psychiatry.Somatoform disorders animation part i.(dr.nzar)

Somatoform disorders
Somatoform disorders are a group of disorders in which patients are convinced that their sufferings come from undetected and untreated bodily derangements.
They include:
Somatization disorder
Conversion & Dissociation disorder
Pain disorder
Hypochondriasis
Body dysmorphic disorders

The patient has multiple medically unexplained symoptoms that can not be explained as organic pathology or on any known patholophysiological mechanism .
Somatization Disorder is an illness of multiple somatic complaints in multiple organ systems that occurs over a period of several years and results in significant impairment or treatment seeking, or both.
The complaints are multiple, chronic and affect multiple organ systems .

The disorder is an expression of the basic mechanism by which patients respond to their stressors and express them as somatic symptoms.
The disorder is associated with significant psychological distress , impaired social and occupational functioning, and excessive medical-help-seeking behavior
The condition was previously called hysteria.

Epidimiology
Male/female ratio is ½ to 1/6 and it varies in various studies.
Affects 1% of the general population and (1-6)% of primary care attendants and inpatients
Onset is from early childhood to 40 years.
the disorder is inversely related to social position and occurs most often among patients who have little education and low incomes.
Co morbidity occurs in 50% of cases mostly with personality disorder and learning Disability.

Etiology:
symptoms substitute for repressed instinctual impulses
Psychosocial Factors
Predisposing factors include physical and sexual abuse and parental complaints of unexplained poor physical health in childhood.
Social, cultural, and ethnic factors may also be involved in the development of symptoms.
Biological factors
Hypersensitivity of the limbic system towards bodily stimuli was suggested.

Clinical features
The symptoms may refer to any part or system of the body. They depend on the patient’s sociocultural background and life experience.
Nausea and vomiting (other than during pregnancy), difficulty swallowing, pain in the arms and legs, shortness of breath unrelated to exertion, amnesia, and complications of pregnancy and menstruation are among the most common symptoms.
Patients frequently believe that they have been sickly most of their lives.

Neurological symptoms include
incoordination, weakness, paralysis, dysphagia, lump in the throat, aphonia, urinary retention, anesthesia, hallucination, diplopia, blindness, pseudoseizures and coma.

Somatization Disorder
Suicide threats are common, but actual suicide is rare. If suicide does occur, it is often associated with substance abuse.
complaints in a dramatic, emotional, and exaggerated fashion, with vivid and colorful language; they may confuse temporal sequences and cannot clearly distinguish current from past symptoms
Female patients with somatization disorder may dress in an exhibitionistic manner.
Patients may be perceived as dependent, self-centered, hungry for admiration or praise, and manipulative.

Somatization Disorder Management
Good history and physical examination are necessary for the diagnosis. Once certain of the diagnosis, we should avoid excessive and unnecessary investigations.
Somatization disorder is best treated when the patient has a single identified physician as primary caretaker. When more than one clinician is involved, patients have increased opportunities to express somatic complaints.

Somatization Disorder management
Psychotherapy, both individual and group, decreases these patients' personal health care expenditures by 50 percent, largely by decreasing their rates of hospitalization.
In psychotherapy settings, patients are helped to cope with their symptoms, to express underlying emotions, and to develop alternative strategies for expressing their feelings

Somatization Disorder management
British Journal of Psychiatry (1993), 162, 472â€”480
The Management of Chronic Somatisation
Somatisation' is a process in which there is inappropriate focus on physical symptoms and psychosocial problems are denied.
In some patients this process becomes chronic (in excess
of six months). Special skills and strategies are required by non-psychiatrists to manage these patients, for whom the acceptance of psychiatric treatment should be facilitated. When taking the history,
doctors should be aware of psychosocial cues; there after they should be consistent and unambiguous in their management.

Somatoform disorders in general practice Prevalence, functional impairment and comorbidity with anxiety and depressive disorders † Margot W. M. De Waal , MSc, Ingrid A. Arnold , MD and Just A. H. Eekhof , PhD Department of General Practice and Nursing Home Medicine, Leiden University Medical Centre Albert M. Van Hemert , PhD + Author Affiliations Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands M.W.M. de Waal, LUMC Department of General Practice and Nursing Home Medicine, PO Box 2088, 2301 CB Leiden, The Netherlands. Tel: +31 71 5275318; fax: +31 71 5275325; e-mail: [email_address]
General practitioners play a pivotal part in the recognition and treatment of psychiatric disorders.
21.9%.Comorbidity of somatoform disorders and anxiety/depressive disorders was 3.3 times more likely than expected by chance.
In patients with comorbid disorders, physical symptoms,
depressive symptoms and functional limitations were additive.
Conclusions
Our findings underline the importance of a comprehensive
diagnostic approach to psychiatric disorders in general practice.
The British Journal of Psychiatry (2004) 184: 470-476doi:10.1192/bjp.184.6.470

