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SOMATOFORM DISORDERS IN PRIMARY CARE

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Title: SOMATOFORM DISORDERS IN PRIMARY CARE


1
SOMATOFORM DISORDERSIN PRIMARY CARE
  • Virginia Kladder, MD, MPH
  • Virginia Commonwealth University
  • February 27, 2002

2
OBJECTIVES
  • Define Somatoform Disorder
  • Demographics of Somatoform disorder
  • Define the five subtypes of somatoform disorder
    somatization disorder, conversion disorder, pain
    disorder, hypochondriasis, body dysmorphic
    disorder
  • Discuss the features of each of the five subtypes
  • Discuss management of somatoform disorders in a
    primary care setting

3
SOMATOFORM DISORDERS
  • Definition Somatoform disorders represent a
    group of disorders characterized by physical
    symptoms suggesting a medical disorder however,
    there are no demonstrable physical findings or
    known physiological mechanisms that might account
    for the symptoms, and there must be positive
    evidence-or a strong presumption-that the
    symptoms have a psychological origin.

4
Demographics of Somatoform Disorder
  • Prevalence reported as low as 2 in the general
    population and as high as 11.6
  • Mortality/Morbity not increased by somatoform
    disorders alone
  • FemaleMale ratio estimated to be 101 for
    somatization d/o, 21 to 51 for conversion d/o,
    21 for pain d/o, and 11 for hypochondriasis

5
Five Subtypes of Somatoform Disorder
  • Somatization Disorder
  • Conversion Disorder
  • Somatoform Pain Disorder
  • Hypochondriasis
  • Body Dysmorphic Disorder

6
SOMATIZATION DISORDER
7
Somatization DisorderDefinition
  • A disorder characterized by many somatic symptoms
    that cannot be explained adequately based on
    physical and laboratory examinations.

8
Features
  • Onset before age 30
  • Multiple and chronic complaints of unexplained
    physical symptoms
  • After an appropriate investigation, each of the
    symptoms cannot be explained by a general medical
    condition or the direct effects of a substance
  • The symptoms are not intentionally feigned or
    produced

9
DSM-IV Diagnostic Criteria
  • A history of pain related to at least 4 different
    sites or functions
  • Head , abdomen, back, joints, extremities, chest,
    rectum
  • During menstruation, during sexual intercourse,
    during urination

10
  • Two gastrointestinal symptoms other than pain
  • Nausea, bloating, diarrhea, food intolerance
  • One sexual symptom other than pain
  • Sexual indifference, erectile dysfunction,
    irregular menses, excessive menstrual bleeding
  • One symptom or deficit suggesting a neurological
    condition not limited to pain
  • Impaired balance, paralysis, weakness, difficulty
    swallowing, lump in throat, aphonia, double
    vision, blindness, deafness, seizures

11
Differential DiagnosisIncludes physical
disorders that present with vague or multiple
somatic complaints
  • Multiple Sclerosis
  • Systemic Lupus Erythematosus
  • Hyperparathyroidism
  • Porphyria

12
Etiology Pathogenesis
  • The specific cause of the disorder is unknown-is
    presumed psychological in origin
  • Proposed theories include
  • Pathological identification with a parent
  • Immature efforts to deal with dependency needs
  • Maladaptive resolution of intrapsychic conflict

13
Management
  • Review all available medical records to determine
    the range of symptomatic complaints brought to
    physicians and the adequacy of documented
    evaluations.
  • Respond to physical symptoms by taking a careful
    history and doing appropriate physical
    examination
  • Avoid specialty consultations, hospitalization,
    and laboratory investigation unless there is
    objective evidence to purse further investigation
  • May consider tsh, urine drug screen, etoh if
    indicated to r/o general medical conditons
  • Rule out other explanations for somatization
  • As a feature of psychiatric disease such as
    Major Depression
  • As a feature of a personality disorder
    (especially hystrionic type)

14
  • Assure the patient of your continued availability
    and schedule regular brief visits so that access
    to medical attention does not require the
    development of new symptoms
  • Do not tell the patient that the symptoms are
    entirely psychologic, but point out that
    emotional factors worsen physical distress and
    attempt to get the patient to discuss life
    problems
  • Praise evidence of coping with the demands of
    daily life despite illness and discomfort

15
  • Somatization disorder is very difficult to
    treat because patients adhere vigorously to the
    idea that they are physically ill they will
    rarely accept referral to psychiatric services
    such as counseling/psychotherapy. A strong
    relationship between patient and primary care MD
    can assist in long term management.

