SOMATOFORM DISORDERS
Farid R. Talih, MD
Diplomate of the American Board of Psychiatry and Neurology
Psychiatry and Sleep Medicine
Assistant Professor of Psychiatry
Dept. of Psychiatry
AUBMC
SOMATOFORM DISORDERS
!One or multiple somatic complaints that cannot be
attributed to a medical condition, drug abuse, or a
psychiatric disorder.
!R/O factitious disorder or malingering.
they are extremely common they are from the people who have headaches , stomach aches
people are so invested in their disease that they wont let go of it so if you tell the patient your ok go check a psych they will take it in a bad way so when you
have multiple somatic complains that cannot be attributed to any condition like for example an alcoholic that wakes up with hangover everyday we think he has
a headache
if i think that ophtalo have implanted a cam in my eye and can see what i see this is not somatoform this is psychosis or schizo
somatomform are unconsciously being manifested and not on purpose this is the hallmark diff btw factious and amlingering that is obv faking for a reason
(hand hurts so i cant move it this is cz i dont want to work
facticious is faking it for psych reasons i want to be sick i want attention
Somatoform Disorders
!Somatization Disorder
!Hypochondriasis
!Body Dysmorphic Disorder
!Conversion Disorder
!Pain Disorder
!Undifferentiated Somatoform Disorder
!Somatoform Disorder NOS
conversion disorder is
pseudoneurological.
neurologists deal with
conversions.
pain disorder are very
problematic lead to
addiction i keep on
going to the dr because
of the pain and
eventually i end up with
high doses of addictive
medicine and get stuck.
common manifestation
is that they are
unconsciously
triggered as a
manifestation of
repressed issues or
desires or
manifestations of
certain fear: females
who had traumatic
sexual experiences as
young women: develop
dosmatic symptoms
related to genital area.
pelvic pain
dyspareunia ,vaginism
us
SOMATIZATION DISORDER
!Multiple somatic complaints (at least 4 pain, 2 GI, 1
sexual, and 1 pseudo-neurological)
!Multiple medical work-ups are non-revealing
!Disruption of usual or daily functional activities
!Significant psychological distress
!known as Briquets syndrome
!Prevalence 0.1-0.2%; F/M is 5:1.
!onset before age 30 and lasts for years
!Co-morbidity with anxiety and depression/personality
traits or disorder
all of the group is called somatoform disorders and
somatization is one of the major ones somatization is one of
the psychosomatic disorders. NS in the gut is extremely
widespread, equivalent to neurons in the brain but they are
widespread all over the viscera and this is why we have the
gut feeling expression you can feel lots of stuff in your stomach
usually you have to do a basic screening but if you are the fifth
GI dr they have seen they would have been dead by now so
you probably wont go again and do every single test its better to
sit reassure the patient you have to take away their fear concept
and that this is not a deadly disease and you have to start
talking abt other things in life
in some children you can see it he saw girl was started with pain med at 12, because of
migraines. she is now an addict. was very mistreated, abused, the only way toe xpress
herelf sas a child was pain and it became her identity.
need to take away the fear concept. these people insted of talking about their problems they
talk about their pain. they invest everything in the pain. see different doctors, travel, do
everything but never get better. more common in females. could be related to more
psychosocial stress in females. correlates directly with being repressed. so women have
less areas to epxress themselves academically socially and even sexually so lots of
repression , usually starts in the mid 20s and lasts for years it could be life long
somatization is very common,
seen in every specialtiy. many
people believe that food
allergies are
somatoform:gluten
a lot are scams.
chest pain.
military medicine deals a lot with malingering.
somatization highly related to specific things;
people who have a lot communicating
socially.see it alot in abused women the only
way to express one self is sometimes through
physical symptoms.
SOMATIZATION DISORDER
ETIOLOGY
!Psychosocial Factors
it maybe to get something or to avoid something we play the sick role and
being sick helps sometimes. some adults who cant cope anymore tend to act
sick u see it in women with alot of sexual repression and some people with
sexual identity issues and cant achieve their sexuality a young man who has
to suppress his own sexuality
!Social communication
soem adults take the sick role. seen in some people with sexual identity issues and cant achieve
!Avoid obligation/sick role? their identity. homosexual cant express himself.
!Express emotions or symbolize a feeling
!Substitution for repressed impulses
!Biological Factors
but its mostly a psychological issue. poeple statr making stuff up.
