somatoform disorders
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Somatoform Disorders
Dr. Okine
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Somatoform Disorders
Have you ever used or faked Sx to get out of having to perform important activities (exams, classes, work, social functions)?
Have you ever used tactics to gain attention and sympathy?
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Characteristics of the Somatoform Disorders
Somatization: the expression of psychological pain through physical sx or concerns
Unexplained physical symptoms or bodily preoccupations Somatization Disorder, Conversion Disorder, Pain
Disorder, Undifferentiated Somatoform Disorder: experiencing pain with no apparent medical basis
Hypochondriasis: preoccupation with having a serious medical condition or disease
Body Dysmorphic Disorder: preoccupation with a perceived serious defect in appearance
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Characteristics of the Somatoform Disorders
Psychological factors are associated with the initiation or exacerbation of Sx
Diagnoses of exclusion – Dx requires you to rule out: Underlying general medical causes Other psychological disorders, e.g. an Anxiety
or Mood Disorder Intentional feigning or production of Sx, as in
Factitious Disorder (motivated by a desire to assume the sick role), or Malingering (motivated by external incentives for behavior, e.g. economic gain, avoiding legal responsibility)
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Somatization Disorder: Diagnostic Criteria
A. History of physical symptoms: beginning before 30 occurring over several years resulting in TX being sought or
significant impairment in functioning
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Somatization Disorder: Diagnostic Criteria
B. Must meet each of the following criteria during the course of the disorder:
4 Pain Sx: a Hx of pain related to at least 4 different sites (e.g. head, abdomen, back, joints, chest) or functions (e.g. menstruation, sexual intercourse, urination)
2 Gastrointestinal Sx: a Hx of at least 2 GI Sx other than pain (e.g. nausea, bloating, vomiting, diarrhea, intolerance of several foods)
1 Sexual Sx: a Hx of at least 1 sexual or reproductive Sx other than pain (e.g. sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
1 Pseudoneurological Sx: a Hx of at least 1 Sx or deficit suggesting a neurological condition without pain (e.g. impaired coordination or balance, paralysis, localized weakness, difficulty swallowing, lump in throat, loss of touch or pain sensation, double vision, blindness, deafness, seizures, urinary retention)
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Somatization Disorder: Diagnostic Criteria
C. Either (1) or (2):(1) Symptoms not fully accounted for by a general medical condition or the effects of a substance(2) When there is a related medical condition, the complaints and resulting social or occupational impairment exceed what would be expected
D. Symptoms are not intentionally feigned or produced, as in Factitious Disorder or Malingering
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Somatization Disorder: General Characteristics
a complex medical history inconsistencies between subjective
complaints and objective findings colorful, dramatic quality to
complaints – exaggerating and elaborating on physical and psychiatric Sx
respond to psychological/social problems with physical symptoms
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Somatization Disorder: Facts & Figures
Prevalence: 0.2-2% among women; less than 0.2% among men.
