Somatoform disorder

1. •SOMATOFORM DISORDERS AND
THEIR MANAGEMENT
• DR. DARE ADEWUYA MB;BS IBADAN
• 17/04/2019

2. OUTLINE
• Case presentation
• Introduction
• Types of Somatoform Disorder
• Somatization Disorder
• Historical perspective
• Aetiology
• Epidemiology
• Clinical features
• Prognosis
• Management
• Other somatoform disorders
• Conclusion
• References

3. CASE PRESENTATION
• Mrs A.J a 35 year old feamale, married trader who presents with 6year history of
recurrent abdominal pain of varying intensity and frequency
• Has associated chest pain and breathlessness, dysuria and pain in the limbs.
• She has recurrence of symptoms during or after periods of intense emotional
stress and sometimes report additional symptoms.
• Physical examination was essentially normal.
• Laboratory investigations were essentially normal.
• An assessment of somatization disorder was made.
• Co-managed with the psychiatrist and currently on CARE MD management
approach.

4. INTRODUCTION
• Mental illnesses may present with physical/somatic symptoms and often
patients accept their respective psychiatric diagnoses and comply with
treatment when these somatic symptoms are a minute proportion of the
psychiatric manifestations.
• However, some patients with a form of mental illness present with
predominant physical symptoms and often physicians miss the diagnosis
for weeks to years.
• Further complication is that when presented with the diagnosis, the
patient is prone not to accept it.

5. INTRODUCTION
• Patient convinced of physical origin to the undiagnosed distress.
• Can lead to a disconnect between patient and physician.
• Somatization is a clinical and public health problem as it can lead to
social dysfunction, occupational difficulties and increased healthcare
use.

6. INTRODUCTION
• First grouped together in DSM3 in 1980
• Classified as a group of disorders in which bodily sensations and
patient’s predominant focus are influenced by a disorder of the mind.

7. TYPES
• Somatization disorder
• Conversion disorder
• Pain disorder
• Hypochondriacal disorder
• Body dysmorphic disorder
• Residual category
• Undifferentiated somatoform disorder
• Somatoform disorder N.O.S.

8. SOMATIZATION DISORDER
• Essential feature of this disorder is recurrent multiple somatic
complaints requiring medical attention but not associated with any
physical disorder.
• Currently eight symptoms are required; and must meet this particular
pattern
• 4 sites of pain
• 2 GIT symptoms
• 1 reproductive system symptom
• 1 reproductive symptom

9. HISTORICAL PERSPECTIVE
• Prior to 1800, physicians did not conduct clinical evaluations and could not
distinguish somatic from psychogenic illness.
• Early 17th century,Ancient Greek Physicians : The term hysteria; a disorder thought
to result from abnormalities of position or function of the uterus.
• Late 17th century: hysteria is a disorder of the brain.
• Sydenham said, “hysteria could simulate any medical disease”
• Sigmond Freud and Joseph Breuer: (1893-1895)hysteria caused by emotionally
charged ideas, usually sexual in nature, which had become lodged in the patient ’s
unconscious mind as a result of some past experience, and which were excluded
from conscious awareness by repression

10. PSYCHOANALYTIC
• Freud 1900, somatic involvement occurs in conversion hysteria;
symbolic substitute expression of an unconscious conflict. Psychic
repressed energy is let out via physical outlets.
• Sandor Ferenczi 1910: Conversion hysteria is applied to organs
innervated by the autonomic nervous system. Emotion~somatic
symptoms.
• George Groddeck 1910: organic diseases are held to have primary
organic meanings; i.e expression of unconscious fantasies.
• Franz Alexander 1934, 1968: Psychosomatic symptoms in organs
innervated by ANS. No psychic interpretation but physiologic
manifestation of unconscious repressed conflicts.