!Possible genetic predisposition
!Possible involvement of cytokines
!Decreased metabolism in frontal lobe
!Abnormal cognitive constructs
!Abnormal sensory gating/filtering
inflammation
SOMATIZATION DISORDER
!Clinical Features
it travels and can come and go hallaa weje3ne batne next week rasse
!Multiple & recurrent somatic complaints
!Complaints are usually vague, nonspecific, and exaggerated
!Patients give a long history of being sick with unclear details and in a
disorganized & dramatic manner
!Problematic interpersonal relationships
!Associated psychiatric conditions/suicide
if you dig into it, could be a lot of problems we have to be
confident cant be cavalier about it. have a duty to make sure that
its not a real illness.if im convinced that they have seen
reasonable people ill ask her to stop
!Differential diagnosis
!R/O medical problem
!Depression/ Generalized Anxiety Disorder/ Schizophrenia
!Panic Disorder
!Other somatoform disorders
chronic progressive difficult to treat and it can be really disabling and when u have more stress you have more pain
can be very disabling to the family. more stress = more pain.
SOMATIZATION DISORDER
!Course and Prognosis:
!Chronic and recurrent
!Patients always seek medical attention
!Symptoms increase with psychological distress
somebody who has been having these problems for so long
and no body is able to help you ofcourse you are going to get
sad so you endorse the physical symptoms as an entry way. if
i had severe stomach ache for ten yrs and nobody knew why
ofcourse you are going to get depressed
!Treatment:
frequent visits with one person who coordinates with the others and
regardless if your good or not you have to come and see me every
month. avoid unneeded testing and start telling the patient that
their symptoms are related to emotional and psychological stress
!Regular appointments with one primary physician
!Avoid unnecessary/not indicated laboratory or
radiologic tests
!Attempt to make the patient aware that these
symptoms could be related to emotional/psychological
factors
!Psychotherapy
!Treat the associated anxiety/depressive symptoms
CONVERSION DISORDER
neurological or pseudoneurological sudden loses with la
belle indiference, casual not freaking out.if i suddenly
cannot see anymore i freak out while people with
conversion disorder show up to the ER super chill. wake
up, cant see, but chill about it.
!One or two neurological symptoms
!Relationship to psychological factors
!Originally known as hysteria
!Mild symptoms are common
!Several psychiatric consultations are related to conversion
symptoms
!Common in adolescents and young adults
!More common in females
!Common in soldiers after combat
!Common in people with education, IQ, and
socioeconomic status
hysteria: the uterus = hyster, under the influence of the moon moves into the body
and makes females crazy. lunatic = moon. the moon affects the fluid internally and
causes mental disturbances. very common in young people: conversion corerlates
more with low socioeconomic and psychologic immaturity.so if youa re
sophisticated and highly educated and somebody who is psychologically mindlend
its unlikely you will have conversion if you are young immature or psych resitant
you will have conversion so either young kids or people from unsophisticated
background very common in soldiers
CONVERSION DISORDER
!Etiology
freud. if suddenly cannot see, could be because saw something very horrible and want someone to ask me
about it. if can't speak: selective mutism or pshycongeic dysphonia.some people cannt speak anymore
but if you ask them to whistle they can blindness most common. and the most common one is the
nonepileptic seizures
!Symbolic substitution of unconscious conflicts
!Hypo-metabolism of the dominant hemisphere and hypermetabolism of the non-dominant one
!Abnormal neuropsychological testing
!Clinical Features
!Paralysis, blindness, and mutism are the most common
!Sensory or motor symptoms
we no longer say pseudoepileptic
!Pseudoseizures
!Other associated features
non epileptic seizures.
CONVERSION DISORDER
!Differential diagnosis
!15-65 % may have a concomitant or previous history of a
neurological disorder
!25-50 % may end having a medical or neurological disorder
!Neurological disorders
the catch is that many of these people end up having
!Depressive/anxiety disorders
neurological diseases 20% of people with non epi seizure
end up having some type seizures
!Schizophrenia
!Other somatoform disorders
!Factitious disorder
!Malingering
CONVERSION DISORDER
!Course and Prognosis
!Conversion symptoms resolve quickly in the majority of cases
!Under stress symptoms may recur in 25% of patients with
conversion disorder
!Good prognostic factors: sudden onset, short duration, good
premorbid history, clear stressful precipitant, and absence of
medical or psychiatric illness
it is different than somatization. comes quickly and goes away quickly. come to the ER blind we give you an injection of valium you are cured
you go home w meshe l 7al its not going to keep on happening like somatization . can be reproduced by suggestion. you can elicit it by showing
and talking to them but you cannot elicit somebody to a seizure by talking to them
spontaneous remission very common.
