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Somatoform Disorders

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Somatoform Disorders David Bienenfeld, M.D. Department of Psychiatry Wright State University One of Charcot's students was young Sigmund Freud. He was more impressed ... – PowerPoint PPT presentation

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Title: Somatoform Disorders


1
Somatoform Disorders
  • David Bienenfeld, M.D.
  • Department of Psychiatry
  • Wright State University

2
Objectives Somatoform disorders
By the conclusion of the presentation, the
student will be able to
  • Identify the diagnostic features of the most
    common somatoform disorders
  • List characteristics differentiating somatoform
    disorders from malingering and factitious
    disorders
  • Outline management strategies for patients with
    somatoform disorders.

3
Somatoform disorders
  • Context and definitions
  • Epidemiology
  • Social and medical cost

4
Ms. A
Ms. A is a 43 year old divorced woman who
complains of abdominal pain. She describes a
searing pain that usually follows meals, and
localizes it by pointing to an area just above
her umbilicus. She insists that antacids and
ranitidine are of no help. She is insistent on
having an endoscopy right away. Ms. As chart is
now on its third volume. She has made frequent
visits to the practice over about 20 years,
sometimes for this complaint and sometimes for
others. She has had multiple diagnostic
procedures, and many trials of therapy. None has
brought definitive diagnosis or effective
resolution of symptoms.
5
Somatoform disorders
  • Somatization disorder
  • Hypochondriasis
  • Pain disorder
  • Body dysmorphic disorder
  • Conversion disorder

6
Somatization disorder
  • Briquets syndrome
  • Clinical features
  • Epidemiology

7
Somatization disorder DSM IV criteria
  • 4 pain symptoms
  • 2 gastrointestinal symptoms
  • 1 sexual symptom
  • 1 pseudoneurologic symptom

8
Screening criteria I - 5 of
  • Abdominal gas
  • Diarrhea
  • Abdominal pain
  • Chest pain
  • Pain in extremities
  • Weakness
  • Nausea
  • Feeling sickly
  • Dizziness
  • Fainting spells
  • Vomiting

9
Screening criteria II - 2 of
  • Vomiting
  • Pain in extremities
  • Dyspnea without exertion
  • Amnesia
  • Dysphagia
  • Burning sensation in sexual organs or rectum
  • Painful menstruation

10
Frequency of common symptoms in somatization
disorder
  • See Andreasen Black (4th Ed.), Table 8-3

11
Ms. A - 2
You remind Ms. A that she had an upper GI series
of X-ray studies less than a year ago, and an
upper endoscopy about six months ago. The
complaints were identical then, and the results
were negative. You begin to make some
recommendations about changes in eating patterns,
when she interrupts. Ive tried all that and it
doesnt work. I know I have an ulcer and the
exams last year were negative because they missed
it. I never had much faith in that
gastroenterologist you referred me to, anyway.
Youve got to find someone who can make the
diagnosis and take care of it properly.
12
Hypochondriasis
  • Generalized fear of or belief in illness
  • Prevalence in men women
  • Pervasive disruption of psychosocial function

13
Hypochondriasis - clinical features
  • Complaints GI, pain, cardiovascular
  • Chronic, variable
  • Preoccupied, disabled
  • Attitudes towards physicians

14
Pain disorder
  • Pain in one or more sites
  • Psychological factors in origin and/or
    maintenance of pain

15
Body dysmorphic disorder
  • Preoccupation with imagined or slight
    imperfection in appearance
  • Most commonly skin, hair, nose
  • Also penis, muscles, breasts, buttocks
  • Men women
  • Some family link to OCD
  • SSRIs modestly helpful with quality of life

16
Conversion disorder
  • Loss of, or alteration in, physical function,
    resulting from psychologic need or conflict
  • Historical roots

17
Jean-Marie Charcot
18
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19
Sigmund Freud
20
Bertha Pappenheim (Anna O)
21
The defining characteristic of conversion
disorder is
  1. insistence on the presence of a particular
    illness.
  2. large variety of unsubstantiated physical
    complaints.
  3. persistent complaints of pain with
    disproportionate disability.
  4. personality style featuring physical
    manifestations of psychological problems.
  5. sensory or motor symptoms suggesting neurologic
    origin.

