1. Somatoform Disorder

2. 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

3. 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

4. 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

5. 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

6. 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

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

9. 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

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

11. 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)

12. 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.)

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

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

15. 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)

16. 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

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

18. 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

19. 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

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

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

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

24. 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

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

26. 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

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

28. 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)

29. 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

30. 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

31. 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

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

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

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

35. PTSD Questionnaire

36. 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

37. 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

38. 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