Somatoform Disorder

Seeking medical attention for that physical distress wandering uterus Soma – Meaning Body Experiencing physical distress/symptoms in response to mental/emotional conflict Seeking medical attention for that physical distress wandering uterus Types of DSM-IV Somatoform Disorders Hypochondriasis Somatization disorder Conversion disorder Pain disorder Body dysmorphic disorder

Somatization Disorder Seeking treatment for many physical complaints, with onset before age 30 Four pain symptoms Two gastrointestinal symptoms One sexual symptom One pseudoneurological symptom

Associated Features Stories are often vague, inconsistent, colorful and dramatic Frequently seek care from multiple providers with repeated work-ups High comorbidity with personality disorders (especially histrionic) More common in women Chronic and fluctuating course One or more symptoms affecting voluntary motor or sensory function Resembles neurological or medical disease Psychological factors must be involved The symptoms are NOT intentionally produced

Causes- Treatment- Familial history of illness Relation with antisocial personality disorder Weak behavioral inhibition system Treatment- No treatment exists with demonstrated effectiveness Reduce tendency to visit numerous medical specialists Assign “gatekeeper” physician Reduce supportive consequences of talk about symptoms

Hypochondriasis Preoccupation with fears of having a serious disease based on misinterpretation of bodily sensations Preoccupation goes on despite medical evaluation and reassurance (poor insight) Duration is at least six months Serious childhood illnesses and past experience with illness in a family member are common “Doctor-shopping” and costly medical work-ups are common Appears equally common in men and women

Causes Treatment Cognitive perceptual distortions Familial history of illness Treatment Challenge illness-related misinterpretations Provide more substantial and sensitive reassurance

Body Dysmorphic Disorder Preoccupation with an imagined defect in appearance If the individual already has a mild physical “flaw” the concern surrounding it is excessive Frequent inspection of the “defect” can consume many hours a day, lead to suicidal thoughts Insight is often poor- can become delusional Medical and surgical treatments are often pursued High prevalence in cosmetic surgery and dermatology clinics

Common Locations of Defects Hair Nose Skin Eyes Head / Face Lips

Factitious Disorder “I know I’m producing my symptoms, but I don’t understand why” Intentional production of physical or psychological signs and symptoms The motivation for the behavior is to assume the sick role (primary gain) External incentives (such as economic gain, or avoiding responsibilities) are absent (i.e., no secondary gain)

Associated features Often involves multiple hospitalizations at multiple sites Invasive procedures and surgery Usually have few visitors while in the hospital Patients often have extensive knowledge of medical terminology (health care workers, etc.)

Munchausen Syndrome? Another term for Factitious Disorder Baron Von Munchausen was a fictional eighteenth-century character known for story-telling, exaggeration and frequent travel

Munchausen by Proxy Parent induces illness in a child The child is repeatedly hospitalized as a result

Malingering Intentional production of false or exaggerated physical or psychological symptoms The malingerer is aware that he is producing the symptoms for gain (secondary gain)

Causes- Treatment- Little is known Shares similarities with obsessive-compulsive disorder Treatment- Parallels that for obsessive-compulsive disorder Medications (i.e., SSRIs) provide some relief Exposure and response prevention is also helpful Plastic surgery is often unhelpful

Neurasthenia- increased fatigue , body weakness, muscular pain, dizziness, dyspepsia , functional impairment, soft physical signs, sleep disturbance, headache,irritability >>> distressing complaints after mental complaints

Depersonalization Disorder Feeling detached from and outside of one’s body (like you’re in a dream) During the experience reality testing is still intact (not a psychotic episode) Prevalence is unknown, but appears common in mild form Many people without psychiatric pathology have had this experience

Derealization A feeling or experience that the external world is strange or unreal May occur during Depersonalization Disorder Other people may seem unfamiliar or mechanical Size or shape of objects in external world may seem altered

RX… Rule out medical causes Medications not helpful with Dissociation, but may help with comorbid anxiety or depression Depersonalization Disorder may respond to SSRIs

Hyperventilation Syndrome Excessive fatigue, chest pain, headache, palpitation, sweating and feeling of lightheadedness In severe hyperventillation- carpopedal spasm, paresthesias and LOC

Rx… Jacobson’s progressive muscular relaxation, hypnosis, yoga, transcendental meditation Breathing-in-bag technique Rx. If anxiety, depression

Irritable Bowel Syndrome Spastic colitis, irritable colon syndrome, nervous diarrhea, mucus colitis, colon neurosis Abdominal pain, cramps Alteration of bowel habits Sensation of incomplete evacuation 40% in all pt. attending gastroenterology clinics Psychological stressors leads to – hypo-motility and hyper-motility

Rx… Supportive psychotherapy Identification of stressors Anti-anxiety and Anti-depressants Prokinetic agents and fibre rich diet

Premenstrual Syndrome Premenstrual tension is characterized by feelings of irritability, depression, crying spells, restlessness and anxiety Swelling of breasts, pedal edema, wt. gain, gastrointestinal manifestations Starts after few days of ovulation, 4- 5 days before menstruation Due to excess estrogen, progesterone deficiency

Rx… Diuretics, restriction of excess fluid intake Psychotherapy Hormonal therapy Bromocriptine, anti-anxiety and anti-depressant

Other specified Neurotic Disorders/Cultural Bound Syndromes Dhat Syndrome- whitish discharge in the urine (semen) It’s a masturbatory anxiety and over concern with noctural emission Amok- sudden unprovoked episode of rage which may kill or injure (Malaysia)

Koro- a belief that penis is shrinking and may disappear (shrinking of breasts and vulva in females) Wihtigo (windigo)-a belief that one has transformed into a cannibal monster during starvation Piblokto (Arctic Hysteria)- screaming and tearning of clothes, may imitate birds and animals, followed by transient amnesia Latah(Startle Reaction)-automatic obedience, echo-lalia, echo-praxia due to sudden stimulus

Post Traumatic Stress Disorder Exposed to traumatic event The person’s response involved intense fear, helplessness or horror witnessed, or was confronted with an event involving actual or threatened death, serious injury The traumatic event is re-experienced in one or more of the following ways Recurrent images, thoughts, recurrent distressing dreams of the event Persistent avoidance of stimuli associated with trauma and numbing as indicated by 3 or more: Avoiding thoughts, feelings, or discussion, activities, places or people that bring back recollections; sense of foreshortened future, feeling detached Persistent symptoms of increased arousal by 2 or more: Difficulty falling or staying asleep, Irritability or outbursts of anger Difficulty concentrating Duration for more than 1 month

1-14% community, 3-58% in at-risk populations 25-30% lifetime prevalence in Vietnam veterans 85% in concentration camp survivors 30% recover completely 40% continue with mild symptoms 20% moderate symptoms 10% unchanged or worsen

Examples of Traumatic Events Complicated or unexpected bereavements Accidents Captivity Violent crime Sexual trauma Chronic physical abuse Military combat Natural disasters Manufactured disasters

Treatment Talking about the trauma allowing Individual or group therapy, hypnosis , followed by support Pharmacotherapy Psychotherapy Relaxation Training

DREAMS Detachment Re-experiencing the event Emotional effects Avoidance Month in Duration Sympathetic hyperactivity or hypervigilance

PTSD Questionnaire

A 22 year old woman presents to the doctor convinced that there is something wrong with her. She reports frequent headaches that are not relieved with aspirin. She has been to numerous physicians and all have told her that there is nothing wrong with her. She expects that you can help her bcoz she knows that there is something wrong and that you can adequately treat her condition. what is your diagnosis? Generalized Anxiety Disorder Mood Disorder Hypochondriasis Factitious Disorder

A 40 year old homeless man presents to the hospital on a cold night complaining of auditory hallucinations telling him to kill himself. When asked about the past psychiatric history, he is unable to give any detailed information. He seems concerned about being admitted immediately and refuses all medications, when offered. What is your diagnosis? Factious Disorder Malingering Disorder Schizophrenia Panic Disorder

The mother of a 20 year old man presents to your office in tears The mother of a 20 year old man presents to your office in tears. She insists that you come to her house and see her son, who has been homebound for several years. She tells you that her son refuses to leave the house bcoz he believes that he is ugly and people will laugh at him. He feels deformed and refuses to let others see him. When you arrived at the house , you find an attractive young man with no observable deformities. What is your diagnosis? Mental retardation Psychosis Body Dysmorphic Disorder Munchausen by Proxy