1. All " Members" IMA Pathankot
“ IMA PRAYER ”
May happiness comes to all May all be free from disease May everyone of us ensure that no one suffer from pain or sorrow Neither do I desire the crown nor heaven nor rebirth I only desire to alleviate the sufferings of the creatures burning in the fire of pain or sorrow
Friday, 05-June-15
All " Members" IMA Pathankot

2. Dr. Sameer Mahajan Consultant Psychiatrist Pathankot

3. Somatoform disorders DSM-IV ICD-10
Somatoform disorders are distinguished by physical symptoms suggesting medical condition, yet the symptoms are not fully explained by the medical condition, by substance use or by another mental disorder.
ICD-10
Somatoform disorders are described as repeated presentation of physical symptoms together with persistent requests for medical investigation although the patients have been repeatedly reassured by the physician that the symptoms have no physical basis.

4. Somatoform disorders ------- some imp. Facts:-
Significant distress
Impaired social functioning
Impaired occupational functioning
Severe enough
Symptoms are not intentionally produced as in factitious disorders and in malingering.
No medical condition can fully explain the somatic symptoms.
Onset, duration and severity of symptoms are strongly linked to
psychological factors.
Both physician and patients can be frustrated by the attempts to understand and alleviate these disorders.

5. Types of Somatoform disorders
Somatization disorder
Conversion disorder
Hypochondriasis
Body dysmorphic disorder
Somatoform pain disorder
Undifferentiated somatoform disorder
Somatoform disorder not otherwise specified

6. Somatization disorder
Conversion disorder
Somatization disorder

7. Somatization disorder
( Briquet’s syndrome )
Multiplicity of Complaints
The Multiple Organ Systems affected.
Distinguished by combination of pain, gastrointestinal, sexual and pseudo-neurological symptoms.
Pts describe their complaints in a dramatic, emotional and exaggerated manner.
Usually begins before the age of 30 yrs, continue for years
Prevalence
0.1 to 0.2 percent
Female predominance
F : M = 20 : 1

8. Cause is -------------------------- unknown
Somatization disorder Cont....
Genetic Factors
Social , cultural and ethnic factors
Neuro -chemical factors as abnormal level of cytokines
Cause is unknown

9. No Factitious Disorder
Somatization disorder Cont....
Many physical complains
< 30 years age
Symptoms chronicity
Social, occupational loss
Diagnostic Criteria
Pain related to at least 4 different
sites or functions.
2 GI symptoms.
1 sexual symptoms
1 Pseudo- neurological symptoms
Any of the symptoms NOT due to
any drug abuse or medication.
Symptoms are always in “ Excess”
No Factitious Disorder Or
No Malingering

10. Three Features most suggestive of Somatization Disorder are:-
Somatization disorder Cont....
Thyroid
Hyper parathyroid
Intermittent Porphyria
Multiple Sclerosis
SLE
Differential Diagnosis
Three Features most suggestive of Somatization Disorder are:-
1. Involvement Multiple Organ System
2. Even with early onset and Chronic course of symptoms
there is NO physical sign and structural abnormality.
3. All Lab Investigations ---- Normal

11. Somatization disorder Cont....
Course and prognosis
Chronic, Undulating, and Relapsing disorder that rarely remits completely.
Research has indicated that a person diagnosed with Somatization disorder has approximately an 80 percent chance of being diagnosed with this disorder 5 years later.
Although patients with this disorder consider themselves to be medically ill, good evidence is that they are no more likely to develop another medical illness in the next 20 years than people without Somatization disorder.

12. Psychotherapy Treatment Somatization disorder Cont....
Somatization disorder is best treated when the patient has a single identified physician as primary caretaker.
Once somatisation disorder has been diagnosed, the treating physician should listen to the somatic complaints as emotional expression rather than as medical complaints.
Psychotherapy
Few available data indicate that Psychopharmacological treatment is effective in patients without coexisting mental disorders.
Medication must be monitored, because patients with somatisation disorder tend to use drugs erratically and unreliably.

13. Video Clip relevant to somatization disorder

14. Somatization disorder
Conversion disorder
Conversion disorder

15. Dissociative reaction. Somatization disorder
CONVERSION DISORDER
Hysteria or
Conversion reaction
Dissociative reaction.
Conversion disorder +
Somatization disorder
Conversion disorder is an illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors because the illness is preceded by conflicts or other stressors.

16. ( Father of Psychoanalysis) ( The Napoleon of neurosis )
Conversion disorder Cont….
Introduce the term “ Conversion disorder ”
Hypothesized that the symptoms of conversion disorder reflect unconscious conflicts.
Sigmund Freud
( Father of Psychoanalysis)
The influence of heredity on the symptom
The association with a traumatic event.
Paul Briquet
Jean-Martin Charcot
( The Napoleon of neurosis )

17. 11 in 100,000 To 300 in 100,000 Women : Men = 2 : 1 to 10 : 1
Conversion disorder Cont….
11 in 100, To in 100,000
Women : Men = 2 : 1 to : 1
On the left side > On the right side
An association exists between conversion disorder and antisocial personality disorder in men.
The onset of conversion disorder is generally rare before 10 years of age or after 35 years of age

18. An elaboration of symptoms stemming from the original organic lesion.
Conversion disorder Cont….
Co morbidity
Medical disorder
Neurological disorder
Psychiatric disorder
May or
May not
Conversion disorders
An elaboration of symptoms stemming from the original organic lesion.

