April 2007 Somatic Disorders Elizabeth Harris


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  • Soma = “axial” part of the body – head, neck, trunk and tail, excludes limbs
  • “ hysteria” = “wandering uterus” Greek: hystera = womb; “ conversion” remains as a diagnosis, stigmatizing “hysteria” has been dropped from use
  • Ancient Greek: “hypochondrium” was the region below the ribs, it was believed that the organs in this area affected mental status – this is still an accepted definition for the word hypochondriac
  • People who fear developing a disease have an illness phobia; people who fully believe they have the disease are candidates for a hypochondriasis diagnosis Some culturally specific syndromes are seen in various areas of the world: “ koro” is found primarily in Chinese males (having to do with the body absorbing the genitals) African patients present symptoms of a feeling of something crawling in the head, Patients in Pakistan and India present burning sensations in hands or feet Also, children may present symptoms (usually abdominal in nature) as a reaction to stress
  • Higher Appraisal of Risk is one of the cognitive distortions in Hypochondriasis patients, includes elements of risk, jeopardy and vulnerability – these fears do not seem to extend to non-illness related topics (broken bones, accidents, robberies). Directly related to patient’s tendency to “over exaggerate” their own bodily sensations Looking to more clearly define symptoms that point to hypochondrasis, expand those to allow formal diagnosis Time limit on diagnosis – patients who might be helped with cognitive-behavioral treatments, may be lost to results after 6 months. Early intervention into changing thought process is key to recovering functionality
  • Patient must present at least 7 symptoms, grouped as shown, within the course of the diagnostic history Factitious and Malingering Disorders both present with voluntarily produced/caused symptoms (faked) – with malingering, usually the symptoms are to get out of something (work, legal problems) or to gain something (legal settlement) – they are manipulating others to reach a desired goal. in factitious, there is no gain to be had within diagnosis – except maybe attention and sympathy (Munchausen's falls in this category)
  • Connection with Personality Disorders was found in family studies to look at genetic risk for somatization – possibilities include the “inhibition” factors of personality disorders as the connection – consider short-term gain instead of long-term effects. Gender and Socialization effects are still being studied.
  • Gender difference in diagnosis criteria – studies looking at prevalence rates suggest an uneven number of symptoms reported in men and women. However, the study could not conclude as to the number needed for either gender to produce a statistically accurate diagnosis rate matching those rates found in the general public. Differences are very prevalent in the types of symptoms reported by men and women highest rates of symptoms reported by women occur in the areas of pain during sexual intercourse, “flushing”/blushing reactions, pain in the genital area and loss of touch or pain sensations. Highest gender difference in symptoms reported by men was in the area of urinary retention.
  • Pain is “real” and hurts, syndromes run from primarily caused by a general medical condition to primarily caused by psychological factors
  • Pain may have begun as part of another condition – that condition clears, but the pain remains. Prevalence in the general population is judged to be somewhere between 5 – 12%
  • “ Hysterical” blindness, paralysis or other physical malfunction (difficulty speaking (aphonia)); most cases affect the sensory-motor systems, but can mimic the full range of physical functions – loss of sense of touch, loss of speech, pseudoseizures (no change in EEG seen) – most common? “Frog in the throat” – difficulties eating, swallowing, talking
  • Conversion disorder is often preceded by an event of extreme stress (52-93%), believed that since emotions cannot be expressed for whatever reason, they manifest themselves in the physical malfunction Some patients have been able to function normally at times, but don’t recognize the activity (avoiding a collision while blind, reacting to loud noises while deaf, etc.) Others may experience spontaneous recovery (being able to run in an emergency) but aren’t able to explain their actions Evidence of factitious and malingering disorders must be ruled out in the process of the diagnosis. Evidence of conversion lower in mental health settings, these patients are normally in the neurological/orthopedic/other specialties and may not be diagnosed until all testing alternatives have been exhausted.
