Somatoform Disorders PPT PDF

Somatoform disorder at glance.  Disorder characterized by recurring, multiple, clinically significant complaints about pain, gastrointestinal, sexual and pseudoneurological symptoms  Causes  Defense against psychological distress  Heightened sensitivity to physical sensations  Psych...

Somatoform disorder at glance.  Disorder characterized by recurring, multiple, clinically significant complaints about pain, gastrointestinal, sexual and pseudoneurological symptoms  Causes  Defense against psychological distress  Heightened sensitivity to physical sensations  Psychodynamic, cognitive & behavioural view  Symptoms  Pain  Gastrointestinal, neurological & sexual symptoms  Menstrual problems  Incidence  More common in women than men Glance cont’d…  Diagnosis  No Laboratory tests  Little evidence of definable medical illness  History of multiple physical complaints  Symptoms might cause significant impairment to social, occupational & other areas of functioning  Pain affecting atleast four differential body parts  Physical exam for non-organic pain  McBride's test  Hoover's test  Burn's test  Treatment  Cognitive behaviour therapy  Medications Somatoform disorders  Group of disorders that includes physical symptoms for which an adequate medical explanation cannot be found  Psychological factors --> symptom’s onset, severity, duration  Not malingering or factitious disorder  Psychosomatic complaints frequently involve:  Chronic pain  Problems with the digestive system, nervous system, and reproductive system  Typical onset – before age 30  Higher prevalence for women than men  Somatization  Physical complaints or impairments:  Without organic pathology  That are grossly in excess of what would be expected from the physical findings  Malingering  Intentionally feigning or grossly exaggerating illness or disability to derive benefit or secondary gain (e.g., to escape work, gain compensation, or obtain drugs)  Factitious disorder  Characterized by:  Physical or psychological symptoms that are intentionally produced or feigned in order to assume the sick role  Conscious fabrication of symptoms to gain attention  5 Specific somatoform disorders: 1. Somatization Disorder 2. Conversion Disorder 3. Hypochondriasis 4. Body Dysmorphic Disorder 5. Pain Disorder 6. Undifferentiated Somatoform Disorder 7. Somatoform Disorder Not Otherwise Specified  Hysteria, Briquet’s Syndrome  Many somatic symptoms  Multiple complaints and organ systems affected  Chronic & debilitating  Epidemiology  Lifetimeprevalence = 0.1-0.2%  F > M (5-20X) = 5:1 Diagnosis  Onset before the age of 30 years  Complain of at least 4 pain sxs, 2 GI sxs, 1 sexual sx, 1 pseudoneurological sx  No physical or laboratory explanation  Clinical features  Many somatic complaints; long complicated medical history  Psychological distress: anxiety, depression  Common suicidal threats  Medical history is circumstantial, vague, imprecise, inconsistent, disorganized  Patients are dependent, self-centered, hungry for admiration or praise  Common associated mental Disorders - MDD, PD, SRD, GAD, phobias Differential diagnosis 1. Non-psychiatric medical condition 2. Mental Disorder - MDD, GAD, schizophrenia 3. Other somatization Disorders  Treatment  Single identified MD  Visits: regular, avoid additional lab/diagnostic procedures  Somatic symptoms - emotional expressions  Psychotherapy: individual, group Conversion disorder  One or more neurological symptoms (paralysis, blindness, paresthesias)  Psychological factors --> onset, exacerbation  Epidemiology  F:M = 2:1 - 5:1  Onset is any age (common during adolescence and young adults)  Rural population, little educated, low IQ, low SE group, military personel  Comorbid with MDD, anxiety, schizophrenia Etiology 1. Psychoanalytic - repression of unconscious conflict/anxiety --> physical sx Nonverbal means of controlling and manipulating 2. Biological factors - hypometabolism of dominant hemisphere impaired hemispheric communication Diagnosis  Symptoms or deficits affecting neurological functions  Psychological factors --> onset, exacerbations  Not intentionally feigned or produced  Clinical features  Most common symptoms: paralysis, blindness, mutism  Most commonly associated with passive-aggressive, dependent, antisocial and histrionic PDs  Sensory Sxs: anesthesia and paresthesia, esp extremities  distribution usually inconsistent with central or peripheral neuro dse  hicharacteristic stocking and glove anesthesia or hemianesthesia (along the midline)  organs of special senses - deafness, blindness, tunnel vision --> N neuro exam Clinical features cont’d… 2. Motor Sxs: abnormal movements, gait disturbance, weakness, paralysis generally worsen by attention 3. Seizure Sxs: pseudoseizure 4. Mixed presentation  Other associated features:  Primary gain: represent an unconscious psychological conflict  Secondary gain: accrue tangible advantages & benefits  Le belle indifference: unconcerned about what appears to be a major impairment  Identification: unconsciously model their sxs on those someone important to them Differential diagnosis  Rule out medical disorder: thorough medical