!Treatment:
!Spontaneous remission is common
!Psychotherapy can facilitate
the resolution
can help
!Medications: Amytal or lorazepam (anxiolytics)
it is one of the rare things in which hypnosis
!Hypnosis can
help
in general hypnosis is overrated, its just a
stage of heightened relaxation but it does help.
EEG is not very good, test prolactin. after
seizures, prolactin goes up. after non
epilpectic seizure, prolacitn levels not up. or
can do video EEG: put the person in the
hospital for 2 days non stop recording EEG
with videos. link video to EEG, if see seizure
activity but EEG normal its not. but you dont
go to the patient and tell him that you caught
him he maybe having a seizure but not from
epilepsy
if they came with nonepileptic seizure do a prolactin test should be low or an EEG they
should lack a postictal stage maintain therir ocnciousness non cyanotic or incontinent and
quickly recover
Non epileptic Seizures
Need to do EEG (up to 20% of epilepsy pts. can
have normal EEG between episodes)
Usually have quick recovery, no post-ictal
deficits, no LOC, no incontinence or cyanosis,
suggestible and triggered by stress
If results inconclusive Video EEG 24-48 hrs in
hospital
20% of Non Epileptic seizures pts. can have
epileptic seizures
if they come with unilateral blindness and hemiparesis do optokinetic
Psychogenic vision loss
very common
Monocular blindness with ipsilateral hemi paresis
always psychogenic. Not anatomically possible!
bilateral visual loss is also usually psychogenic
Vertically stripped rotating drum: optokinetic
reflex: eyes will reflexively respond and follow
the strips. Cannot happen in physiological
binocular blindness
test for the optokinetic reflex which you cannot suppress so if someone has an intact retinal
nerve passing a black and white stipped tissue and their eyes move is a sign that he can see
dystonia and atonia
atasia-abasia: psychogenic gate problems. they seem that they
have a gate problem but they never really fall dont fall if push
them, their reflexes are intact. byetrana7 bass ma byou2a3
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tunnel vision is
psychogenic.
people who have lower .. paralysis put your hand under the good leg and tell them try to lift the bad leg if they are
trying but truley paralyzed you will feel them pushing on your hand if there is no pressure on your hand then they are
not trying to lift their leg
HYPROCHONDRIASIS
!Preoccupation with fear of having a serious illness/
misinterpretation with bodily sensations
!Very common in general medical workers
!Commonly starts at age 30-40
!No effect of sex, marital status, education, or
socioeconomic status
unlike conversion
different from the med student syndrome starts in the 30-40 they think if a little dot appears then it is cancer so go and check it comes in people who are anxious and
obsessive this can happen in people of higher SES and with more access to info. many people come with handouts and prints if you dont they get very upset
!Etiology:
!More sensitive and less tolerant of discomfort
!Induction of sick role
!Association with depressive and anxiety disorders
!Psychodynamic: way to express repressed anger;
defense against guilt
it is sometimes psychodynamically imp, it is a freudian interpretation it is to express repressed anger a defense
mechanism against guilt it is not delusional they do respond to reassurance they go to the Dr they tell them it isnt
cancer we are fine until we find another theory but if u are delusional you are not going to be reassured you will not
believe the Dr and think that he wants you to die from skin cancer
HYPROCHONDRIASIS
!may change from one illness to another
!Not delusional and not restricted to appearance
!Duration is at least six months
!Transient hypochondriacal states can happen under stress/
sometimes reinforced by familys reaction or physicians
they do respond to
reassurance so its not
delusional. if delusional,
wont be reassured.
!Differential Diagnosis:
!Somatoform disorders
!Depressive and anxiety disorders
!Schizophrenia and other psychotic disorders
!Factitious disorder and malingering
HYPROCHONDRIASIS
!Course and Prognosis
!Episodes last for months to years with equal time of relief
!Level of stress can affect the course
!1/3 to may improve markedly
!Good Prognostic factors: anxiety and depression that respond to
treatment; absence of medical conditions or personality disorder;
better socio-economical situation
its not easy to treat half of them will suffer for a very long time and the episodes will last for years and people get second and third opinionstry
try to psychoeducate the person sometimes putting hypochondriacs together
helps
!Treatment
!Regular appointment/avoid unnecessary tests/
strategies to cope with stress
!Meds for associated anxiety/depression
!Group psychotherapy
try to psychoeucate the patietn, putting hypochondiracs together can help.