  • Allow patient to begin to understand what is “normal” and to control their overstatement of the effects they feel
  • April 2007 Somatic Disorders Elizabeth Harris

    1. 1. Somatic Disorders Elizabeth Harris PSYC 2621H - Spring 2007
    2. 2. Overview <ul><li>“soma” = body </li></ul><ul><li>“somatic” = relating to the soma </li></ul><ul><li>Pathological concerns with the appearance or functioning of the body, usually in the absence of any identifiable medical condition </li></ul>
    3. 3. Overview (continued) <ul><li>Formerly known as “hysterical neurosis” </li></ul><ul><ul><li>thought to be found primarily in women since the time of the Ancient Greeks & Egyptians </li></ul></ul><ul><li>Freud suggested “conversion hysteria” </li></ul><ul><ul><li>due to the process of unconscious emotional conflicts being “converted” into physical symptoms </li></ul></ul>
    4. 4. Hypochrondriasis <ul><li>Current Diagnostic Criteria </li></ul><ul><ul><li>preoccupation with fears of having a serious disease </li></ul></ul><ul><ul><li>preoccupation persists despite appropriate medical evaluation and reassurance </li></ul></ul><ul><ul><li>preoccupation is not of a delusional intensity and is not restricted to concern over physical appearance </li></ul></ul><ul><ul><li>clinically significant distress or impairment because of preoccupation </li></ul></ul><ul><ul><li>duration of at least 6 months </li></ul></ul>
    5. 5. Hypochrondriasis (cont.) <ul><li>Etiology / Causes / Risk Factors </li></ul><ul><ul><li>hypersensitivity to “normal” situations/changes </li></ul></ul><ul><ul><li>inability to accept “non-findings” </li></ul></ul><ul><ul><li>tends to run in families, possible learned behaviors (“sick” role) </li></ul></ul><ul><ul><li>can begin in reaction to a stressful life event </li></ul></ul><ul><ul><li>comorbidity with anxiety & depression is high </li></ul></ul><ul><li>Prevalence / Incidence Rates </li></ul><ul><ul><li>no gender difference in occurrence rates seen </li></ul></ul><ul><ul><li>studies show 1% - 14% prevalence, rates higher in older population </li></ul></ul><ul><ul><li>cultural effects must be considered </li></ul></ul>
    6. 6. Hypochrondriasis (cont) <ul><li>Course / Prognosis </li></ul><ul><ul><li>chronic due to nature of not accepting results showing nothing wrong </li></ul></ul><ul><ul><ul><li>acute onset, mild symptoms, identifiable general medical condition and no comorbid condition are indicators for full recovery </li></ul></ul></ul><ul><ul><li>Patients tend to move from provider to provider to seek answers/support </li></ul></ul><ul><ul><li>patients tend to have a higher than average appraisal of risk than non-affected </li></ul></ul><ul><li>Current Issues in regards to DSM V development </li></ul><ul><ul><li>suggestions to wider the scope of diagnosis, that current is too narrow </li></ul></ul><ul><ul><li>time requirement may be limiting </li></ul></ul><ul><ul><ul><li>patients get “set in their ways” by the 6 month point </li></ul></ul></ul>
    7. 7. Somatization Disorder <ul><li>Current Diagnostic Criteria </li></ul><ul><ul><li>History of many physical complaints beginning before the age of 30 that occur over years and result in treatment being sought or significant impairment in important areas of functioning </li></ul></ul><ul><ul><li>each of the following: </li></ul></ul><ul><ul><ul><li>Four pain symptoms </li></ul></ul></ul><ul><ul><ul><li>two gastrointestinal symptoms other than pain </li></ul></ul></ul><ul><ul><ul><li>one sexual symptom </li></ul></ul></ul><ul><ul><ul><li>one pseudoneurologic symptom </li></ul></ul></ul><ul><ul><li>physical complains cannot be fully explained by </li></ul></ul><ul><ul><ul><li>a known general medical condition </li></ul></ul></ul><ul><ul><ul><li>the effects of a substance </li></ul></ul></ul><ul><ul><ul><li>or where there is a general medical condition, the physical complains or impairment are in excess of what would be expected </li></ul></ul></ul><ul><ul><li>complaints or impairment are not intentionally produced or feigned </li></ul></ul><ul><ul><ul><li>Rule out factitious disorder and malingering disorder </li></ul></ul></ul>
    8. 8. Somatization Disorder (cont) <ul><li>Etiology / Causes / Risk Factors </li></ul><ul><ul><li>Evidence of biological and psychosocial contributions </li></ul></ul><ul><ul><ul><li>Freud assumed a “constitutional diathesis” existed in patients </li></ul></ul></ul><ul><ul><ul><li>Family patterns are possible, as well as history of illness in patient/family member </li></ul></ul></ul><ul><ul><li>comorbidity with anxiety and depression common </li></ul></ul><ul><ul><ul><li>also some Personality Disorders are sometimes present (anti-social, histrionic, borderline) </li></ul></ul></ul><ul><li>Prevalence / Incidence Rates </li></ul><ul><ul><li>Dutch study found a prevalence of .5% in general practice patients, rose to 13% </li></ul></ul><ul><ul><li>for undifferentiated somatization disorder, American rates between 4.4 – 20% </li></ul></ul><ul><ul><li>prevalence rates rise as age factors in </li></ul></ul><ul><ul><li>gender differences are high, studies put female: male ratio between 3:2 and 3:1 </li></ul></ul><ul><ul><li>cultural differences in prevalence are great </li></ul></ul>