and neuro work-up  25-50% diagnosed with conversion DO --> neuro or non-psychiatric medical DO 1. Neuro DO - dementia, brain tumors, degenerative dse, basal ganglia dse 2. Psychiatric DO - schiz, deprssive DO, other somatoform, malingering, factitious DO Course & Prognosis  90-100% resolve in few days to less than a month  Good prognosis: sudden onset, easily identifiable stressor, good premorbid adjustment, no comorbid psychiatric or medical DO  25-50% --> neuro or non-psychiatric DO  Treatment  Spontaneously resolve  Insight-oriented supportive or behavioral therapy HYPOCHONDRIASIS  Unrealistic or inaccurate interpretations of physical symptoms or sensations --> preoccupation and fear that they have serious disease  Significant distress; impaired function  Epidemiology  F=M  Onset at any age Etiology  Misinterpretation of bodily symptoms  Social learning model  Variant form of other mental disorder - depression and anxiety DO (80%)  Aggressive and hostile wishes Diagnosis, Signs & Syp.  Preoccupied with false belief based misinterpretation of physical s/sxs  At least 6 months  Not a delusion or restricted to distress of appearance  Clinical features  Believe that they have a serious disease not yet detected  Conviction persist despite negative lab results, benign course, reassurances  Usually with depression and anxiety Differential diagnosis  Non-psychiatric medical condition  Other somatoform disorders  MDD, anxiety Disorders, schizophrenia, other psychotic Disorders  Course &Prognosis  Episodic, months to years  Good prognosis: high SE class, treatment- responsive anxiety or depression, sudden onset, (-) PD, (-) related non-psychiatric medical condition Treatment  Usually resistant to psychiatric treatment  Focus on stress reduction and education in coping with chronic illness  Group psychotherapy  Regular scheduled PE Body dysmorphic disorder  Preoccupation with an imagined bodily defect or an exaggerated distortion of a minimal or minor defect  Causes significant distress; impaired function  Epidemiology  Rare; poorly studied  Most common age of onset: 15-30 yo  F > M, unmarried  Commonly coexists with other mental Disorders: (MDD, anxiety, psychotic DOs) Etiology  Serotonin  Cultural and social effects  Psychodynamic models  Diagnosis  Preoccupied with an imagined defect in appearance or an overemphasis of a slight defect  Significant emotional distress; impaired functioning Clinical features  Most common concerns: facial flaws  Common associated symptoms: ideas of reference, attempts to hide deformity, excessive mirror checking or avoidance  Avoid social or occupational exposure  Housebound; attempt suicide  Traits: O-C, schizoid, narcissistic PD  Comorbid: depression, anxiety Disorders Differential diagnosis  Anorexia nervosa, gender identity DO, brain damage  Delusional DO, somatic type  Narcissistic PD, depressive DO, OCD, schizophrenia  Course & Prognosis  Gradual onset  Usually chronic  Treatment  Serotonin-specific drugs - clomipramine, fluoxetine  Treat coexisting mental DO PAIN DISORDER  Psychogenic pain DO  Pain in one or more sites --> no non-psychiatric medical or neurological condition  Emotional distress; functional impairment  Epidemiology  F>M  Peak onset on 4th to 5th decades  Blue-collar occupation, 1st degree relatives Etiology  Psychodynamic: expression of intrapsychic conflict  defense mechanism-displacement, substitution, repression  Behavioral: reinforced with reward and inhibited when ignored/punished  Interpersonal: manipulation and gaining advantages  Biological: 5HT and endorphins  Diagnosis  Significant complaints of pain  Emotional distress and functional impairment Clinical features  Collectionof different histories of various pains  Pain maybe post-traumatic, neuropathic, neurological, iatrogenic, musculoskeletal  (+) psychological factor  Long history of medical and surgical care, visits many MDs, requests many meds  Complicated by SRD  MDD: 25-50% of patients  Dysthymic or depressive DO sxs - 60-100% Differential diagnosis  Physical pain VS Psychogenic pain  Physical Pain: fluctuates in intensity, highly sensitive to emotional, cognitive, attentional and situational influence  Psychogenic Pain: does not vary, insensitive to any of above factors, does not wax or wane, not temporarily relieved by distraction  Other somatoform Disorders  Course & Prognosis  Abrupt onset and increases in severity Treatment  Address rehabilitation  PAIN IS REAL  Pharmacotherapy - antidepressant  Behavioral therapy  Psychotherapy  Pain control program Geneeral treatment of Psychosomatic disorders  CARE-MD treatment approach  Cognitive behavioral therapy (CBT)  Assess: rule out medical causes  Regular visits: Short frequent visits with focused exams  Explorestressors, promote healthy coping  Set boundaries  Empathy  Med-psych interface  Do no harm  Do not dispute the reality or severity of the patient’s physical complaints  Be aware that somatizing patients are often intellectually challenging NCP Psychosomatic disorders  Cognitive-behavioral treatment  Biofeedback  Relaxation training  Group therapy  Family therapy NCP Psychosomatic disorders NCP Psychosomatic disorders