16
CONVERSION DISORDER
17
Conversion DisorderDefinition
  • Disorder in which an unexplained loss or
    alteration of body dysfunction develops in the
    presence of evidence that the symptoms solve or
    express a psychologic conflict or need.

18
Features
  • The symptoms often simulate neurologic disease
    but conform to the patients notion of body
    function rather than to the rules of
    neuroanatomy.
  • Medical evaluation yields no evidence of
    diagnosable disease
  • Amnesia, aphonia, blindness, paralysis, seizures,
    numbness are among the most common conversion
    symptoms
  • Occurs more often in women than in men
  • Generally begins in adolescence or early
    adulthood
  • There may only be one episode or episodes may
    recur over a lifetime
  • Patients may have histrionic or dependent
    personalities
  • Patients may exhibit remarkable serenity in the
    face of their impairments (la belle indifference)

19
DSM-IV Diagnostic Criteria
  • One or more symptoms or deficits affecting
    voluntary motor or sensory function that suggest
    a neurological or other general medical condition
  • Psychological factors are judged to be associated
    with the symptom or deficit because the
    initiation or exacerbation of the symptom or
    deficit is preceded by conflicts or stressors

20
Contd
  • The symptom or deficit is not intentionally
    produced or feigned
  • The symptom or deficit cannot, after appropriate
    investigation, be fully explained by a general
    medical condition, or by the direct effects of a
    substance, or as a culturally sanctioned behavior
    or experience

21
Contd
  • The symptom or deficit causes clinically
    significant distress or impairment in social,
    occupational, or other important areas of
    functioning or warrants medical evaluation.
  • The symptom or deficit is not limited to pain or
    sexual dysfunction, does not occur exclusively
    during the course of somatization disorder, and
    is not better accounted for by another mental
    disorder.

22
Etiology Pathogenesis
  • An unacceptable sexual or aggressive drive is
    denied expression and repressed and thus becomes
    unconscious. The mental energy associated with
    the drive, which would normally push the drive
    into conscious experience, is converted into a
    somatic symptom. This allows the individual to
    remain unaware of the drive and at the same time
    permits symbolic expression of it.
  • Protection from experiencing the drivePrimary
    Gain
  • Sympathy and Attention, which may gratify
    dependency needs Secondary Gain

23
MANAGEMENT
  • Be certain that the patient has had an adequate
    medical evaluation because some patients with
    conversion symptoms have an undiagnosed medical
    disorder (ie. Multiple sclerosis).
  • Emphasize the evidence that no serious disease is
    present, and express optimism about the prospect
    of full recovery.
  • Do not bluntly confront the patient with the
    psychologic origins of the symptoms, but stress
    that emotional factors may exacerbate such
    problems
  • Some patients benefit from psychotherapy or
    hypnosis

24
SOMATOFORM PAIN DISORDER
25
Somatoform Pain Disorder Definition
  • A chronic disorder characterized by
    unexplained or amplified complaints of pain.

26
Features
  • Onset is bimodal in adolescence and early
    adulthood and in the 4th and 5th decades of life
  • Associated with marked disability
  • Patients often make repeated visits to doctors
    for diagnosis or pain relief subsequent
    substance abuse/narcotic addiction not uncommon
  • Usually begins suddenly and increases in severity
    over days to weeks

27
DSM-IV Diagnostic Criteria
  • Pain in one or more anatomic sites is the
    predominant focus of the clinical presentation
    and is of sufficient severity to warrant clinical
    attention.
  • The pain causes clinically significant distress
    or impairment in social, occupational, or other
    important areas of functioning
  • Psychologic factors are judged to have an
    important role in the onset, severity,
    exacerbation, or maintenance of the pain
  • The pain is not better accounted for by a mood,
    anxiety, or psychotic disorder the pain is not
    feigned or intentionally produced

28
Etiology
  • It has been proposed that the pain of this
    disorder is a conversion symptom produced by the
    same mechanisms resonsible for the symptoms of
    conversion disorder

29
Management
  • Respond to pain complaints with a thorough
    history and physical examination. Make sure that
    adequate evaluation of the pain has been done.
  • Rule out psychiatric illnesses
  • Convey optimism but do not promise cure
  • Assure patient of your availabilityschedule
    brief visits regularly
  • Consider topical treatments and physical therapy
    because of their intrinsic value , safety, and
    symbolic value as indicators that the physical
    reality of the pain is recognized
  • Tricyclic antidepressants have proven beneficial
    in some studies

30
Management Contd
  • In general, avoid benzodiazepines and narcotic
    analgesics persuade addicted patients to detox
    if patients are functional and on a stable opioid
    regimen, it is reasonable to continue the
    regimen.
  • Do not tell the patient that his/her symptoms are
    purely psychologic
  • Consider referral to a center specializing in the
    multidisciplinary care of patients with chronic
    pain syndromes.

