPTOM AND RELATED DISORDER This diagnostic category applies to presentations in which symptoms characteristic of a somatic symptom and related disorder cause clinically significant distress or impairment in societal, occupational, or other important areas of functioning but do not meet the full criteria for any of the disorders in the somatic symptom and related disorders diagnostic class. This category of disorder should not be used unless there are decidedly unusual situations where there is insufficient information to make a more specific diagnosis. General Principles for the Treatment of Somatizing Patients As noted earlier in this chapter, the somatizing disorders display considerable phenomenological overlap and fluidity of symptomatic expression over time. Relatively few somatizing patients fit clearly into one of the somatoform disorder categories described in this chapter. Table 21–2 provides general guidelines for the management of somatizing disorders. Table 21–2 General Guidelines for the Treatment of Somatizing Disorders 1. The clinician must remain vigilant to the possibility that the patient has covert physical disease and may develop physical disease during the course of treatment for his or her somatization. 2. A patient with somatization should not be conceptualized from an either–or perspective. Most somatizing patients have some degree of concurrent physical disease. 3. To the greatest extent possible, medical or surgical care should be coordinated by one primary care physician. Psychiatric consultation, however, is often valuable in helping the primary care physician formulate a treatment plan for the patient. 4. The somatizing patient frequently has a comorbid psychiatric disorder. When identified, such disorders should be treated because the somatization may represent the symptomatic expression of one of these disorders. 5. The somatizing patient should not be told that his or her symptoms are psychogenic or "all in your head." Such comments are almost inevitably rejected and destroy therapeutic rapport, and they may be inaccurate. 6. Invasive diagnostic or therapeutic procedures for the somatizing patient should be initiated only for objective signs and symptoms, not for subjective complaints. 7. The acute onset of a somatoform disorder may be associated with an acute stressor in the patient's life (e. g., physical or sexual abuse). 8. Chronic somatization is rarely responsive to traditional insight­oriented psychotherapy, but behavioral modification techniques are often useful in modifying the patients' illness behavior. 9. The treatment of somatization disorders generally requires multiple treatment techniques provided by a multidisciplinary treatment team. 10. Somatization is often a chronic condition (i.e., "illness as a way of life"), and cure is improbable. Somatizing patients require ongoing management using techniques that reduce the risk of iatrogenic complications. Downloaded 2024­10­28 11:16 A Your IP is Chapter 21: Somatic Symptom and Related Disorders, Charles V. Ford; Louis Trevisan Page 17 / 17 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility