SOMATOFORM DISORDERS BERFİN GİZEM USLU

Somatoform disorders are a group of illnesses, each of which is marked by physical symptoms that are not explained by a general medical condition.

Somatic symptoms and related disorders in DSM-5 Somatic symptom disorder Illness anxiety Conversion disorder Psychological factors affecting other medical conditions Factitious disorder

Somatoform disorders common to the American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) Somatization disorder Conversion disorder Pain disorder Hypochondriasis Body dysmorphic disorder Undifferentiated somatoform disorder Somatoform disorder not otherwise specified

The somatoform disorders category includes the following diagnoses: Somatization disorder Conversion Hypochondriasis Body dysmorphic disorder Factitious disorder

SOMATIZATION DISORDER (Briquet’s Syndrome) In Briquet’s syndrome, first described by Paul Briquet in 1859, patients feel that they have been sickly most of their lives and complain of a multitude of symptoms referable to numerous different organ systems. This conviction of illness persists despite repeatedly negative and unrevealing consultations, hospitalizations, and diagnostic procedures, and patients continue to seek medical care, to take prescription medicines, and to submit to needless diagnostic procedures.

EPIDEMIOLOGY — Somatization is common in the general population EPIDEMIOLOGY — Somatization is common in the general population. More than 50 percent of patients presenting to outpatient medical clinics with a physical complaint do not have a medical condition. Risk factors for somatization include: ●Female sex ●Fewer years of education ●Minority ethnic status ●Low socioeconomic status

DSM-IV-TR diagnostic criteria for somatization disorder 1.A history of many physical complaints that begin before age 30, occur over a period of several years, and lead to seeking treatment or to significant impairment in occupational, social, or other important areas of functioning. 2.Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: Four pain symtoms Two gastrointestinal symptoms One sexual symptom One pseudoneurological symptom

1. Four pain symptoms: a history of pain related to at least four different sites or functions (eg, head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination) 2. Two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (eg, nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods) 3. One sexual symptom: a history of at least one sexual or reproductive symptom other than pain (eg, sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy) 4. One pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)

3.Either (1) or (2): 1. After appropriate investigation, each of the symptoms in criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (eg, a drug of abuse, a medication) 2. When there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings 4.The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering).

CLINICAL PRESENTATION Pain symptoms, including headache, back pain, dysuria, joint pain, diffuse pain, and extremity pain ●Gastrointestinal symptoms, including nausea, vomiting, abdominal pain, bloating, gas, and diarrhea ●Cardiopulmonary symptoms, including chest pain, dizziness, shortness of breath, and palpitations ●Neurologic symptoms, including fainting, pseudoseizures, amnesia, muscle weakness, dysphagia, double or blurred vision, difficulty walking, difficulty urinating, deafness, and hoarseness or aphonia ●Reproductive organ symptoms, including dyspareunia, dysmenorrhea, and burning in sex organs

CONVERSION  Conversion disorder (functional neurologic symptom disorder) is characterized by neurologic symptoms (eg, weakness, abnormal movements, or nonepileptic seizures) that are inconsistent with a neurologic disease, but nevertheless are genuine, cause distress and/or psychosocial impairment.

 A DSM-5 diagnosis of conversion disorder requires each of the following criteria 1.One or more symptoms of altered voluntary motor or sensory function 2.Clinical findings that demonstrate incompatibility between the symptom and recognized neurologic or general medical conditions (eg, Hoover's sign of functional limb weakness or a positive entrainment test for functional tremor) 3.The symptom or deficit is not better explained by another medical or mental disorder 4.The symptom or deficit causes significant distress, psychosocial impairment, or warrants medical evaluation  

Conversion disorder can present with : ●Nonepileptic seizures ●Weakness and paralysis ●Movement disorders ●Speech disturbances ●Globus sensation ●Sensory complaints ●Visual symptoms ●Cognitive symptoms

Hypochondriasis Preoccupations with fear of having a serious disease with misinterpretation of bodily symptoms. Persists despite appropriate medical evaluation and reassurance.Lasts at least 6 months.

DSM-IV-TR diagnostic criteria for hypochondriasis A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms. B. The preoccupation persists despite appropriate medical evaluation and reassurance. C. The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder) D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The duration of the disturbance is at least six months. F. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder.

Choosing treatment — We suggest that acute treatment of illness anxiety disorder proceed according to the sequence described in the subsections below. Patients initially receive first line therapy and progress through each step until they respond: ●First line – Cognitive-behavioral therapy ●Second line – A different psychotherapy ●Third line – Antidepressant medication

Body dysmorphic disorder  Body dysmorphic disorder (BDD) is characterized by preoccupation with nonexistent or slight defects in physical appearance, such that patients believe that they look abnormal, unattractive, ugly, or deformed, when in reality they look normal. The preoccupation with perceived flaws leads to repetitive behaviors (eg, checking their appearance in mirrors), which are difficult to control and are not pleasurable.

DSM-5 diagnostic criteria for body dysmorphic disorder A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors (eg, mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (eg, comparing his or her appearance with that of others) in response to the appearance concerns. C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Factitious disorder (Munchausen syndrome) Factitious disorder imposed on self is characterized by falsified general medical or psychiatric symptoms. Patients deceptively misrepresent, simulate, or cause symptoms of an illness and/or injury in themselves, even in the absence of obvious external rewards such as financial gain, housing, or medications. Factitious disorder imposed on self is distinguished from factitious disorder imposed on another, such as a child or older adult.

Diagnostic criteria — We suggest diagnosing factitious disorder imposed on self according to the criteria in DSM-5, which require each of the following: ●Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception ●The individual presents himself or herself to others as ill, impaired, or injured ●The deceptive behavior is evident even in the absence of obvious external rewards ●The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder