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Somatoform Disorders

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Differential Diagnosis. other somatoform disorders. factitious/malingering ... Presenting the Diagnosis. Physician: 'It's all in your head' ... – PowerPoint PPT presentation

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Title: Somatoform Disorders


1
Somatoform Disorders
  • Jason Rosenstock, M.D.
  • March 14, 2002

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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

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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

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

22
Somatoform Disorders Differential Diagnosis
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Somatoform DisordersComorbidity
  • Personality disorders
  • secondary depression
  • secondary anxiety
  • general medical
  • substance-induced

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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

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

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

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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

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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

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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
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