Somatoform Disorders DSM IV TR Somatic Symptom and

Somatoform Disorders (DSM IV TR) = Somatic Symptom and related disorders (DSM V) Jacob Alexander Senior Lecturer/Consultant Psychiatrist CHSA

Introduction • Group of illnesses where bodily signs and symptoms are a major focus • Believed to originate from faulty mindbody interactions- the brain sends signals that impinge on the patients awareness falsely suggesting a serious problem in the body • The symptoms are medically unexplained • Patients are convinced that their suffering comes from some type of undetected and untreated bodily derangement

Historical background……. • “Somatoform”/ “ Somatic” derived from Greek “soma” – body • Grouped together for the first time in the DSM III in 1980 • Observed for a long time before that and several terms used to refer to these disorders including neurasthenia, hysteria and Briquet’s syndrome • Some famous contributors-Jean Marie Charcot, Paul Briquet, Sigmund Freud

Somatoform disorders 1. Somatization disorders- multiple organ system involvement 2. Conversion disorders- neurological complaints 3. Hypochondriasis- worried about being sick with a particular illness rather than a focus on physical symptoms (Now Illness Anxiety disorder in DSM V) 4. Body dysmorphic disorder- dissatisfaction with a body part (Now shifted to Obsessive disorders in the DSM V) 5. Persistent somatoform pain disorder- pain is the main complaint (Now part of Somatic Symptom disorder in DSM V) 6. Undifferentiated somatoform disorder 7. Somatoform disorder not otherwise specified

DSM V: Somatic Symptoms and related disorders • Somatic Symptom Disorder • Illness anxiety disorder (Hypochondriasis) • Conversion disorder (Functional Neurological Symptom disorder) • Psychological Factors affecting other medical conditions • Factitious disorders • Other specified Somatic Symptoms and related disorders (pseudocyesis) • Unspecified Somatic Symptom and related disorder

Somatic Symptom disorder A. One or more somatic symptoms that are distressing or result in significant disruption of daily life B. Excessive thoughts, feelings or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following: • Disproportionate and persistent thoughts about the seriousness of one’s symptoms • Persistently high levels of anxiety about health or symptoms • Excessive time and energy devoted to these symptoms or health concerns C. State of being symptomatic is persistent > 6 months Specify: predominant pain, persistent, severity

Somatic symptom disorder A- many physical symptoms - starting before the age of 30 - occur over a period of years - leads to multiple medical consultations and other attempts at seeking treatment -significant impairment in social, occupational, or other areas of functioning B -4 pain symptoms- related to at least 4 different sites or functions -2 gastrointestinal symptoms other than pain -1 sexual or reproductive symptom -1 pseudoneurological symptom

Somatic Symptom disorder C- despite appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance -when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what could be expected from the history, physical examination, or laboratory findings. D- the symptoms are not intentionally produced or feigned

Somatic symptom disorder- some facts • Commoner in women (life time prevalence 0. 2 -2% of women and 0. 2% of men) • 5 -10 % of patients presenting to a GP • Inversely related to social position • Usually beginning in teenage years • Often co-morbid with other mental dis. depression and anxiety • Common personality traits-avoidant, paranoid, self-defeating, obsessivecompulsive

Somatic Symptom disorder Psychodynamic factors Learning theory Social/Cultural factors Biological factors Genetic factors Cytokines

Somatization disorder-clinical features (commonest) Common characteristics of presenting problem • • • Long, complicated medical histories-confused time frames Patients frequently report they have been sickly all their life Psychological and interpersonal problems Suicide threats common but rarely acted upon Dramatic and emotional presentation of history and appearance Self centred, hungry for admiration, manipulative Commonest Symptoms reported • • • Nausea and vomiting other than during pregnancy Pain in the arms and legs Shortness of breath unrelated to exertion Amnesia Complications of pregnancy and menstruation

Somatic Symptom disorder-DD, course and prognosis Differential Diagnosis • • • Genuine illness Psychiatric syndromes-depression, anxiety Life stressors with associated psychophysiological symptoms Other somatic related disorder Voluntary psychogenic symptoms or syndromes Course • chronic, undulating and relapsing illness • Rarely fully remits- unusual for patients to be symptom free for more than a year • Not more likely than others to develop a medical illness at 20 yr follow up

Somatic Symptom disordertreatment • Single, identified physician as primary care giver • Regular, scheduled visits usually at monthly intervals • Keep interviews brief with a partial physical exam for each new symptom expressed • Generally avoid lab/diagnostic investigations • Once diagnosed view these problems as being communications of emotional distress • Try and raise awareness of these symptoms being responses to psychological pressures and see if you can motivate patient to see a mental health clinician • Individual or group psychotherapy

Somatic Symptom disorder- tasks of psychotherapy • Decrease the patients personal health expenditures • Help to cope with their symptoms • Assist with expressing underlying emotions • Help to develop alternative strategies for expressing their feelings • Psychopharmacological intervention difficult

