SOMATOFORM DISORDERS Maria L.A. Tiamson, MD Asst. Professor, Psychiatry New York Medical College

SOMATIZATION, the concept w Poorly understood…”crocks”..”turkeys”.. “hysterics”..”worried well” w the tendency to express and communicate psychological distress in the form of somatic symptoms for which they seek medical help w “one of medicine’s blind spots”

Psychosomatic Illnesses w Asthma w Ulcerative colitis w Rheumatoid arthritis w Eczematous disorders w Irritable bowel syndrome

Forms of Somatization w Medically unexplained symptoms w Hypochondriacal somatization w Somatic presentation of psychiatric disorders (ie., depressive equivalents)

Most common presenting symptoms w Abdominal pain w chest pain w dyspnea w headache w fatigue w Cough w back pain w nervousness w dizziness

Infectious Diseases w Lyme disease w AIDS w Infectious mononucleosis w Syphilis w Chronic Fatigue Syndrome w Post-infection syndromes

SOMATIZATION, the cost w 10% of total direct healthcare costs with the potential to bankrupt the healthcare financing system w Somatizers have 9x more total charges, 6x more hospital charges, 14x more MD services w Somatizers are sick in bed an average of 7 days a month vs days for the general population

SOMATIC COMPLAINTS w Patients who experience their symptoms but do not deliberately produce them (SOMATOFORM DISORDERS) w Patients who knowingly create symptoms in themselves, either for material gain (MALINGERING), or for more subtle benefits, such as gratification of the patient role (FACTITIOUS DISORDERS)

Pathophysiological Mechanisms w Physiological Mechanisms autonomic arousal muscle tension hyperventilation vascular changes cerebral information processing physiological effects of inactivity sleep disturbance

Pathophysiological Mechanisms w Psychological Mechanisms perceptual factors beliefs mood personality factors w Interpersonal Mechanisms reinforcing actions of relatives and friends health care system disability system

DSM-IV Somatoform Disorders w A group of disorders that include medical symptoms and complaints FOR WHICH AN ADEQUATE MEDICAL EXPLANATION CANNOT BE FOUND. w Not intentionally produced w Onset, severity and duration of symptoms are strongly linked to psychological factors

DSM-IV Somatoform Disorders w Somatization Disorder w Conversion Disorder w Hypochondriasis w Body Dysmorphic Disorder w Somatoform Pain Disorder w Undifferentiated Somatoform Disorder w Somatoform Disorder, NOS

Somatization Disorder w “hysteria”, Briquet’s Syndrome w multiplicity of somatic complaints involving multiple organ systems w female predominance w before age 30 w chronic w excessive medical help-seeking behavior

Somatization Disorder w Cannot be fully explained by any known GMC or substance use w if GMC is present, physical complaints or impairment are in excess of what could be expected w significant impairment in functioning

Somatization Disorder w Four pain symptoms w One sexual symptom w One pseudoneurological symptom w Two GI symptoms

Somatization Disorder w Complaints described in colorfiul, exaggerated terms but lack specific factual information w prominent anxiety and depressive symptoms w 10-20% female 1st degree relatives of SD women, increased ASPD and SUD in male rrelatives

Conversion Disorder w Monosymptomatic (one or more neurological symptoms) w Most common in adolescents, young adults rural populations low education and low IQ low socioeconomic group military personnel exposed to combat

Conversion Disorder w Symptom has a symbolic relation to the unconscious conflict w “la belle indifference”

Conversion Disorder w Impaired coordination, balance w paralysis, weakness w aphonia, difficulty swallowing, lump in the throat w urinary retention w loss of touch/pain, double vision, blindness w deafness, seizures

Conversion Disorder w Symptoms do not conform to known anatomical pathways and physiological mechanisms w often inconsistent w DDX: multiple sclerosis, myasthenia gravis, dystonias

Conversion Disorder w Dramatic or histrionic w suggestible w sx are self-limited and do not lead to physical changes/disability w associated with dissociative disorders, MDD, histrionic, antisocial and dependent personality disorders

Hypochondriasis w Preoccupation with the fear of contracting, or the belief of having, a serious disease w Usually with co-morbid depression, anxiety w Misinterpretation of physical symptoms and sensations w Request for admission to the “sick role”, which offers an escape

Hypochondriasis w Preoccupation is with any of the ff: bodily functions, minor physical abnormalities, vague and ambiguous physical sensations w medical history is presented in great detail and length w “doctor shopping” w associated with serious illness in childhood, past experience with disease in a family member

Body Dysmorphic Disorder w Preoccupation with an imagined defect or an exaggerated distortion of a minimal or minor defect in physical appearance w dysmorphophobia w Comorbid with major depression (90%), anxiety disorder (70%), psychotic disorder (30%)

Body Dysmorphic Disorder w Marked distress over supposed deformity w frequent mirror checking and checking in other reflecting surfaces w excessive grooming behavior w use of special lighting or magnifying glasses w avoidance of usual activities

Somatoform Pain Disorder w Presence of pain that is the “predominant focus of clinical attention” w Not fully accounted by a nonpsychiatric medical or neurological condition w The symbolic meaning of body disturbances relate to atonement for perceived sin, to expiation of guilt, or to suppressed aggression

Nonspecific Somatoform Disorders w Undifferentiated somatoform disorder unexplained physical effects that last for at least six months w Somatoform Disorder, NOS residual category

Relation of Depression and Somatization w Patients with SD have a high prevalence of depression (48-94%) w Patients with MDD have substantial levels of somatization (63-84%) w Depression can be treated successfully when it coexists with SD Smith, 1992

Relation of Depression and Pain w Patients with chronic pain have a significant current prevalence of depressive disorders w More than half of patients with MDD complain of pain w Pain is reduced with the treatment of depression Smith, 1992

Baron Karl Friedrich Hieronymus von Munchausen

Factitious Disorders w Psychological symptoms w Physical symptoms w Munchausen’s syndrome, pseudologica fantastica, peregrination w usually co-morbid with psychiatric conditions w intentional production of symptoms but goal is intangible and psychologically complex

ALERT…ALERT…ALERT... w Numerous surgical scars, usually in the abdominal area w Patient is truculent and evasive w Personal and medical history were fraught with acute and harrowing adventures w History of many hospitalizations, malpractice claims, insurance claims w Involved in the healthcare profession

Symptom Types w Total fabrications w Exaggerations w Simulations of the disease w Self-induced disease

A Physical Diagnosis is more likely if…. w Symptoms do not meet DSM-IV criteria. w Premorbid social history is unremarkable. w There is an ABRUPT change in personality, mood, or ability to function. w There are RAPID fluctuations in mental status. w There is lack of response to usual biologic or psychologic interventions.

Principles of Management w Emphasize explanation w Arrange for regular follow-up w Treat mood/anxiety disorder w Minimize polypharmacy and multiple diagnostic tests w Provide specific treatment when indicated

Remember…. w Reassurance that “nothing is wrong” does NOT help. w The patient does not want symptom relief but rather a RELATIONSHIP and understanding. w Little is to be gained by saying that “it’s all in your head”.

Remember... w You should acknowledge the patient’s plight, avoid challenging the patient. w A positive organic diagnosis will not cure the patient. w SOMATIZATION MAY CO-EXIST WITH ANY PHYSICAL ILLNESS AND MAY INITIALLY MASK THE ILLNESS.

Malingering w Intentional fabrication of symptoms to achieve a secondary gain, usually material benefits