Dr. Parag Moon

Dept. Of Neurology,

GMC ,Kota

A group of disorders in which people experience significant physical symptoms for which there is no apparent organic cause

Symptoms are often inconsistent with possible physiological processes

People do not consciously produce or control the symptoms but truly experience the symptoms

Symptoms pass only when the psychological factors that led to the symptoms are resolved

Conversion disorder Loss of functioning in some part of the body for

psychological rather than physical reasons

Somatization

disorder

History of complaints about physical symptoms,

affecting many different areas of the body, for

which medical attention has been sought but no

physical cause found

Pain disorder History of complaints about pain, for which

medical attention has been sought but that

appears to have no physical cause

Hypchondriasis Chronic worry that one has a physical disease in

the absence of evidence that one does; frequently

seek medical attention

Body dysmorphic

disorder

Excessive preoccupation with some part of the

body the person believes is defective

Somatoform and

Pain Disorders

Subjective experience of many

physical symptoms, with no organic

causes

Psychosomatic

Disorders

Actual physical illness present and

psychological factors seem to be

contributing to the illness

Malingering Deliberate faking of physical

symptoms to avoid an unpleasant

situation, such as military duty

Factitious

Disorder

Deliberate faking of physical illness

to gain medical attention

Somatoform disorders are problems that appear to be medical but are due to psychosocial factors

◦ Unlike psychophysiological disorders, in which psychosocial factors interact with physical ailments, somatoform disorders are psychological disorders masquerading as physical problems

Dissociative disorders are patterns of memory loss and identity change that are caused almost entirely by psychosocial factors rather than physical ones

When a physical ailment has no apparent medical cause, physicians may suspect a somatoform disorder

People with a somatoform disorder do not consciously want, or purposely produce, their symptoms◦ They believe their problems are genuinely medical

There are two main types of somatoform disorders:◦ Hysterical somatoform disorders◦ Preoccupation somatoform disorders

People with hysterical somatoform disorders suffer actual changes in their physical functioning◦ These disorders are often hard to distinguish

from genuine medical problems

◦ It is always possible that a diagnosis of hysterical disorder is a mistake and that the patient’s problem has an undetected organic cause

DSM-IV-TR lists three hysterical somatoform disorders: ◦ Conversion disorder

◦ Somatization disorder

◦ Pain disorder associated with psychological factors

Recognized since the time of ancient Egypt. An early name for somatization disorder

was hysteria, a condition incorrectly thought to affect only women. (The word hysteria is derived from the Greek word for uterus, hystera.)

In the 17th century, Thomas Sydenham recognized that psychological factors, which he called antecedent sorrows, were involved in the pathogenesis of the symptoms.

In 1859, Paul Briquet, a French physician, observed the multiplicity of the symptoms and the affected organ systems and commented on the usually chronic course of the disorder.

The disorder was called Briquet's syndrome for a time, although the term somatizationdisorder became the standard in the United States when the third edition of DSM (DSM-III) was introduced in 1980.

Somatization is “the tendency to experience and communicate somatic distress and symptoms unaccounted by pathological findings.”

Can coincide with another illness.

Prevalance- 0.2% to 2% among women and is less than 0.2% in men

Usually begins in the teenage and young adulthood years.

Onset after 30 years is extremely rare

More common in less educated and lower socioeconomic groups

Observed in 10% to 20% of female first-degree relatives.

Male relatives of women with somatizationdisorder have an increased risk of antisocial personality, substance abuse disorders, and somatization disorder.

Psychosocial Factors◦ interpretations of the symptoms as social communication

avoid obligations

express emotions

symbolize a feeling or a belief

◦ the symptoms substitute for repressed instinctual impulses

◦ A behavioral perspective

Biological Factors◦ characteristic attention and cognitive impairments

◦ decreased metabolism in the frontal lobes and in the nondominant hemisphere

◦ genetic components

◦ Research into cytokines

Patients with somatization disorder have the tendency to react to psychosocial distress and environmental stressors with physical bodily symptoms.