Psychosomatic Medicine ISSN: 0033-3174 Copyright (C) 2011 by American Psychosomatic Society Issue: Volume 73(8) pgs. 637-722 October 2011 Abuse History, Depression, andSomatization Are Associated With Gastric Sensitivity and Gastric Emptying in Functional Dyspepsia Lukas Van Oudenhove , MD, PhD, Joris Vandenberghe , MD, PhD, Rita Vos , MSc, Benjamin Fischler , MD, PhD, Koen Demyttenaere , MD, PhD and Jan Tack , MD, PhD
Abstract
Objective Gastric sensitivity testing relies on subjective reporting and may therefore be influenced by psychosocial factors and somatization. Furthermore, psychological processes may affect gastric motor function (accommodation to a meal emptying) through efferent brain-gut pathways. This study sought to determine the association of abuse history, psychiatric comorbidity, andsomatization with gastric sensorimotor function.
Methods In 201 patients with functional dyspepsia, gastric sensitivity and accommodation were studied with a barostat. Gastric emptying of solids was studied using a breath test. Sexual and physical abuse history, psychiatric comorbidity (depression and panic disorder), and somatization were assessed using validated questionnaires. Multiple linear regression models were used to identify patient characteristics independently associated with gastric sensitivity and emptying.
Results Age ( p = .02), sexual abuse history ( p < .001), physical abuse history ( p = .004), and somatization ( p < .001) were independently associated with gastric discomfort threshold (R 2 = 0.30); a significant depression-by-sexual abuse interaction effect was also found ( p = .003). None of the factors studied were associated with gastric accommodation to a meal. Physical abuse history ( p = .003) and somatization ( p = .048) were independently associated with gastric emptying (R 2 = 0.19).
Conclusions These results demonstrate the complex relationship among abuse history, psychiatric comorbidity, somatization, and gastric sensorimotor (dys)function. Although the psychobiological mechanisms underlying these relationships remain to be determined, the autonomic nervous, stress hormone, and immune systems may be involved.

Military deployment to the Gulf War as a risk factor for psychiatric illness among US troops NANCY FIEDLER, GOZDE OZAKINCI,WILLIAM HALLMAN, DANIELWARTENBERG, NOEL T. BREWER, DRUE H. BARRETT and HOWARD M. KIPEN
Gulf War veterans had a significantly higher prevalence of
Psychiatric diagnoses, with twice the prevalence of anxiety disorders and depression.
Lower rank, female gender and divorced or single marital status were significant independent predictors of Psychiatric disorder.
Conclusions
Deployment to the Gulf War is associated with a range of mental health outcomes more than 10 years after deployment.
The British Journal of Psychiatry (2006)
Volume: 188, Pages: 453-459

Conversion & Dissociation Disorder
Conversion and dissociation 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.
The symptoms or deficits of conversion & dissociation disorder are not intentionally produced, are not caused by substance use, are not limited to pain or sexual symptoms, and the gain is primarily psychological and not social, monetary, or legal.
It was originally combined with the syndrome known as somatization disorder and was referred to as hysteria, conversion reaction, or dissociative reaction.

History
conversion disorders were understood to be conditions in which a psychological conflict occurred to which the patient could not consciously admit. According to Freud, there was at least one motive which could be allowed to emerge into consciousness. For example, a woman may develop hysterical symptoms because a forbidden Oedipal wish—to be closer to a man who, to her, represents her father—is in conflict with unconscious feelings of guilt that she is thereby displacing her mother in such a relationship. The resolution of both these unconscious wishes with a symptom like a paralysis which prevented a man from courting her would constitute the primary gain of her illness.

History cont’d
This notion of primary gain is basic to the Freudian dynamic theory. It should not be confused with secondary gain which is more often mentioned and which represents the advantages that follow from the sick role (e.g. the loss of the use of a limb), with such benefits as extra attention, nursing, special consideration, and perhaps financial reward in compensation cases. According to this theory, secondary gain is an important part of the reinforcing mechanisms in the maintenance of hysterical symptoms—a rather common-sense idea. However, primary gain is part of the causal system.