    9. 9. Somatization Disorder (cont) <ul><li>Course / Prognosis </li></ul><ul><ul><li>chronic, rarely remits </li></ul></ul><ul><ul><li>stressful events may heighten symptoms </li></ul></ul><ul><ul><ul><li>unconscious defenses block experience of anxiety, expression only comes in the form of physical symptoms </li></ul></ul></ul><ul><li>Current Issues in regards to DSM V development & other </li></ul><ul><ul><li>looking at number of symptoms required for diagnosis, </li></ul></ul><ul><ul><ul><li>possible difference for women and men </li></ul></ul></ul>
    10. 10. Pain Disorder <ul><li>Diagnostic Criteria – Current </li></ul><ul><ul><li>presence of serious pain in one or more anatomical sites </li></ul></ul><ul><ul><li>pain causes clinically significant distress or impairment in functioning </li></ul></ul><ul><ul><li>psychological factors judged to play primary role in onset, severity, exacerbation or maintenance of the pain </li></ul></ul><ul><ul><li>pain is not feigned or intentionally produced </li></ul></ul>
    11. 11. Pain Disorder (cont) <ul><li>Etiology / Causes / Risk Factors </li></ul><ul><ul><li>pain may be a learned behavior from a medical condition, previous or current </li></ul></ul><ul><ul><li>physical and psychosocial factors may be involved (neurotransmitter pathways may become “keyed” and react during stress) </li></ul></ul><ul><li>Prevalence / Incidence Rates </li></ul><ul><ul><li>back pain is cause of 10-15% of disability claims, roughly 50% have no physically identifiable reason </li></ul></ul><ul><ul><ul><li>abdominal pain presents in 75% of general medical practice patients, </li></ul></ul></ul><ul><ul><ul><li>75% of these (50% overall) have no physically identifiable reason (this is most common complaint in children – strong reaction to stress) </li></ul></ul></ul>
    12. 12. Pain Disorder (cont) <ul><li>Course / Prognosis </li></ul><ul><ul><li>If duration is less than 6 months, recovery chances are great, chronicity sets in past that point </li></ul></ul><ul><ul><li>site/location of pain is another factor </li></ul></ul><ul><ul><li>comorbidity with additional psychological syndrome will also negatively affect recovery chances </li></ul></ul>
    13. 13. Conversion Disorder <ul><li>Diagnostic Criteria – Current </li></ul><ul><ul><li>one or more conditions affecting voluntary motor or sensory function that suggest a neurological or general medical condition </li></ul></ul><ul><ul><li>psychological factors are judged to be associated with the condition because of preceding conflicts or other stressors </li></ul></ul><ul><ul><li>condition cannot otherwise be explained by: </li></ul></ul><ul><ul><ul><li>a general medical condition, </li></ul></ul></ul><ul><ul><ul><li>effects of a substance or </li></ul></ul></ul><ul><ul><ul><li>as a culturally sanctioned behavior or experience </li></ul></ul></ul><ul><ul><li>clinically significant distress or impairment caused by condition </li></ul></ul>
    14. 14. Conversion Disorder (cont) <ul><li>Etiology / Causes / Risk Factors </li></ul><ul><ul><li>childhood trauma, family illness behaviors, stressful events (unconscious converts anxiety into physical symptoms) </li></ul></ul><ul><ul><li>the less medical knowledge of the patient, the less plausible are the symptoms; more sophisticated knowledge will present more detailed symptoms </li></ul></ul><ul><li>Prevalence / Incidence Rates </li></ul><ul><ul><li>Rates range from 1-24%, depending on comorbid syndromes, physical symptoms presented </li></ul></ul>
    15. 15. Conversion Disorder (cont) <ul><li>Course / Prognosis </li></ul><ul><ul><li>normally chronic when adult onset; </li></ul></ul><ul><ul><ul><li>children/adolescents see high rate of recovery </li></ul></ul></ul><ul><ul><li>if remission is probable, normally happens within days/weeks of onset </li></ul></ul><ul><ul><li>interpersonal relationships, dealing with stressors is key to recovery </li></ul></ul><ul><ul><li>Comorbidity factors lessen chances for favorable outcome </li></ul></ul>
    16. 16. Treatment options <ul><li>Treatment of all somatoform disorders should be undertaken by a single or communicating group of physicians </li></ul><ul><ul><li>lessen repeated “gains” through repetitive tests and treatment plans </li></ul></ul><ul><li>Reassurance seems to work </li></ul><ul><ul><li>it requires time be spent that many doctors don’t have to spend; </li></ul></ul><ul><ul><li>goal to provide patient with “insight” into validity of symptoms to control unnecessary tests, hospital/doctor visits </li></ul></ul>
    17. 17. Treatment options (cont) <ul><li>Absence of “secondary gain” important to recovery efforts </li></ul><ul><ul><li>lessen gains gathered by assuming “sick role” </li></ul></ul><ul><ul><li>improving skills in interpersonal relationships to make physical symptoms less of a focus for attention gathering, reducing maladaptive attachment style </li></ul></ul><ul><li>Cognitive-behavioral training to focus on stress management </li></ul><ul><ul><li>avoid misinterpretation of stress reactions as “symptoms” </li></ul></ul><ul><li>Course is for management, not curative in nature </li></ul><ul><ul><li>techniques to lessen “pain-related behavior” </li></ul></ul><ul><ul><li>encourage increased activity level </li></ul></ul><ul><ul><li>avoid pain medication reliance </li></ul></ul>