Can be vague and dramatic in reporting their medical history.

Frequently move abruptly from complaining of one symptom to another symptom.

Usually present with numerous symptoms, such as headaches, back pain, persistent lack of sleep, stomach upset, and chronic tiredness

Without demonstrable medical causes

Have a persistent conviction of being ill, despite repeated negative results on laboratory tests, diagnostic tests, consultations with specialists, and recurrent hospitalizations

Has impaired social/work/personal functioning

Symptoms may be exacerbated by stress

No element of feigning symptoms to occupy sick role (Facititious Disorder) or for material gain (Malingerer)

Physical examination is normal

May reveal some skin lesions or scars that resulted from previously performed surgeries

Affects the patient’s perception of wellness

Patient begins to believe that she or he is physically disabled and unable to work

Characteristically deny the influences of psychosocial distress in producing the symptoms,resist psychiatric referral

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria

Medical conditions - multiple sclerosis, brain tumour, hyperparathyroidism, hyperthyroidism, lupus erythematosus

Affective (depressive) and anxiety disorders-1or2 symptoms of acute onset and shortduration

Hypochondriasis - patient´s focus is on fear ofdisease not focus on symptoms

Panic disorder - somatic symptoms duringpanic episode only

Conversion disorder - only one or two Pain disorder - one or two unexplained pain

complaints, not a lifetime history ofmultiple complaints

Delusional disorders - schizophrenia with somatic delusions or depressive disorder with hypochondriac delusions, bizzare, psychotic sy.

Undifferentiated somatization disorder -short duration (e.g. less than 2 years) and less striking symptoms

The major importance for successful management

Trusting relationship between the patient and one (if possible) primary care physician

Frequent changes of doctors are frustrating and countertherapeutic.

Regularly scheduled visits every 4 or 6 weeks. Brief outpatient visits - performance of at least

partial physical examination during each visit directed at the organ system of complaint.

Explain to the patient and family relationship between psych and somatic

Empathic attitude

Avoid more diagnostic tests, laboratory evaluations and operative procedures unless clearly indicated

Treatment of underlying depression and anxiety.

Potentially addicting medications should be avoided

Psychotherapy, both individual and group ◦ decreases personal health care expenditures

(50%)◦ decreasing their rates of hospitalization.◦ helped to cope with their symptoms ◦ to express underlying emotions ◦ to develop alternative strategies for expressing

their feelings

• Increased Activity Involvement–Combats stress – Improves overall mood–Provides Distraction from somatic

symptoms –Pain perception has a subjective

component—improved mood and distraction reduce the experience of pain

–Exercise has physiological effects that combat somatization and stress

• Directly acts on physical symptoms, given its effects on breathing, heart rate, muscle tension, etc.

• Patients report benefit soon upon learning the technique

• Helps with stress management

• Includes Diaphragmatic Breathing, Progressive Muscle Relaxation, Biofeedback

– Establish consistent sleep patterns (same bedtime and waketime everyday)

– Go to bed only when sleepy (stimulus control)

– If not asleep within 20-30 minutes leave bed and return when sleep again (stimulus control)

– Comfortable sleep environment

– Avoid alcohol/caffeine during 6 hours before bedtime

– Exercise regularly, but not within 4 hours of bedtime

• Much like CBT for depression– Looking for adaptability of thoughts

– Eliminating distortions

• Use somatic symptoms as anchors for examining thoughts

• Look for variations in adaptability of thoughts and discuss their effect

• Patients are likely to have difficulty identifying thoughts/emotions.

Thanks

Somatization Disorders:Diagnosis, Treatment, and Prognosis;Psychosocial: vol 32no2 Feb 2011

Somatisation in neurological practice;J Neurol Neurosurg Psychiatry. Oct 2004; 57(10): 1161–1164.

Somatization A Debilitating Syndrome in Primary Care; Psychosomatics 42:1, January-February 2001

Kaplans and Sadocks textbook of psychiatry