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Somatoform Disorders

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Somatoform Disorders

  1. 1. Somatoform Disorders Dr. Okine
  2. 2. Somatoform Disorders <ul><li>Have you ever used or faked Sx to get out of having to perform important activities (exams, classes, work, social functions)? </li></ul><ul><li>Have you ever used tactics to gain attention and sympathy? </li></ul>
  3. 3. Characteristics of the Somatoform Disorders <ul><li>Somatization: the expression of psychological pain through physical sx or concerns </li></ul><ul><li>Unexplained physical symptoms or bodily preoccupations </li></ul><ul><ul><li>Somatization Disorder, Conversion Disorder, Pain Disorder, Undifferentiated Somatoform Disorder: experiencing pain with no apparent medical basis </li></ul></ul><ul><ul><li>Hypochondriasis: preoccupation with having a serious medical condition or disease </li></ul></ul><ul><ul><li>Body Dysmorphic Disorder: preoccupation with a perceived serious defect in appearance </li></ul></ul>
  4. 4. Characteristics of the Somatoform Disorders <ul><li>Psychological factors are associated with the initiation or exacerbation of Sx </li></ul><ul><li>Diagnoses of exclusion – Dx requires you to rule out: </li></ul><ul><ul><li>Underlying general medical causes </li></ul></ul><ul><ul><li>Other psychological disorders, e.g. an Anxiety or Mood Disorder </li></ul></ul><ul><ul><li>Intentional feigning or production of Sx, as in Factitious Disorder (motivated by a desire to assume the sick role), or Malingering (motivated by external incentives for behavior, e.g. economic gain, avoiding legal responsibility) </li></ul></ul>
  5. 5. Somatization Disorder: Diagnostic Criteria <ul><li>A. History of physical symptoms: </li></ul><ul><ul><li>beginning before 30 </li></ul></ul><ul><ul><li>occurring over several years </li></ul></ul><ul><ul><li>resulting in TX being sought or significant impairment in functioning </li></ul></ul>
  6. 6. Somatization Disorder: Diagnostic Criteria <ul><li>B . Must meet each of the following criteria during the course of the disorder: </li></ul><ul><ul><li>4 Pain Sx: a Hx of pain related to at least 4 different sites (e.g. head, abdomen, back, joints, chest) or functions (e.g. menstruation, sexual intercourse, urination) </li></ul></ul><ul><ul><li>2 Gastrointestinal Sx: a Hx of at least 2 GI Sx other than pain (e.g. nausea, bloating, vomiting, diarrhea, intolerance of several foods) </li></ul></ul><ul><ul><li>1 Sexual Sx: a Hx of at least 1 sexual or reproductive Sx other than pain (e.g. sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy) </li></ul></ul><ul><ul><li>1 Pseudoneurological Sx: a Hx of at least 1 Sx or deficit suggesting a neurological condition without pain (e.g. impaired coordination or balance, paralysis, localized weakness, difficulty swallowing, lump in throat, loss of touch or pain sensation, double vision, blindness, deafness, seizures, urinary retention) </li></ul></ul>
  7. 7. Somatization Disorder: Diagnostic Criteria <ul><li>C. Either (1) or (2): </li></ul><ul><li>(1) Symptoms not fully accounted for by a general medical condition or the effects of a substance </li></ul><ul><li>(2) When there is a related medical condition, the complaints and resulting social or occupational impairment exceed what would be expected </li></ul><ul><li>D. Symptoms are not intentionally feigned or produced, as in Factitious Disorder or Malingering </li></ul>
  8. 8. Somatization Disorder: General Characteristics <ul><li>a complex medical history </li></ul><ul><li>inconsistencies between subjective complaints and objective findings </li></ul><ul><li>colorful, dramatic quality to complaints – exaggerating and elaborating on physical and psychiatric Sx </li></ul><ul><li>respond to psychological/social problems with physical symptoms </li></ul>
  9. 9. Somatization Disorder: Facts & Figures <ul><li>Prevalence: 0.2-2% among women; less than 0.2% among men. </li></ul><ul><li>Course: chronic, fluctuating disorder; rarely remits completely </li></ul><ul><li>Onset: adolescence; before 25 years old </li></ul><ul><li>Most common among those who are: unmarried, female, & from lower SES groups </li></ul>