11. PSYCHOANALYTIC
• Helen Dunbar 1936: specific personality associated with specific
psychosomatic presentations
• Peter Sifneos&John Nemiah 1970: alexithymia leads to psychosomatic
symptoms.
• Stoudemire: the concept of somatothymia and effect of culture
• Two complementary syndromes; monosymptomatic(conversion),
polysymptomatic(somatization)

12. PSYCHOPHYSIOLOGY
• Walter Cannon 1927:the physiological correlates of emotions using Palvov’s
learning theory.
• Harrold wolff 1943: life stress~physiological response~structural change.
• Hans Selye: Stress~ACTH~Physiological response
• Meyer Friedman 1959: Type A personality a risk factor for cardiovascular
disease.
• Robert Ader 2007: Established the concept of Neuroimmunology

13. SOCIOCULTURAL
• Karen Horney(1939), James Halliday(1948): the role of culture in the
development of psychosomatic illness, mother to child relationship
and its effects.

14. SYSTEMS THEORY
• Adolph Meyer(1958): Biopsychosocial model contributing to the
development of psychosomatic illness.
• Lipowski 1970: A total approach; external, internal, present and past
history.
• GeorgeEngel 1977: coined the term biopsychosocial.
• Leon Eisenberg 1995: midbrain responds to biological and social
vectors.

15. COMPARATIVE NOSOLOGY
• In 1962, psychiatrists in St Louis (Perley and Guze, 1962) described a
syndrome of chronic multiple somatic complaints without any identified
organic cause, which they regarded as a form of hysteria.
• They named it Briquet’s syndrome after a nineteenth-century French
physician who wrote a monograph on hysteria. A similar syndrome, called
somatization disorder, was introduced in DSM-III.
• A similar category is found in ICD-10. In DSM-5 the disorder has been
abandoned and is absorbed into the broader somatic symptom disorder
category.

16. AETIOLOGY
• Genetic: Alexithymia, trait anxiety, anxiety insensitivity.
• Somatization tends to run in families (Asmundson & Taylor, 2005).
• The modelling of a somatic illness focus by parents can then result in their
children also becoming illness focused.
• During the 19th century, Briquet found a strong tendency for family clustering to
occur in cases of hysteria. Of course, family clustering may be the result of
genetic or environmental influences, and it is likely that both play a role.
• Cloninger and others found that male relatives of patients with Briquet’s
syndrome had increased prevalence of antisocial personality and alcoholism and
that female relatives of a male prison population revealed a high prevalence of
Briquet’s syndrome

17. AETIOLOGY
• Hysteria in women was a more prevalent and less deviant manifestation of the same process that
causes sociopathy in men and that SD had a different familial pattern in women, compared with men.
Another study of women (n = 859) who had been adopted at an early age by nonrelatives found that the
adoptees had a significant excess of somatizers, compared with a nonadopted control group. The parents
of the adoptees were known to have excess numbers who showed criminal or psychotic
behavior(Sivardson et all AGP 1984).
Some twin studies have found evidence of a genetic component (Ljumberg et all APNS 1957, Torgersen et
all AGP 1986)
However others have drawn negative conclusions. (Slater E JMS 1961, Shields J. John Wiley 1982)
Although genetic factors may play a role in SD, the effect is a limited one.

18. ORGANIC AETIOLOGY
• Several studies have investigated a possible connection between hysteria and
cerebral pathology.
• It has also been proposed that a dysfunction of attention and memory associated
with inhibition of afferent stimulation exists in these patients and that bifrontal
cerebral impairment exists, particularly in the nondominant hemisphere .
• Patients with SD, compared with control subjects, have been found to have
deficiencies on neuropsychological testing .
• These studies strongly suggest a nonspecific association between somatization
and organic (in particular, cerebral) disease

19. PSYCHODYNAMIC THEORIES
• Learning Theory: Learned illness behavior: maladaptive way of obtaining social needs.
• Illness in significant others;(Craig ea, 2002)
• Lack of parental care during childhood followed by childhood illness, i.e. being ill
becomes a powerful form of communication and commands attention
• Lack of expressive emotional communication
• Conflict with mother or father
• Difficulties in the control and regulation of aggression and frustration
• Childhood hospitalisation
• Poor well-being of family members
• Early life trauma
• Major life events and
• Daily stressors.

