SOMATOFORM DISORDERS IN PRIMARY CARE

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SOMATOFORM DISORDERSIN PRIMARY CARE

• Virginia Kladder, MD, MPH
• Virginia Commonwealth University
• February 27, 2002

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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

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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.

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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

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Five Subtypes of Somatoform Disorder

• Somatization Disorder
• Conversion Disorder
• Somatoform Pain Disorder
• Hypochondriasis
• Body Dysmorphic Disorder

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SOMATIZATION DISORDER
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Somatization DisorderDefinition

• A disorder characterized by many somatic symptoms
  that cannot be explained adequately based on
  physical and laboratory examinations.

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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

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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

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• 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

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Differential DiagnosisIncludes physical
disorders that present with vague or multiple
somatic complaints

• Multiple Sclerosis
• Systemic Lupus Erythematosus
• Hyperparathyroidism
• Porphyria

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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

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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)

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• 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

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• 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.

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CONVERSION DISORDER
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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.

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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)

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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

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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

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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.

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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

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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

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SOMATOFORM PAIN DISORDER
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Somatoform Pain Disorder Definition

• A chronic disorder characterized by
  unexplained or amplified complaints of pain.

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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

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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

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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

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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

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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.

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HYPOCHONDRIASIS
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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.

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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

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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

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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.

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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.

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BODY DYSMORPHIC DISORDERJust a little info.
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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.

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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

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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

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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

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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.