  10. 10. Somatization Disorder: Causes <ul><li>Hx of family illness or injury during childhood </li></ul><ul><li>Neurobiologically-based disinhibition syndrome characterized by impulsive behavior and pleasure-seeking </li></ul><ul><li>Short-term gain of immediate attention and sympathy </li></ul><ul><li>Dependence </li></ul>
  11. 11. Somatization Disorder: Treatment Considerations <ul><li>No well-established treatment. </li></ul><ul><li>Most crucial issue is to “do no harm.” Harm can be done by not considering a possible medical basis for Sx, by unnecessary medical tests & Tx, & by inadequate Tx for valid medical conditions </li></ul><ul><li>Comprehensive assessment: </li></ul><ul><ul><li>medical history – illnesses, surgeries, pain, fatigue, distress produced by Sx </li></ul></ul><ul><ul><li>current medications </li></ul></ul><ul><ul><li>abused substances </li></ul></ul><ul><ul><li>psychiatric symptoms – comorbid disorders that could account for Sx </li></ul></ul><ul><ul><li>Stressors – past, present, typical response to stress </li></ul></ul><ul><ul><li>Use additional informants & review medical records </li></ul></ul>
  12. 12. Somatization Disorder: Treatment Considerations <ul><li>Long term supportive psychotherapy: therapist can provide an important, reassuring, sympathetic relationship; use brief, widely-spaced sessions </li></ul><ul><li>Antidepressants </li></ul><ul><li>Use of a “gate-keeper” physician </li></ul><ul><li>Work in tandem with a primary care physician & psychiatrist </li></ul>
  13. 13. Undifferentiated Somatoform Disorder: Diagnostic Criteria <ul><li>A. One or more physical complaints (fatigue, loss of appetite, GI Sx, urinary complaints) which: </li></ul><ul><li>cause significant distress or impairment </li></ul><ul><li>warrant medical attention </li></ul><ul><li>last for at least 6 months </li></ul><ul><li>B. R/O alternative explanations for sx: </li></ul><ul><li>General medical conditions </li></ul><ul><li>Effects of a substance </li></ul><ul><li>Factitious Disorder or Malingering </li></ul><ul><li>Other psychological disorders </li></ul>
  14. 14. Conversion Disorder: Diagnostic Criteria <ul><li>One or more Sx or deficits affecting voluntary motor or sensory functioning and indicative of a neurological or other medical condition </li></ul><ul><li>Psychological factors are associated with the Sx – the initiation or exacerbation of Sx is preceded by conflicts or stressors </li></ul><ul><li>The Sx is not intentionally feigned or produced, as in Factitious Disorder or Malingering </li></ul><ul><li>The Sx cannot be fully explained by a general medical condition, the effects of a substance, or a culturally sanctioned behavior or experience </li></ul><ul><li>Sx cause significant distress or impairment in functioning or warrant medical attention </li></ul><ul><li>The Sx is not limited to pain or sexual dysfunction, does not occur exclusively in the course of Somatization Disorder, and is not better accounted for by another mental disorder </li></ul>
  15. 15. Conversion Disorder: Specifiers <ul><li>Specifiers: </li></ul><ul><ul><li>With Motor Sx or Deficits – e.g. impaired coordination or balance, paralysis, localized weakness, difficulty swallowing, lump in throat, urinary retention </li></ul></ul><ul><ul><li>With Sensory Sx or Deficits – loss of touch or pain sensation, double vision, blindness, deafness, hallucinations </li></ul></ul><ul><ul><li>With Seizures or Convulsions </li></ul></ul><ul><ul><li>With Mixed Presentation </li></ul></ul>
  16. 16. Conversion Disorder: Facts & Figures <ul><li>More common in: </li></ul><ul><ul><li>rural populations </li></ul></ul><ul><ul><li>lower SES </li></ul></ul><ul><ul><li>less medically/psychologically sophisticated </li></ul></ul><ul><ul><li>women than men (2-10x) </li></ul></ul><ul><li>In women, sx are much more common on the left than right side of the body </li></ul><ul><li>11-500 out of 100,000 in general population meet criteria for conversion disorder </li></ul><ul><li>3% of outpatient referrals to mental health clinics </li></ul><ul><li>1-14% of medical/surgical inpatients </li></ul><ul><li>Onset: late childhood through early adulthood; rarely before 10 or after 35 </li></ul>