20. OTHER FACTORS
• Ethnicity
• Education
• Low social class
• Female
• Iatrogenic factors
• Personality factors: alexithymia
• Cognitive interpretation

21. EPIDEMIOLOGY
• Epidemiologic studies have shown a lifetime prevalence of
somatization disorder that varies between 0.2% and 2.0% in women
Escobar et all AGP 1987
• In men, the prevalence is likely less than 0.2%.
• Causes significant morbidity and social deficit.
• A retrospective study of 13 314 consultations in a consultation-liaison
service found that SD caused disability and unemployment more
frequently than any other psychiatric disorder. Thomason et al Gen.
Hosp. Psych. 2003.

22. EPIDEMIOLOGY
• Paediatric studies sex disparity in the prevalence of somatic
symptoms during adolescence (11% of girls and 4% of boys) persists
into adulthood.
• Local studies
• R.O.A. Makanjuola March 1987 APS: 30 patients diagnosed as having
ode ori met the criteria for somatization disorder.
• Gureje Obikoya September APN 1992: 214 patients studied
• 1.1% somatization
• 4.7% pain disorder
• 10.8 undifferentiated somatoform disorder

23. CLINICAL FEATURES
• It differs from the other somatoform disorders by this multiplicity of
complaints and the multiple organ systems involved.
• The disorder is chronic, with onset before 30 years of age.
• Causes significant psychological distress, psychosocial dysfunction and
excessive help-seeking behaviour.

24. CLINICAL FEATURES
• Patients are usually inconsistent historians.
• Complaints vary and may be forgotten between consultations.
• Exaggeration is common, e.g. ‘I bled for days’.
• The style is histrionic (unlike the hypochondriac who tends to be
obsessional).
• A sense of urgency pervades presentations.

25. DIAGNOSTIC CRITERIA ICD 10
• A history of at least two years complaints of multiple and variable
physical symptoms that cannot be explained by any detectable
physical disorders. (Any physical disorders that are known to be
present do not explain the severity, extent, variety and persistence of
the physical complaints, or the associated social disability). If some
symptoms clearly due to autonomic arousal are present, they are not
a major feature of the disorder, in that they are not particularly
persistent or distressing.
• Most commonly used exclusion criteria: not occurring only during any
of the schizophrenic or related disorders, any of the mood (affective)
disorders, or panic disorder.

26. DIAGNOSTIC CRITERIA ICD 10
• Preoccupation with the symptoms causes persistent distress and leads the
patient to seek repeated (three or more) consultations or sets of investigations
with either primary care or specialist doctors. In the absence of medical services
within either the financial or physical reach of the patient, persistent self-
medication or multiple consultations with local healers must be present.
• Persistent refusal to accept medical advice that there is no adequate physical
cause for the physical symptoms, except for short periods of up to a few weeks at
a time during or immediately after medical investigations.
• A total of six or more symptoms from the following list, with symptoms occurring
in at least two separate groups:

27. DIAGNOSTIC CRITERIA ICD 10
• Gastro-intestinal symptoms
• (1) abdominal pain;
• (2) nausea;
• (3) feeling bloated or full of gas;
• (4) bad taste in mouth, or excessively coated tongue;
• (5) complaints of vomiting or regurgitation of food;
• (6) complaints of frequent and loose bowel motions or discharge of fluids from anus;
• Cardio-vascular symptoms
• (7) breathlessness without exertion;
• (8) chest pains;
• Genito-urinary symptoms
• (9) dysuria or complaints of frequency of micturition;
• (10) unpleasant sensations in or around the genitals;
• (11) complaints of unusual or copious vaginal discharge;
• Skin and pain symptoms
• (12) complaints of blotchiness or discolouration of the skin;
• (13) pain in the limbs, extremities or joints;
• (14) unpleasant numbness or tingling sensations.

28. COMORBIDITIES
• Depression
• Anxiety disorders
• Cluster-B personality disorder (histrionic and borderline)
• eating disorders.
• There may be a history of childhood sexual abuse and
• Complex post-traumatic stress disorder (PTSD).

29. COURSE AND PROGNOSIS
• A chronic relapsing condition with no cure.
• Patients develop new symptoms in times of emotional stress.
• A typical episode lasts 6-9months with quiescent of 9-12months.
• Patients believe they are more sick than they really are.

30. MANAGEMENT OF SOMATIZATION DISORDER
• Somatoform disorders can be very difficult to manage.
• Most patients present to GPs.
• Some young energetic doctors want to make a rare diagnosis and would order
sophisticated investigations that eventually lead to no diagnosis.
• End result is frustration for both patient and doctor with patient being referred or
going to another doctor to continue another cycle.