Conversion disorder Neurological complaint • • • With weakness or paralysis With abnormal movement With swallowing problems With speech problems With attacks or seizures With anaesthesia or sensory loss • With special sensory symptoms • With mixed symptoms

Conversion disorder • • Qaulifiers: Acute Episode < 6 months Persistent With/out psychological stressor

Conversion disorder A- one or more symptoms of deficit affecting voluntary motor or sensory function that suggest a neurological or other general medical condition B-Psychological factors are judged to be associated with the symptom deficit because the initiation or exacerbation of the symptoms or deficit is preceded by conflicts or other stressors C-The symptom or deficit is not intentionally produced or feigned D-The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition or by the direct effects of a substance, or as a culturally sanctioned behaviour or experience E-Causes clinically significant distress or impairment in social, occupational or other important areas of functioning or warrants medical evaluation F-The symptoms or deficit is not limited to pain or sexual dysfunction, does not exclusively occur during the course of a somatisation disorder and is not better accounted for by another mental disorder

Conversion disorder Common amongst: -F>M -rural population -little education -low SES -military personnel exposed to combat situations Co-morbidities include-MDD, Anxiety, schizophrenia, somatisation, histrionic pd, passive-dependent pd

Conversion disorder-clinical features Motor symptoms • Involuntary movements • Tics • Blepharospasm • Torticollis • Opisthotonus • Seizures • Abnormal gait • Falling • Astasia-Abasia • Paralysis • Weakness • aphonia Sensory deficits • Anaesthesia of extremities • Midline anaesthesia • Blindness • Tunnel vision • Deafness Visceral symptoms • Psychogenic vomiting • Pseudocyesis • Globus hystericus • Swooning or syncope • Urinary retention • diarrhoea

Conversion disorder-aetiology Psychodynamic factors- intrapsychic conflict, repression, sublimation, projection Learning theory/ social factors – nonverbal means of controlling and managing others Biological factors- impaired hemispheric function Genetic factors- women probands more prone to somatisation, depression and anxiety, male probands more prone to ASPD and substance abuse

Psychological Concepts in Somatoform disorders • Primary Gain- distracts from primary intrapsychic conflict • Secondary Gain-receives tangible benefits to sick role • La Belle indifference-indifference to what should normally be anxiety provoking symptoms • Identification-assumption of symptoms of a significant other

Conversion disorder-course and prognosis • Usually acute onset • 95% remit spontaneously within 2 weeks of hospital admission • If symptoms present for more than 6 months less than 50% remit spontaneously • Good prognostic factors- clearly identifiable stressor, acute onset, above average intelligence and quick institution of treatment

Conversion disorder- treatment • Relationship with a caring and confident psychotherapist • Insight-oriented supportive or behaviour therapy • Telling patients their symptoms are imaginary makes them worse • Hypnosis, anxiolytics and behavioural relaxation exercises • Psychodynamic psychotherapy

Illness Anxiety disorder • Preoccupation with having or acquiring a specific illness • Somatic symptoms not present or mild • Concern excessive if at high risk or if another medical condition present • High level of anxiety about health, easily alarmed about personal health status • Performs excessive health related behaviours or exhibits maladaptive avoidance • Lasting 6 months or more • Preoccupation causes significant impairment or distress in a person’s life

Illness Anxiety disorderaetiology Psychodynamic factors- intra -psychic conflict, projection, deserving of punishment Learning theory/ social factors –symptoms often learnt from past experiences, often have related medical illnesses Biological factors- low threshold for and low tolerance of physical discomfort

Illness Anxiety disorder. Treatment • Psychiatric treatment in a medical setting • Focus on stress reduction and education in coping with a chronic illness • Appear to do well in group therapy because it provides them with the social support and interaction that they need • Long term regular follow up with physical exams and investigations as necessary reassures the patients that their physicians are not abandoning them and their complaints are being taken seriously. • Pharmacotherapy useful only when hypochondriacs have an underlying drug responsive condition.

Psychological Factors Affecting other Medical Conditions • Physical Medical condition is present • Psychological or Behavioural factors affect the medical condition: 1. Influence the course of the medical condition- exacerbation or delayed recovery 2. Interfere with treatment of the medical condition 3. Constitute additional well-established health risks for the individual 4. Factors influence underlying pathophysiology, precipitating or exacerbating symptoms necessitating medical attention Qualifiers: • Mild- increased medical risk • Moderate- aggravates underlying medical condition • Severe-results in hospitalisation or ED attendance • Extreme- results in life-threatening risk

Factitious disorders 1. Imposed on self 2. Imposed on another • • • Falsification of physical or psychological signs or symptoms Presents as an ill person Deception evident even in the absence of obvious external reward • • • Qualifiers: Single episode Recurrent episode

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