In both ICD-10 and DSM-IV dissociative symptoms are regarded as arising from emotional conflict.
In ICD-10 , ‘in the dissociative disorders it is presumed that ... ability to exercise a conscious and selective control is impaired .
DSM-IV adopts a different approach. Conversion disorders are classified under ‘somatoform disorders', in which the common feature of all conditions is the presence of physical symptoms that suggest a general medical condition. The symptoms are required to cause clinically significant distress or impairment in social, occupational, or other areas of functioning .

The difference between conversion disorder and somatization disorder lies in the number of symptoms and in the fact that conversion disorders are primarily limited to voluntary motor or sensory function without pain, but resemble neurological disease.
In DSM-IV it is assumed that in dissociative disorder there is a disruption in the integrated functions of consciousness. Several types are listed: dissociative amnesia, dissociative fugue, dissociative identity disorder or depersonalization disorder, and dissociative disorder not otherwise specified.

Conversion disorder
Clinical symptoms
Motor symptoms:
Weakness, paralysis, seizures, aphonia and abnormal movements, tremor.
Sensory deficits :
Anesthesia, blindness, deafness, peripheral nerve sensory loss, visual hallucinations.
Visceral symptoms :
Vomiting, diarrhea, urinary retention, pseudocyesis, globus hystericus.

Dissociative symptoms
Stupor
is marked by a profound diminution or absence of voluntary movement, but normal responsiveness to external stimuli such as light, noise, and touch. There is an apparent disturbance of consciousness but the patient is neither asleep nor unconscious.
Amnesia
In amnesia of psychological origin (psychogenic amnesia) there is a loss of knowledge of personal identity with preservation of other information, often including complex learned information or skills. The patient may not know who he is, but knows who is the President, or his doctor.

Dissociative symptoms
Fugue
The main phenomenon is sudden unexpected travel away from home or a customary place of work. There is also inability to recall their personal past history. Sometimes a partial or completely new identity is assumed. The memory for some recent traumatic or stressful event may be lost, although these matters are discovered when other informants become available.
Dissociative identity disorder
(formerly multiple personality disorder ) the presence of two or more distinct identities, or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self'. At least two of these identities or personality states must recurrently take control of the person's behaviour. There should also be inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

Conversion disorder
Data indicate that conversion disorder is most common among rural populations, persons with little education, those with low intelligence quotients, those in low socioeconomic groups, and military personnel who have been exposed to combat situations. It is more in females than males.

Conversion disorder
Am J Psychiatry 159:1908-1913, November 2002 © 2002 American Psychiatric Association
Article
Childhood Abuse in Patients With Conversion Disorder
Karin Roelofs, Ph.D., Ger P.J. Keijsers, Ph.D., Kees A.L. Hoogduin, M.D., Ph.D., Gérard W.B. Näring, Ph.D., and Franny C. Moene, Ph.D.
Patients with conversion disorder reported a higher incidence of physical/sexual abuse, a larger number of different types of physical abuse, sexual abuse of longer duration, and incestuous experiences more often than comparison patients. In addition, within the group of patients with conversion disorder , parental dysfunction by the mother—not the father—was associated with higher scores on the Dissociative Experiences Scale and the Somatoform Dissociation Questionnaire. Physical abuse was associated with a larger number of conversion symptoms (Structured Clinical Interview for DSM-IV Axis I Disorder s).
The present results provide evidence of a relationship between childhood traumatization and conversion disorder .

Conversion disorder
Am J Psychiatry 159:1908-1913, November 2002 © 2002 American Psychiatric Association
Article
Childhood Abuse in Patients With Conversion Disorder
Karin Roelofs, Ph.D., Ger P.J. Keijsers, Ph.D., Kees A.L. Hoogduin, M.D., Ph.D., Gérard W.B. Näring, Ph.D., and Franny C. Moene, Ph.D.
RESULTS: Patients with conversion disorder reported a higher incidence of physical/sexual abuse, a larger number of different types of physical abuse, sexual abuse of longer duration, and incestuous experiences more often than comparison patients. In addition, within the group of patients with conversion disorder , parental dysfunction by the mother—not the father—was associated with higher scores on the Dissociative Experiences Scale and the Somatoform Dissociation Questionnaire. Physical abuse was associated with a larger number of conversion symptoms (Structured Clinical Interview for DSM-IV Axis I Disorder s).

Conversion disorder
Treatment
Resolution of the conversion disorder symptom is usually spontaneous, although it is probably facilitated by insight-oriented supportive or behavior therapy.
The most important feature of the therapy is a relationship with a caring and confident therapist
Parenteral amobarbital or lorazepam may be helpful in obtaining additional historic information, especially when a patient has recently experienced a traumatic event

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