31. MANAGEMENT GOALS
• 1)Prevent adoption of the sick role and chronic invalidism.
• 2.) Minimize unnecessary costs and complications by avoiding
unwarranted hospitalizations, diagnostic and treatment procedures,
and medications
• 3.) Pharmacological control of comorbid syndromes.
• 4.) Instill, whenever possible, insight regarding temporal association
between symptoms and personal, interpersonal, and situational
problems.

32. MANAGEMENT: NON PHARMACOLOGICAL
• First, a “management” rather than a “curative” strategy is recommended.
• The CARE MD approach has been formulated and is generally used for the
management of somatization disorder.
• 1) Consultation and CBT
• Refer to a psychiatrist
• CBT reduces the frequency and severity of somatic preoccupations
• Daily Dysfunctional Thought record to monitor depressive or anxious
emotions associated with negative thoughts.
• Review DTR during clinic visits.

33. MANAGEMENT
• Woolfolk and Allen (2007) “Affective Cognitive Behavioural Therapy”,
• It includes the following recommendations for physicians:
• Provide continuity of care
• Avoid unnecessary tests and procedures
• Provide frequent, brief and regular office visits
• Always conduct a physical exam
• Avoid making disparaging comments (e.g., “Your symptoms are all in your
head”) • Set reasonable therapeutic goals (e.g., maintaining function
despite ongoing pain)

34. MANAGEMENT
• Relaxation training and exercise treatments have been shown to give
pain relief and improve mood (Woolfolk & Allen, 2007).
• Kashner, Rost, Cohen and Anderson (1995) demonstrated that group
therapy sessions, in addition to the consultation provided by the
physician, lead to significant improvement in physical and mental
health in patients with somatization disorder compared to a control
group who did not attend these sessions.
• The authors also showed that the more group sessions attended by
the patient, the greater the improvement in physical and mental
health.

35. MANAGEMENT
• 2) Assess medical and psychiatric comorbidities
• “I am more sick than my doctors think” –Alfred Nobel

36. MANAGEMENT
• Assess thoroughly for medical illness
• Chronic pelvic pain~endometriosis
• Chronic epigastric pain ~H.Pylori
• Screen for common psychiatric diagnoses:Anxiety and
depression(comorbid)
• All patients with a score greater than five on PHQ should be assessed
for a possible major depressive disorder.

37. MANAGEMENT
• 3)Regular visits.
• Regular visits with one primary care physician.
• Short, frequent appointments or telephone calls have been shown to decrease outpatient medical costs while
maintaining patient satisfaction.
• Brief but focused history and physical exam
• Open-ended questions like, “How are things at home?” or “What is your biggest problem?”
• If the patient is undergoing cognitive behavioral therapy, say “Tell me about your most frequent negative or
inaccurate thoughts since your last visit.”
• Over time, patients can use these scheduled, supportive, caring interactions in place of excessive phone calls and
visits to the emergency room or clinic.
• Gradually shift agenda to psychosocial issues.

38. MANAGEMENT
• 4) Empathy.
• Simply briefly “becoming the patient”
• During visits, spend more time listening to the patient rather jumping to a diagnostic test
• Acknowledge patient’s reported discomfort
• Key component to developing a strong therapeutic relationship with the patient.
• Helps to minimize physicians’ negative feelings or countertransference.
• Truly empathic remarks are often helpful.
• However, it can also be emotionally taxing to the physician

39. MANAGEMENT
• 5) Medical-psychiatric interface
• Help the patient self-discover the connection between physical
complaints and emotional stressors (“the mind-body” connection)
• Avoid comments like, “your symptoms are all psychological” or “there
is nothing wrong with you medically” or “its all in your head”
• Patient education
• Encourage and reassure on psychiatric consultations

40. MANAGEMENT
• 6) Do no harm:
• Avoid unnecessary diagnostic procedures
• Minimize consults to medical specialties
• Once a reasonable diagnostic workup is negative, feel comfortable
with a somatoform-type diagnosis and initiate treatment.