BODY DYSMORPHIC
DISORDER
more common among younger female and unfortunately due to many psychological stressors in life this is how they percieve themselves men have inflated self image
not delusional
BODY DYSMORPHIC DISORDER
!Patients insistence that there is a defect in his appearance/or
excessive reaction to a slight defect
!In a survey at a plastic surgery clinic 2% met the criteria for the
disorder
!Affects women more/15-20 years old
!Usually single
!Anxiety and depressive disorders are very common
!History of psychotic disorder in 30%
!Etiology:
most common expensive psychotherapy plastic surgery
!Serotonin
!social pressure
!psychodynamic
see it it people whose families are image oriented: mother criticizes appearance of the daughter
BODY DYSMORPHIC DISORDER
do lots of stuff to cover up like putting hats
!Commonly the defects are in face
!Concern may change from one area to another during the illness
!Avoidance behavior and attempts to cover the defects are
common/some patients may become housebound
!Co-morbidity with obsessive-compulsive/schizoid/narcissistic
!Differential Diagnosis:
!Anorexia Nervosa/gender identity disorder/neglect syndrome
!Normal concerns
many men are obsessed that their genitalia are inadequate due
to excess pornography with excess sized organs
!Delusional disorder/somatic type
!Narcissistic/OCD/depression/ schizophrenia
seen in abuse and over use of plastic surgery trying to reach a perfect image is problematic
BODY DYSMORPHIC DISORDER
!Course and Prognosis
!Gradual onset
!Usually seek medical or surgical help
!Preoccupation with the defect may wax and wane
!Chronic if untreated
avoid using surgery because these people will become addictive to the surgery these patients will always be unsatisfied costumers
!Treatment
!Using medical or surgical interventions to deal with
the alleged defect is unsuccessful
!SSRI are effective in 50% of cases
!Case reports of good results with TCA, MAO
inhibitors, and pimozide
due to the OCD component
this is reverse body dysmorphia seen in the subculture of body builders or fitness enthusiasts they consume
alot of drugs and proteins and they are convinced that they are small and weak and not big enough LOL:P
reverse epilepsia
Body Dysmorphic Disorder in Body
Building Subculture?
reverse body dysmorphia: consume massive amoutns of drugs and exercise, and convinced they are small, weak and not big
enough. conveptualized as a reverse anorexia.
PAIN DISORDER
!Pain in one or more body sites
!M/F is
!Onset peaks at age 40-50 years
!Possible genetic inheritance
!Comorbidity with substance abuse and depressive &
anxiety disorders
middle aged of life
possibly learned behavior (form mother). very comorbid with substance abuse.
substance abuse is mostly iatrogenic doctors are giving medications and
more and more pain medicines but this doesnt work . pain is not in leg.
could be a manifestation of severe interpersonal repression or suppression and
sometimes its behaviorally reinforced there could be secondary gain
sick role
!Etiology
!Symbolic expression of intrapsychic conflict
!Behavioral reinforcement
!Secondary gains
!Serotonin/endorphin/abnormal perception of pain
delayed. primary gain = something immediate. cross the line to firbomyalgia,
chornic fatigue etc..treatment of fibromylagia is antidepressants.
there could be some biological predisposition and this is where you cross the line to fibromyalgia and chronic fatigue
PAIN DISORDER
!Pain can be anywhere (Headaches, back, face, pelvis, face,
vulvodynia, etc.)
!Pain can be posttraumatic, neuropathic, neurological,
iatrogenic, or musculoskeletal
!Importance of psychological factor
!Patients attributed all their anxiety and depressed mood to
their pain
!Most evolve to chronic, may lead to narcotic pain
medication addiction
genital pain is related to sexual trauma and is the reason not to have sexual intercourse because its is painful and unwanted
it can cause addiction
usually chronic and life long
!Differential Diagnosis
!Physical pain
!Other somatoform disorders
!Factitious or malingering
PAIN DISORDER
!Course and Prognosis
!Pain is usually chronic
!Improvement with elimination or management of psychological
distress
!Poor prognostic factors: long duration of pain/material gain
(disability)/substance abuse and passive attitude
!Treatment
simialr to fibromyalgia. strong placebo
effect. do well with accupuncture
and such things
!TCA and SSRI
!Avoid analgesics and benzodiazepines /risk of abuse
!Biofeedback/hypnosis/transcutaneous nerve
stimulation/dorsal column stimulation
!Psychotherapy: psychodynamic/cognitive
avoid addictive drugs
dealing with somatizers is very difficult challenging and draining you will never cure
them they are always unhappy ull feel inadequate they will make you feel like your
not a good doctor they suck the life out of you and they cause countertransference
dealing with somatizer isvery difficult,
never cure them, always unhappy,
make you feel inadequate. make you
feel like youre not a good doctor.
very depressed, negative, unhappy,
suck the life out of you . its very hard
to deal wth them. can casue
countertransferance.