22
The defining characteristic of conversion
disorder is
  1. insistence on the presence of a particular
    illness.
  2. large variety of unsubstantiated physical
    complaints.
  3. persistent complaints of pain with
    disproportionate disability.
  4. personality style featuring physical
    manifestations of psychological problems.
  5. sensory or motor symptoms suggesting neurologic
    origin.

23
Conversion disorder
  • Sensory or motor symptoms suggesting neurologic
    origin
  • Positive evidence of psychologic etiology
  • See Andreasen Black (4th Ed.), Table 8-5 for
    DSM-IV criteria

24
Differential diagnosis
  • Malingering / factitious disorder
  • Somatic delusions
  • Mood disorder

25
The chief difference between malingering and
factitious disorder is
  1. Both are different names for the same condition.
  2. Factitious disorder attempts to achieve
    psychological benefit, malingering attempts to
    achieve external benefit.
  3. Factitious disorder is conscious, malingering is
    primarily unconscious.
  4. Malingering is a much more chronic condition than
    factitious disorder.
  5. Malingering patients complain of a wider variety
    of symptoms.

26
The chief difference between malingering and
factitious disorder is
  1. Both are different names for the same condition.
  2. Factitious disorder attempts to achieve
    psychological benefit, malingering attempts to
    achieve external benefit.
  3. Factitious disorder is conscious, malingering is
    primarily unconscious.
  4. Malingering is a much more chronic condition than
    factitious disorder.
  5. Malingering patients complain of a wider variety
    of symptoms.

27
Diagnostic algorithm
Suspicious symptoms or complaints
Conscious attempt to deceive
No conscious attempt to deceive
Chief goal psychological (primary gain)
Chief goal external (secondary gain)
Somatoform disorders, e.g. Somatization
disorder Conversion disorder Hypochondriasis
Malingering
Factitious disorder
28
Primary gain Solution to an internal
problem Secondary gain Environmental
influences that perpetuate somatization
29
Factitious Disorder
  • Production of symptoms under voluntary control
  • Worsen when observed
  • Bizarre or ridiculous
  • Wax and wane with environmental events
  • Goal is to assume patient role
  • External incentives absent

30
Malingering DSM-IV (V65.2)
  • Intentional production of false or grossly
    exaggerated symptoms, motivated by external
    incentives such as obtaining financial
    compensation or drugs, or avoiding work, military
    duty, or criminal prosecution

31
Malingering
  • Symptoms under voluntary control
  • Patient acknowledgement
  • Direct observation
  • Failure to cooperate with treatment
  • Rapid remission when incentives removed
  • Causal relationship to environmental incentive
  • Avoidance of work, punishment, military service
  • Financial gain
  • Acquisition of drugs
  • Cannot be explained by desire to assume patient
    role, or by other mental disorder

32
ALL PAIN IS REAL
33
Understanding somatization
  • Dimensional characteristic
  • Pain and depression

34
Pain and monoamines
Limbic system
Thalamus
Locus coeruleus
Serotonin
Norepinephrine
35
I thought I had something psychosomatic, but it
turned out to be just my imagination.
36
The goal isMANAGEMENT,not cure
37
Keep in control of the case
38
Schedule regular appointments
  • Break the cycle of symptoms ? attention

39
Management of somatoform disorders
  • Explain chronic nature of condition
  • Explore impact on patients life
  • Avoid implying Its all in your head.
  • Explain tension ? pain cycle

40
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41
Management of somatoform disorders
  • Explain chronic nature of condition
  • Explore impact on patients life
  • Avoid implying Its all in your head.
  • Explain tension ? pain cycle
  • Brief physical exam

42
20 minutes / month 4 hours / year
43
Signs and symptoms of depression
  • Hopelessness
  • Guilt
  • Irritability
  • Diminished interest or pleasure
  • Diminished energy
  • Sleep or appetite disturbance

44
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45
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