41. PHARMACOLOGIC MANAGEMENT
• Only as clearly indicated,or as time-limited empirical trial
• Antianxiety and antidepressant drugs for comorbid anxiety or
depressive disorders; if diagnosis unclear, consider empirical trial.
• Avoid drugs with abuse or addictive potential

42. PHARMACOLOGIC MANAGEMENT
• (Woolfolk & Allen, 2007), antidepressant treatment for functional somatic syndromes has been
shown to improve a patient’s physical symptom severity and overall functioning.
• Amitriptyline shows benefit for fatigue, functional symptoms, global impairment, morning
stiffness, pain, sleep, tender joints.
• Fluoxetine shows benefit for functional status, global well being, morning stiffness, pain, sleep
and tender joints.
• MAOIs, antiepileptics and antipsychotics show no benefit and should not be used.
• To date, however, there is no evidence supporting the long-term efficacy of pharmacological
intervention (Menza et al., 2001)

43. OTHER SOMATOFORM DISORDERS
• Undifferentiated somatoform disorder
• One or more physical complaints (e.g.,fatigue, loss of appetite, gastrointestinal or
urinary complaints)”
• Duration at least 6 months.
• Clinically significant distress or impairment in social, occupational,or other important
areas of functioning.
• Cannot be fully explained by a known GMC
• when there is a related GMC complaints is in excess of…expected”
• Not intentionally produced or feigned
• “…not better accounted for by another mental disorder”

44. Conversion disorder
• One or more symptoms or deficits affecting voluntary motor or sensory
function that suggest a neurological or other GMC
• Psychological factors is preceded by conflicts or other stressors
• Specify: with motor symptom or deficit,
• with sensory symptom or deficit,
• with seizures or convulsions,
• With mixed presentation
• No time requirement
• Clinically significant distress or impairment in social, occupational,or other
important areas of functioning.

45. • No GMC
• Not a culturally sanctioned behavior
• Not intentional
• Not limited to pain or sexual disorder
• not exclusively during the course of somatization disorder
• not better accounted for by another mental disorder

46. PAIN DISORDER
• Pain in one or more anatomical sites
• Psychological factor importantrole in onset, severity, exacerbation, or
maintenance of the pain”
• with psychological
• with both psychological factors and a GMC
• not a mental disorder
• Acute and chronic
• Significant distress
• r/o dyspareunia

47. HYPOCHONDRIASIS
• Preoccupation with fears
• misinterpretation of bodily symptoms
• Duration more than 6 months
• persists despite appropriate medical evaluation and reassurance
• May be with poor insight
• Significant distress
• r/o mental illness
• r/o medical conditions

48. Body dysmorphic disorder
• Preoccupation with an imagined defect in appearance.
• If a slight physical anomaly concern is markedly excessive
• No time requirement
• r/o delusional disorder
• r/o other mental disorder
• r/o GMC

49. Somatoform disorder NOS
• not meet criteria for any specific somatoform disorder”
• Examples: pseudocyesis,
• Nonpsychotic hypochondriacal symptoms,
• Unexplained physical complaints
• Less than 6months
• r/o somatoform disorder

50. CONCLUSION
• There is an increasing incidence of somatization disorder and other
somatoform disorders presenting to the hospitals.
• If these are not properly managed, there will be frustration on the part of
both doctors and patients leading to lack of trust and the patient continues
a vicious cycle of abnormal preoccupation and health seeking behavior.
• The CARE MD approach is a holistic way of managing patients with
somatoform disorders. This has reduced the frequency and intensity of
symptoms and the burden on the health care system.

51. REFERENCES
• Synopsis of Psychiatry tenth edition Kaplan and Saddock
• Comprehensive Textbook of Psychiatry Kay and Tasman 2006
• Shorter Oxford Textbook of Psychiatry
• Woolfolk, R., & Allen, L. (2007). Treating somatization: A cognitive-
behavioural Approach. New York: Guilford Press.
• R.O.A. Makanjuola Ode Ori a culture bound disorder with prominent
somatic features in Yoruba Nigerian patients APS 1987
• Gureje, Obikoya: Somatization in primary care: pattern and correlates
in a clinic in Nigeria APS 1992

52. •THANK YOU