Somatoform Disorders

1
Somatoform Disorders

• Jason Rosenstock, M.D.
• March 14, 2002

2
(No Transcript)
3
(No Transcript)
4
(No Transcript)
5
Somatoform Disorders Agenda

• Goals/Objectives
• Key Common Features
• Somatization Disorder
• Differential Diagnosis
• Comorbidity
• Etiology
• Physician Reaction
• Management Strategies
• Other Somatoform Disorders
• Conclusion

6
Somatoform Disorders Goal

• To make students familiar with the concept of
  somatization, the presentation of somatoform
  disorders in outpatient practices, and principles
  of treatment in primary care.

7
Somatoform Disorders Objectives

• The student will be able to
• State the clinical characteristics of somatoform
  disorders
• Discuss medical and psychiatric comorbidity
  common in patients with somatoform disorders
• Compare and contrast somatoform disorders with
  malingering and factitious disorder
• Explain why psychological distress can manifest
  as somatization
• Discuss difficulties physicians may have with
  somatoform patients
• Summarize management strategies for patients with
  somatoform disorders

8
Somatoform Disorders Key Common Features

• Phenomenology
• Physical symptoms that are suggestive of, but
  cant be fully explained by, medical findings or
  physiological mechanisms

9
Somatoform Disorders Key Common Features

• Pathogenesis
• Behavioral disturbance in which people speak not
  with words or feeling but with their bodies

10
Somatoform Disorders Key Common Features

• Epidemiology
• usually with a female preponderance
• occuring frequently in a primary care setting
• high psychiatric and medical comorbidity
• onset in adolescence or early adulthood, usually
  with a chronic course

11
Somatoform Disorders Key Common Features

• Outcomes
• difficult to diagnose
• difficult to treat
• causes significant distress and functional
  decline

12
Somatoform Disorders

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

13
Somatoform Disorders Somatization Disorder

• Diagnostic Criteria
• 1. History onset before 30yo, symptoms lasting
  years, decline in function or pursuit of medical
  treatment
• 2. Symptoms all four of the following
• a. Pain (four sites)
• b. Gastrointestinal (two non-pain symptoms)
• c. Sexual (one non-pain symptom)
• d. Neurological (one non-pain symptom)
• 3. Medical explanations inadequate
• 4. Rule out other conditions

14
Somatoform Disorders Somatization Disorder

• Epidemiology
• FgtM
• Lower SEC/education
• Ruralgturban
• H/o childhood sexual abuse
• FH
• males w/alcoholism/antisocial personality
• females w/somatization d/o
• Comorbidity Histrionic Personality D/o

15
Somatoform Disorders

• Etiology 1?
• Amplification of bodily sensations
• Altered cognitive schema (somatic filter)
• negative misinterpretations of physical
  sensations
• anxiety from automatic negative thoughts

16
(No Transcript)
17
Somatoform Disorders

• Etiology 2?
• Need for Sick Role
• frequent inability of somatizing patients to
  express concerns in any other way than by being
  physically sick

18
Somatoform Disorders

• Etiologies 3-9?
• unconscious psychological conflict
• hysterical identification
• social learning
• cross-cultural
• primary/secondary gain
• genetic
• neurodevelopmental

19
(No Transcript)
20
(No Transcript)
21
Somatoform DisordersDifferential Diagnosis

• other somatoform disorders
• factitious/malingering
• psychiatric (mood, anxiety, psychotic,
  personality, dissociative)
• general medical
• substance-induced
• cultural

22
Somatoform Disorders Differential Diagnosis
23
(No Transcript)
24
Somatoform DisordersComorbidity

• Personality disorders
• secondary depression
• secondary anxiety
• general medical
• substance-induced

25
(No Transcript)
26
Somatoform DisordersPresenting the Diagnosis

• Physician Its all in your head
• Patient But its NOT in my head its in
  my stomach!

27
Somatoform DisordersPresenting the Diagnosis

• summarizing signs/sx
• good news
• bad news
• seek psychiatrist
• not crazy
• power of suggestion

28
Somatoform DisordersManagement Strategies

• Overall goals
• realistic treatment plan (sx reduction)
• shift focus from body to person
• insure good communication across treatment
  providers
• manage countertransference

29
(No Transcript)
30
Somatoform DisordersManagement Strategies

• Managing appointments
• regular, brief follow-up
• healthy, supportive relationship
• briefer exams, more talk

31
(No Transcript)
32
Somatoform DisordersManagement Strategies

• What to say
• reinforce non-complaining behaviors
• reassure
• be empathic

33
Somatoform DisordersManagement Strategies

• What to do/not do
• limit work-up
• intervene with benign, time-limited measures
• treat comorbidity if present
• psychotherapy (group/individual)
• skills relaxation, stress management, etc.
• psychotropic medication
• complementary treatments

34
(No Transcript)
35
Somatoform Disorders Conversion Disorder

• Diagnostic Criteria
• 1. Unexplained symptoms of voluntary motor or
  sensory function
• 2. Associated psychological factors
• 3. Significant distress or functional decline
• 4. Not merely pain or sexual dysfunction
• 5. Rule out other conditions

36
Somatoform Disorders Conversion Disorder

• Epidemiology
• Prevalence 10-300100K
• 15 have conversion sx at times
• 1-3 of o/p psych referrals
• 5-15 of psych consults
• 4 of neuro o/p visits
• onset 10-35yo
• FgtM 2-101
• Esp. rural, low SEC, medically naïve

37
Somatoform Disorders Conversion Disorder

• Course
• many remit within 2 weeks
• 25 recur within 1st year
• 50 sx-free at 1 year
• 80 sx-free at 5 and 15 years

38
Somatoform Disorders Conversion Disorder

• Prognosis good signs if
• acute onset
• clear precipitant
• early treatment
• intelligence
• good social environment
• no comorbidity (psychiatric/medical)

39
Somatoform Disorders Hypochondriasis

• Diagnostic Criteria
• 1. Preoccupation with fears of having a serious
  disease, triggered by misinterpreted body
  sensations
• 2. Occurs despite reassurance
• 3. Significant distress or functional decline
• 4. gt6mo duration
• 5. Rule out other conditions

40
(No Transcript)
41
Somatoform Disorders Hypochondriasis

• Epidemiology
• 4-9 prevalence in primary care settings
• MgtF generally
• Low SEC
• FH
• Variable age of onset but generally peak sx occur
  in 30s/40s

42
Somatoform Disorders Hypochondriasis

• Prognosis good signs if
• acute onset
• high-functioning, high SEC
• comorbid medical or Axis I dx present
• Axis II absent
• no secondary gain

43
Somatoform Disorders BDD

• Diagnostic Criteria
• 1. Preoccupation with imagined defect (or
  excessive concern with minor defect)
• 2. Significant distress or functional decline
• 3. Rule out other conditions

44
Somatoform Disorders Pain Disorder

• Diagnostic Criteria
• 1. Pain (unexplained, or greater than would be
  expected)
• 2. Psychological factors important
• 3. Significant distress or functional decline
• 4. Rule out other conditions

45
Somatoform DisordersPain Disorder

• Epidemiology
• 40 prevalence in chronic pain populations
• FgtM 21
• FH depression, EtOH, pain
• Low SEC
• Older age of onset 30-40yo