  17. 17. Conversion Disorder: Assessment <ul><li>Assess the following: </li></ul><ul><ul><li>physical sx, medical conditions, medications, abused substances, psychiatric symptoms, and stressors and conflicts </li></ul></ul><ul><ul><li>the person’s level of medical knowledge </li></ul></ul><ul><ul><li>whether the person may be intentionally feigning symptoms </li></ul></ul><ul><ul><li>manner of presenting symptoms – dramatic and histrionic or la belle indifference </li></ul></ul><ul><ul><li>R/O underlying neurological or general medical conditions by referral for a thorough neuorological examination: 5-10% have real medical problems </li></ul></ul>
  18. 18. Conversion Disorder: Theory <ul><li>Psychoanalytic: </li></ul><ul><ul><li>The person experiences a traumatic event, which produces anxiety and psychological conflict </li></ul></ul><ul><ul><li>Anxiety and unconscious psychological conflict are converted to somatic symptoms </li></ul></ul><ul><ul><li>Sx provide primary gain (reduce anxiety and keep the conflict out of awareness) </li></ul></ul><ul><ul><li>Sx provide secondary gain (the person obtains external benefits, such as attention or sympathy, or evades noxious duties and responsibilities) </li></ul></ul><ul><li>Getting sick provides the person an escape from a traumatic situation </li></ul><ul><li>Hx of significant stress </li></ul><ul><li>Over-involved and over-protective parents </li></ul><ul><li>Prior experience with real physical problems </li></ul><ul><li>Underlying psychopathology </li></ul>
  19. 19. Conversion Disorder: Treatment Considerations <ul><li>Role of suggestibility – patients can be suggested into & out of Sx </li></ul><ul><li>Identify and attend to the traumatic or stressful life event </li></ul><ul><li>Address current psychosocial stressors with environmental manipulation, support, advice, and coping skills </li></ul><ul><li>Reduce any reinforcing or supportive consequences from the conversion Sx </li></ul><ul><li>Insight-oriented therapies usually aren’t indicated or helpful </li></ul><ul><li>For acute Sx: positive expectation for recovery; a face-saving way for the patient to recover, e.g. physical therapy </li></ul><ul><li>For chronic Sx: physical rehabilitation, suggestion, & psychotherapy </li></ul><ul><li>Work closely with a medical doctor and psychiatrist </li></ul>
  20. 20. Pain Disorder: Diagnostic Criteria <ul><li>A. Pain in one or more anatomical sites is the predominant focus of clinical presentation and is of sufficient severity to warrant clinical attention. </li></ul><ul><li>B. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. </li></ul><ul><li>C. Pain causes clinically significant distress or impairment in important areas or functioning or warrants medical attention. </li></ul><ul><li>D. Pain is not intentionally feigned or produced, as in Factitious Disorder or Malingering. </li></ul><ul><li>E. Pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder. </li></ul>
  21. 21. 3 Types of Pain Disorder <ul><li>Pain Disorder Associated with Psychological Factors: psychological factors have a major role in the onset, severity, exacerbation, or maintenance of pain </li></ul><ul><li>Pain Disorder Associated with a General Medical Condition: GMC or site of pain is coded on Axis III, e.g. low back, sciatic, pelvic, headache, chest, joint, abdominal, throat, urinary </li></ul><ul><li>Pain Disorder Associated with Both Psychological Factors and a General Medical Condition: most common </li></ul>
  22. 22. Pain Disorder: Specifiers <ul><li>Acute: duration less than 6 months </li></ul><ul><li>Chronic: duration 6 months or longer </li></ul>
  23. 23. Pain Disorder: Treatment Considerations <ul><li>Collect info regarding physical Sx, medical conditions, medications, abused substances, psychiatric symptoms, stressors and conflicts </li></ul><ul><li>Distinguish from Factitious Disorder or Malingering </li></ul><ul><li>Target both the physical and psychological aspects of chronic pain </li></ul><ul><li>Validate the person’s pain, rather than challenging or insight </li></ul><ul><li>Enlist the person’s cooperation in developing strategies for dealing with pain </li></ul>