Course: chronic, fluctuating disorder; rarely remits completely
Onset: adolescence; before 25 years old
Most common among those who are: unmarried, female, & from lower SES groups
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Somatization Disorder: Causes Hx of family illness or injury during
childhood Neurobiologically-based
disinhibition syndrome characterized by impulsive behavior and pleasure-seeking
Short-term gain of immediate attention and sympathy
Dependence
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Somatization Disorder: Treatment Considerations
No well-established treatment. Most crucial issue is to “do no harm.” Harm can be
done by not considering a possible medical basis for Sx, by unnecessary medical tests & Tx, & by inadequate Tx for valid medical conditions
Comprehensive assessment: medical history – illnesses, surgeries, pain, fatigue,
distress produced by Sx current medications abused substances psychiatric symptoms – comorbid disorders that could
account for Sx Stressors – past, present, typical response to stress Use additional informants & review medical records
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Somatization Disorder: Treatment Considerations
Long term supportive psychotherapy: therapist can provide an important, reassuring, sympathetic relationship; use brief, widely-spaced sessions
Antidepressants Use of a “gate-keeper” physician Work in tandem with a primary care
physician & psychiatrist
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Undifferentiated Somatoform Disorder: Diagnostic Criteria
A. One or more physical complaints (fatigue, loss of appetite, GI Sx, urinary complaints) which:
cause significant distress or impairment warrant medical attention last for at least 6 monthsB. R/O alternative explanations for sx: General medical conditions Effects of a substance Factitious Disorder or Malingering Other psychological disorders
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Conversion Disorder:Diagnostic Criteria
A. One or more Sx or deficits affecting voluntary motor or sensory functioning and indicative of a neurological or other medical condition
B. Psychological factors are associated with the Sx – the initiation or exacerbation of Sx is preceded by conflicts or stressors
C. The Sx is not intentionally feigned or produced, as in Factitious Disorder or Malingering
D. The Sx cannot be fully explained by a general medical condition, the effects of a substance, or a culturally sanctioned behavior or experience
E. Sx cause significant distress or impairment in functioning or warrant medical attention
F. The Sx is not limited to pain or sexual dysfunction, does not occur exclusively in the course of Somatization Disorder, and is not better accounted for by another mental disorder
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Conversion Disorder: Specifiers
Specifiers: With Motor Sx or Deficits – e.g. impaired
coordination or balance, paralysis, localized weakness, difficulty swallowing, lump in throat, urinary retention
With Sensory Sx or Deficits – loss of touch or pain sensation, double vision, blindness, deafness, hallucinations
With Seizures or Convulsions With Mixed Presentation
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Conversion Disorder: Facts & Figures
More common in: rural populations lower SES less medically/psychologically sophisticated women than men (2-10x)
In women, sx are much more common on the left than right side of the body
11-500 out of 100,000 in general population meet criteria for conversion disorder
3% of outpatient referrals to mental health clinics 1-14% of medical/surgical inpatients Onset: late childhood through early adulthood;
rarely before 10 or after 35
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Conversion Disorder:Assessment
Assess the following: physical sx, medical conditions, medications,
abused substances, psychiatric symptoms, and stressors and conflicts
the person’s level of medical knowledge whether the person may be intentionally feigning
symptoms manner of presenting symptoms – dramatic and
histrionic or la belle indifference R/O underlying neurological or general medical
conditions by referral for a thorough neuorological examination: 5-10% have real medical problems
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Conversion Disorder: Theory
Psychoanalytic: The person experiences a traumatic event, which produces
anxiety and psychological conflict Anxiety and unconscious psychological conflict are
converted to somatic symptoms Sx provide primary gain (reduce anxiety and keep the
conflict out of awareness) Sx provide secondary gain (the person obtains external
benefits, such as attention or sympathy, or evades noxious duties and responsibilities)
Getting sick provides the person an escape from a traumatic situation
Hx of significant stress Over-involved and over-protective parents Prior experience with real physical problems Underlying psychopathology
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Conversion Disorder: Treatment Considerations
Role of suggestibility – patients can be suggested into & out of Sx
Identify and attend to the traumatic or stressful life event Address current psychosocial stressors with environmental
manipulation, support, advice, and coping skills Reduce any reinforcing or supportive consequences from the
conversion Sx Insight-oriented therapies usually aren’t indicated or helpful For acute Sx: positive expectation for recovery; a face-saving
way for the patient to recover, e.g. physical therapy For chronic Sx: physical rehabilitation, suggestion, &
psychotherapy Work closely with a medical doctor and psychiatrist
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Pain Disorder: Diagnostic Criteria
A. Pain in one or more anatomical sites is the predominant focus of clinical presentation and is of sufficient severity to warrant clinical attention.
B. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
C. Pain causes clinically significant distress or impairment in important areas or functioning or warrants medical attention.