19. Hemispheric communication
Conversion disorder Cont….
Etiology
Psychoanalytic Factors
Learning Theory
E.g. Symptoms of illness, learned in child-hood, are called forth as a means of coping with an otherwise impossible situation.
Biological Factors
Hypo-metabolism of the dominant hemisphere and hyper-metabolism of the non-dominant hemisphere
Impaired
Hemispheric communication
Negative feedback loops between the cerebral cortex and the brainstem reticular formation.

20. Anesthesia, especially of extremities Involuntary movements
Conversion disorder Cont….
Common Symptoms
Sensory Deficits
Anesthesia, especially of extremities
Midline anesthesia
Blindness
Tunnel vision
Deafness
Motor Symptoms
Involuntary movements
Tics
Blepharospasm,
Torticollis
Opisthotonos
Seizures
Abnormal gait
Falling
Astasia-abasia
Paralysis
Weakness
Aphonia
Visceral Symptoms
Psychogenic vomiting
Pseudoseizures
Globus hystericus
Swooning or syncope
Urinary retention
Diarrhea

21. These Motor Symptoms worsen on attention
Conversion disorder Cont….
These Motor Symptoms worsen on attention
In astasia-abasia --- the gait is a wildly ataxic, staggering gait accompanied by gross, irregular, jerky truncal movements and thrashing and waving arm movements.
Motor Symptoms
Involuntary movements
Tics
Blepharospasm,
Torticollis
Opisthotonos
Seizures
Abnormal gait
Falling
Astasia-abasia
Paralysis
Weakness
Aphonia
Patients rarely fall: if they do, they are generally not injured.
In paralysis and paresis
The distribution of the involved muscles does not conform to the neural pathways.
Reflexes remain normal
The patients have no fasciculations or muscle atrophy (except after long-standing conversion paralysis)
Electromyography findings are normal.

22. Anesthesia, especially of extremities Deafness and Blindness
Conversion disorder Cont….
The distribution of the sensory disturbance is usually inconsistent with either central or peripheral neurological disease.
stocking-and-glove anesthesia of the hands or feet
Sensory Deficits
Anesthesia, especially of extremities
Midline anesthesia
Blindness
Tunnel vision
Deafness
Hemi anesthesia of the body beginning precisely along the midline.
Deafness and Blindness
Neurological evaluation reveals intact sensory pathways.
Patients walk around without collisions or self-injury
Their pupils react to light
Their cortical evoked potentials are normal.

23. Pupillary and gag reflexes are retained after pseudo seizures
Conversion disorder Cont….
Pseudo seizures
Tongue-biting, urinary incontinence and injuries after falling are generally not present.
Pupillary and gag reflexes are retained after pseudo seizures
Patients have no post seizure increase in prolactin concentrations.
Visceral Symptoms
Psychogenic vomiting
Pseudoseizures
Globus hystericus
Swooning or syncope
Urinary retention
Diarrhea

24. Diagnostic Criteria One or more symptoms or deficit Motor or Sensory
Conversion disorder Cont….
Diagnostic Criteria
One or more symptoms or deficit
Motor or Sensory
( suggesting Medical or Neurological condition)
Symptoms or Deficit
proceeded by
Conflict or Stresses

25. Conversion disorder Cont….
Several psychological symptoms have also been associated with conversion disorder :-
Symptoms have symbolic value: they represent an unconscious psychological conflict.
PRIMARY GAIN
Patients accrue tangible advantages and benefits as a result of being sick: for example, being excused from obligations and difficult life situations, receiving support and assistance that might not otherwise be forthcoming, and controlling other persons' behavior
SECONDARY GAIN
The patient seems to be unconcerned about what appears to be a major impairment.
LA BELLE INDIFFERENCE
A parent or a person who has recently died may serve as a model so persons commonly have symptoms of the deceased.
IDENTIFICATION

26. Conversion disorder Cont….
Current or Previous neurological disorder Or
A medical systemic disease affecting the brain
18 to 64 %
Thus, a thorough medical and neurological workup is essential in all cases.
If the symptoms can be resolved by suggestion, hypnosis, or parenteral amobarbital or lorazepam, they are probably the result of conversion disorder

27. Differential Diagnosis
Conversion disorder Cont….
Differential Diagnosis
Neurological disorders ( e.g. dementia and other degenerative diseases),
Brain tumors
Basal ganglia diseases
Myasthenia gravis
Polymyositis
Aacquired myopathies MS
Optic neuritis
GuiIlain-Barre syndrome
Creutzfeldt-Jakob disease
periodic paralysis
early neurological manifestations of acquired immunodeficiency syndrome (AIDS)

28. Course and Prognosis Paralysis Aphonia Blindness Good prognosis
Conversion disorder Cont….
Course and Prognosis
Usually acute onset
95 % of acute cases remit spontaneously, usually within 2 weeks
If symptoms present for 6 months ---- the prognosis for resolution is less than 50 %
Paralysis
Aphonia
Blindness
Good prognosis
Tremor and Seizures
Poor prognosis
A short interval between onset and the institution of treatment

29. Treatment Insight-oriented supportive or behavior therapy.
Conversion disorder Cont….
Treatment
Insight-oriented supportive or behavior therapy.
A caring and confident Psycho-therapist.
Psychotherapy should focus on issues of stress and coping.
Hypnosis, anxiolytics, and behavioral relaxation exercises are effective
Parenteral amobarbital or lorazepam may be helpful , especially when a patient has recently experienced a traumatic event.

30. Psychodynamic approaches
Conversion disorder Cont….
Psychodynamic approaches
The longer the duration of these Conversion symptoms
The more they have regressed
The more difficult the treatment

31. Video Clip relevant to Conversion disorder

32. Thanks for kind listening