  24. 24. Pain Disorder: Treatment Considerations <ul><li>Pain management: teach techniques for coping with pain; use of analgesic, anti-inflammatory, and antidepressant medications </li></ul><ul><li>Cognitive behavioral techniques: distraction, stress management, cognitive restructuring, activity pacing, sleep management, logging activities attempted and level of pain associated with each </li></ul><ul><li>Attend to factors that influence recovery: acknowledging pain; giving up unproductive efforts to control pain; participating in regularly scheduled activities despite pain; recognizing and treating comorbid disorders; adapting to a potentially chronic condition; not allowing the pain to become the determining factor in one’s lifestyle </li></ul>
  25. 25. Hypochondriasis: Diagnostic Criteria <ul><li>A. Preoccupation with fear of having or belief that one has a serious illness, based on misinterpretation of bodily Sx or functions </li></ul><ul><li>B. Preoccupation persists despite appropriate medical evaluation, reassurance, and the person’s not developing the feared disease </li></ul><ul><li>C. Preoccupation lasts at least 6 months </li></ul><ul><li>D. Preoccupation causes clinically significant distress or impairment in important areas of functioning </li></ul><ul><li>E. Preoccupation is not better accounted for by other disorders, such as GAD, OCD, Panic Disorder, Major Depression, Separation Anxiety, or another Somatoform Disorder </li></ul>
  26. 26. Hypochondriasis <ul><li>Specifier: </li></ul><ul><li>With Poor Insight: person doesn’t recognize the preoccupation is excessive or unreasonable </li></ul><ul><li>Prevalence: </li></ul><ul><li>1-5% in general population </li></ul><ul><li>Gender Differences: </li></ul><ul><li>Sex ratio is 50-50 </li></ul>
  27. 27. Hypochondriasis: Causes <ul><li>Faulty interpretation of bodily cues and sensations as evidence of physical illness </li></ul><ul><li>Enhanced sensitivity to, & over-focusing on, physical sensations and illness cues </li></ul><ul><li>Stressful life events </li></ul><ul><li>Disproportionate incidence of disease in family during childhood </li></ul><ul><li>Secondary gains associated with the sick role: decreased responsibility and increased attention </li></ul>
  28. 28. Hypochondriasis: Treatments <ul><li>Cognitive behavioral treatment: identifying & challenging illness-related misinterpretations of bodily sensations; showing patients how to create Sx by focusing attention on certain body areas </li></ul><ul><li>Stress management </li></ul><ul><li>Explanatory therapy: reassurance & education regarding the source and origins of Sx </li></ul>
  29. 29. Body Dysmorphic Disorder: Diagnostic Considerations <ul><li>A. Preoccupation with an imagined defect in appearance or markedly excessive concern about a slight physical anomaly </li></ul><ul><li>B. The preoccupation causes clinically significant distress or impairment in important areas or functioning </li></ul><ul><li>C. The preoccupation is not better accounted for by another mental disorder, such as distorted body image in Anorexia Nervosa </li></ul>
  30. 30. Body Dysmorphic Disorder: Common Features <ul><li>Constant and excessive use of mirrors </li></ul><ul><li>Avoidance of mirrors </li></ul><ul><li>Lots of time spent grooming </li></ul><ul><li>Lots of grooming rituals </li></ul><ul><li>Attempts to hide parts of body </li></ul><ul><li>Constantly seeking reassurance about looks, while discounting feedback </li></ul><ul><li>Anxiety or depression about one’s appearance </li></ul>
  31. 31. Body Dysmorphic Disorder: Facts & Figures <ul><li>People with BDD often seek help from dermatologists and plastic surgeons (rates of BDD in these settings is 6-15%) </li></ul><ul><li>BDD is under-recognized & under-diagnosed in nonpsychiatric settings </li></ul><ul><li>BDD is infrequent in mental health settings </li></ul><ul><li>Onset: adolescence and young adulthood </li></ul>
  32. 32. Body Dysmorphic Disorder: Causes <ul><li>Defense mechanism of displacement: displacing underlying psychological conflict and anxiety onto a body part </li></ul><ul><li>Variant of OCD </li></ul>
  33. 33. Body Dysmorphic Disorder: Treatment <ul><li>There is little to no research on treatments for BDD </li></ul><ul><li>Distinguish BDD from normal concerns about appearance or overvaluing of appearance (resistant to reality testing and reassurance; cause significant distress or impairment; delusional) </li></ul><ul><li>Pharmacotherapy: SSRI’s at higher doses & for longer duration </li></ul><ul><li>CBT strategies: exposure and response prevention, self-esteem building, modifying distorted thinking, and coping strategies </li></ul>