D. Pain is not intentionally feigned or produced, as in Factitious Disorder or Malingering.
E. Pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder.
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3 Types of Pain Disorder Pain Disorder Associated with Psychological
Factors: psychological factors have a major role in the onset, severity, exacerbation, or maintenance of pain
Pain Disorder Associated with a General Medical Condition: GMC or site of pain is coded on Axis III, e.g. low back, sciatic, pelvic, headache, chest, joint, abdominal, throat, urinary
Pain Disorder Associated with Both Psychological Factors and a General Medical Condition: most common
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Pain Disorder: Specifiers
Acute: duration less than 6 months
Chronic: duration 6 months or longer
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Pain Disorder: Treatment Considerations
Collect info regarding physical Sx, medical conditions, medications, abused substances, psychiatric symptoms, stressors and conflicts
Distinguish from Factitious Disorder or Malingering
Target both the physical and psychological aspects of chronic pain
Validate the person’s pain, rather than challenging or insight
Enlist the person’s cooperation in developing strategies for dealing with pain
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Pain Disorder: Treatment Considerations
Pain management: teach techniques for coping with pain; use of analgesic, anti-inflammatory, and antidepressant medications
Cognitive behavioral techniques: distraction, stress management, cognitive restructuring, activity pacing, sleep management, logging activities attempted and level of pain associated with each
Attend to factors that influence recovery: acknowledging pain; giving up unproductive efforts to control pain; participating in regularly scheduled activities despite pain; recognizing and treating comorbid disorders; adapting to a potentially chronic condition; not allowing the pain to become the determining factor in one’s lifestyle
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Hypochondriasis: Diagnostic Criteria
A. Preoccupation with fear of having or belief that one has a serious illness, based on misinterpretation of bodily Sx or functions
B. Preoccupation persists despite appropriate medical evaluation, reassurance, and the person’s not developing the feared disease
C. Preoccupation lasts at least 6 monthsD. Preoccupation causes clinically significant distress
or impairment in important areas of functioningE. Preoccupation is not better accounted for by other
disorders, such as GAD, OCD, Panic Disorder, Major Depression, Separation Anxiety, or another Somatoform Disorder
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Hypochondriasis
Specifier: With Poor Insight: person doesn’t
recognize the preoccupation is excessive or unreasonable
Prevalence: 1-5% in general population Gender Differences: Sex ratio is 50-50
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Hypochondriasis: Causes Faulty interpretation of bodily cues and
sensations as evidence of physical illness Enhanced sensitivity to, & over-focusing
on, physical sensations and illness cues Stressful life events Disproportionate incidence of disease in
family during childhood Secondary gains associated with the sick
role: decreased responsibility and increased attention
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Hypochondriasis: Treatments
Cognitive behavioral treatment: identifying & challenging illness-related misinterpretations of bodily sensations; showing patients how to create Sx by focusing attention on certain body areas
Stress management Explanatory therapy: reassurance &
education regarding the source and origins of Sx
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Body Dysmorphic Disorder: Diagnostic Considerations
A. Preoccupation with an imagined defect in appearance or markedly excessive concern about a slight physical anomaly
B. The preoccupation causes clinically significant distress or impairment in important areas or functioning
C. The preoccupation is not better accounted for by another mental disorder, such as distorted body image in Anorexia Nervosa
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Body Dysmorphic Disorder: Common Features
Constant and excessive use of mirrors Avoidance of mirrors Lots of time spent grooming Lots of grooming rituals Attempts to hide parts of body Constantly seeking reassurance about
looks, while discounting feedback Anxiety or depression about one’s
appearance
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Body Dysmorphic Disorder: Facts & Figures
People with BDD often seek help from dermatologists and plastic surgeons (rates of BDD in these settings is 6-15%)
BDD is under-recognized & under-diagnosed in nonpsychiatric settings
BDD is infrequent in mental health settings Onset: adolescence and young adulthood
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Body Dysmorphic Disorder: Causes
Defense mechanism of displacement: displacing underlying psychological conflict and anxiety onto a body part
Variant of OCD
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Body Dysmorphic Disorder: Treatment
There is little to no research on treatments for BDD
Distinguish BDD from normal concerns about appearance or overvaluing of appearance (resistant to reality testing and reassurance; cause significant distress or impairment; delusional)
Pharmacotherapy: SSRI’s at higher doses & for longer duration
CBT strategies: exposure and response prevention, self-esteem building, modifying distorted thinking, and coping strategies