31
HYPOCHONDRIASIS
32
Hypochondriasis Definition
  • Chronic disorder in which unrealistic
    interpretation of physical symptoms leads the
    patient to fear the presence of a serious illness
    in the face of repeated reassurances based on
    medical evaluation.

33
Features
  • Onset usually in the 3rd decade of life-can occur
    later
  • Both sexes are equally affected
  • Obsessive-compulsive personality traits are often
    observed
  • The disorder tends to be chronic with
    waxing/waning intensity
  • Symptomatic exacerbations occur in response to
    psychosocial stress and to stimuli that provoke
    bodily preoccupation and fear of disease
  • Anxiety, depression, drug dependence,and
    itatrogenic diseases are common complications

34
DSM-IV Diagnostic Criteria
  • Preoccupation with fears of having, or the idea
    that one has, a serious disease based on the
    persons misinterpretation of bodily symptoms
  • The preoccupation persists despite appropriate
    medical evaluation and reassurance
  • The preoccupation causes significant distress
  • The duration of the distress is at least 6 months

35
Etiology
  • -Believed to have its origin in maladaptive
    attempts to cope with unmet psychological needs
    or unconscious psychological conflicts.
  • -There is no agreement on the actual mechanisms
    involved.
  • -Some feel that the hypochondriacal patient is
    merely showing excessive self-concern others
    feel that hypochondriasis is an expression of
    very low self esteem.

36
Management
  • Management is essentially the same as that for
    somatization disorder. One difference is that
    these patients may benefit from short term
    counseling. Some feel that is crucial to develop
    a doctor/patient relationship characterized by
    expectant trust if patients are to be persuaded
    that their worries are excessive and that they
    should participate more fully in life activities.

37
BODY DYSMORPHIC DISORDERJust a little info.
38
Definition
  • Disorder characterized by an excessive or
    completely unfounded preoccupation with a defect
    in personal appearance.
  • The DSM-IV diagnostic criteria include the above
    definition as well as the point that this
    perceived defect causes significant distress to
    the patient.

39
Features
  • Prevalence is unknown, but it may be common
  • Onset typically between adolescence and age 30
  • Perceived facial imperfections, such as the shape
    of the nose or jaw, are the most common sources
    of concern
  • Patients may often seek surgical correction of
    the perceived defect

40
Management
  • Little is known about the management of this
    disorder there are some experts that feel that
    this disorder is more likely a symptom of some
    other disorder.
  • Physicians should discourage patients from
    pursuing surgical solutions provide reassurance

41
Conclusions
  • Somatoform disorders are common
  • Primary care doctors will see and treat many of
    these patients
  • There are no easy therapeutic solutions
  • A strong, trusting doctor/patient relationship
    may be the key to dealing with many of these
    patients

42
References
  • Barker, L. et al, ed. Somatization, Principles
    of Ambulatory Medicine, WilliamsWilkins, 1995
    137-147.
  • Barsky, A., et al., Functional Somatic
    Syndromes, Annals of Internal Medicine,
    1999130910-921.
  • Goldman, H., ed., Somatoform Dissociative
    Disorders, Review of General Psychiatry,
    AppletonLange, 1995283-293.
  • Noble, ed., Somatization, Textbook of Primary
    Care Medicine, 3rd ed., Mosby, Inc, 2001
  • Servan-Schreiber, D., Somatizing Patients Part
    1. Practical Diagnosis, American Family
    Physician, 200061-4.
  • Servan-Schreiber, D., Somatizing Patients Part
    2. Practical Management, American Family
    Physician, 200061-5.
  • Servan-Schreiber, D., The Somatizing Patient,
    Primary Care Clinics in Office Practice, 1999
    26-2.
  • Yates, W., Somatoform Disorders, e-Medicine
    Journal Psychiatry, 2002 3-1.
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