SOMATOFORM DISORDER SOMATIC DISORDER

1. Somatoform
Disorders (DSM
IV TR) = Somatic
Symptom and
related disorders
(DSM V)
BY –DR MOHIT BANSAL
PGT-2
DEPARTMENT OF PSYCHIATRY
KMCH

2. Introduction
• Group of illnesses where bodily signs
and symptoms are a major focus
• Believed to originate from faulty
mind-body 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

3. 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

4. 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

6. DSM V –TR : 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

7. In somatic syndrome disorder patient
remains preoccupied with the false belief
that they have a serious disease ,based on
their misinterpretation of physical sign or
sensations . The belief must last at least 6
month ,despite the absence of pathological
findings on medical and neurological
examination . The diagnosis also require
that the belief cannot have the intensity of a
delusion. And cannot be restricted to
disease bout appearance.

8. Somatic Symptom disorder
DIAGNOSTIC CRITERIA
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 IT if symptoms are: predominant pain, persistent, severity

9. 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, obsessive-
compulsive

11. Factors associated with Somatic
Symptom disorder
Psychodynamic factors
Learning theory
Social/Cultural factors
Biological factors
Genetic factors
Cytokines

12. Somatic symptom 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

13. 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

14. Somatic Symptom disorder-
treatment
• 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

15. 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

16. 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

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

18. Conversion disorder
A- one or more symptoms of deficit affecting voluntary motor or sensory
function .
B- clinical findings provide evidence of incompatibility between the
symptoms and recognized neurological or medical condition.
C-The symptom or deficit is not explained by other medical or mental
illness.
D-The symptom or deficit causes clinically significant distress or
impairment in social, occupational ,or other important areas of
functioning .

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

20. 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

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

22. 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

23. 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

24. 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

25. ILLNESS ANXIETY DISORDER /
HYPOCHONDRIASIS

27. Illness Anxiety disorder-
aetiology
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

28. 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.

29. Psychological Factors Affecting other
Medical Conditions
A ,Physical Medical condition is present
B .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 path physiology, precipitating or
exacerbating symptoms necessitating medical attention
C .The physiological and behavioural factors in criteria B are not better
explained by another mental disorder.

30. Factitious disorders

36. Body dimorphic disorder
( CURRENTLY UNDER OCD SPECTRUM
DISORDER)

39. Let’s prepare for next exam

43. THANK YOU