DefinitionA category of psychiatric disorderscharacterized by converting emotionaldistress into physical symptoms that haveno clear organic cause.
What is it? Symptoms cannot be related to a physical cause Many investigations and medical evaluations are doneto exclude physical illnesses Not faking their pain or symptoms, everything theyfeel is real Don’t tell them their pains are imaginary or symptomsare psychological Runs in families, they tend to come and go over time
1.Somatization disorder An illness of multiple somatic complaints in multipleorgan systems Women ˃ men. More in people with little education and lowincomes. Usually starts before age 30.
Etiology Genetics:• Tends to run in families.• Occurs in 10 to 20 percent of the first-degree femalerelatives of patients. Biological Factors: Faulty perception of somatosensory inputs. Psychosocial Factors:• Some patients come from unstable homes and have beenphysically abused.
Diagnosis according to DSM VI TR A. history of many physical complaints beginning before age 30 years that occur over a periodof several years and result in treatment being sought or significant impairment in social,occupational, or other important areas of functioning. B. Each of the following criteria must have been met: Four pain symptoms: a history of pain related to at least four different sites or functions(e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, duringsexual intercourse, or during urination) Two gastrointestinal symptoms: a history of at least two gastrointestinal symptomsother than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, orintolerance of several different foods) One sexual symptom: a history of at least one sexual or reproductive symptom otherthan pain (e.g. erectile or ejaculatory dysfunction, irregular menses, excessive menstrualbleeding, vomiting throughout pregnancy) One pseudoneurological symptom: a history of at least one symptom or deficitsuggesting a neurological condition not limited to pain (conversion symptoms such asimpaired coordination or balance, paralysis or localized weakness,) C. Either (1) or (2): after appropriate investigation, each of the symptoms in Criterion B cannot be fullyexplained by a known general medical condition or the direct effects of a substance when there is a related general medical condition, the physical complaints or resultingsocial or occupational impairment are in excess of what would be expected from the history,physical examination, or laboratory findings D. The symptoms are not intentionally produced or feigned
Treatment Psychotherapy: Both individual and group psychotherapy. Patients are helped to cope with their symptoms, toexpress underlying emotions, and to develop alternativestrategies for expressing their feelings. Pharmacotherapy:• Only in comorbid mood or anxiety disorder.
2.Conversion Disorder Symptoms or deficits that affect voluntary motor orsensory functions, which suggest another medicalcondition, but that is judged to be caused bypsychological factors (preceded by conflicts or otherstressors). The symptoms are not intentionally produced. Female ˃ male. Common age: from late childhood to early adulthood.
Etiology Psychoanalytic theory: The conflict is between an instinctual impulse (e.g., aggression orsexuality) and the prohibitions against its expression. Learning Theory: A classically conditioned learned behavior; learned in childhoodas a means of coping with an impossible situation. Biological Factors: Hypometabolism of the dominant hemisphere. Hypermetabolism of the nondominant hemisphere.
TR Diagnostic Criteria for-IV-DSMConversion Disorder A. One or more symptoms or deficits affecting voluntary motor or sensoryfunction that suggest a neurological or other general medical condition. B. Psychological factors are judged to be associated with the symptom or deficitbecause the initiation or exacerbation of the symptom or deficit is preceded byconflicts or other stressors. C. The symptom or deficit is not intentionally produced or feigned (as infactitious disorder or malingering). D. The symptom or deficit cannot, after appropriate investigation, be fullyexplained by a general medical condition, or by the direct effects of asubstance, or as a culturally sanctioned behavior or experience. E. The symptom or deficit causes clinically significant distress or impairment insocial, occupational, or other important areas of functioning or warrants medicalevaluation. F. The symptom or deficit is not limited to pain or sexual dysfunction, does notoccur exclusively during the course of somatization disorder, and is not betteraccounted for by another mental disorder.
Treatment Resolution of the conversion disorder symptom is usuallyspontaneous. Psychotherapy:o Insight-oriented supportive or behavior therapy.o Hypnosis and behavioral relaxation exercises. Pharmacotherapy :o Anxiolytics and antidepressants especially in comorbid cases.Telling such patients that their symptoms are imaginary oftenmakes them worse.
3.Hypochondriasis Preoccupation with non dellusional fear of having a seriousdisease. Men and women are equally affected. Commonly appears in persons 20 to 30 years old . About 3% of medical students, are complaining ofhypochondrial symptoms, but they are generally transient.
Etiology Faulty cognition: A misinterpretation of bodily symptoms or augmentation of their somaticsensations. Social learning model: The sick role offers an escape from usual duties and obligations. Variant form of other mental disorders: About 80% of patients with hypochondriasis may have underlyingdepressive or anxiety disorders. The psychodynamic school: Aggressive and hostile wishes toward others are transferred (throughrepression and displacement) into physical complaints..
DSM-IV-TR Diagnostic Criteria forHypochondriasis A. Preoccupation with fears of having, or the idea that one has, aserious disease based on the persons misinterpretation of bodilysymptoms. B. The preoccupation persists despite appropriate medical evaluationand reassurance. C. The belief in Criterion A is not of delusional intensity (as indelusional disorder, somatic type) and is not restricted to acircumscribed concern about appearance (as in body dysmorphicdisorder). D. The preoccupation causes clinically significant distress orimpairment in social, occupational, or other important areas offunctioning. E. The duration of the disturbance is at least 6 months. F. The preoccupation is not better accounted for by generalizedanxiety disorder,OCD, panic disorder, a major depressive episode,separation anxiety, or another somatoform disorder.
Treatment Psychotherapy: Includes psychoeducation, Group psychotherapy, behaviortherapy, cognitive therapy, and hypnosis may be useful. Pharmacotherapy: If hypochondriacal symptoms only are associated withunderlying psychiatric condition, such as an anxiety disorderor major depressive disorder.
4- Body Dysmorphic Disorder(Dysmorphophobia) A preoccupation with an imagined defect in appearancethat causes clinically significant distress or impairment inimportant areas of functioning. Patients are more likely to go to dermatologists, internists,or plastic surgeons than to psychiatrists. Most common age of onset is15-30 years. Women ˃ men.
EtiologyUnknown Biological:o The high comorbidity with depression, and OCD, and responsivenessto SSRIs indicate that, in some patients, may involve serotonin. Psychosocial :o Stereotyped concepts of beauty emphasized in certain families andwithin the culture may significantly affect patients. Psychodynamic:o Seen as reflecting the displacement of a sexual or emotional conflictonto a nonrelated body part.
DSM-IV-TR Diagnostic Criteria forBody Dysmorphic DisorderA. Preoccupation with an imagined defect inappearance. If a slight physical anomaly is present,the persons concern is markedly excessive.B. The preoccupation causes clinically significantdistress or impairment in social, occupational, or otherimportant areas of functioning.C. The preoccupation is not better accounted for byanother mental disorder (e.g. dissatisfaction with bodyshape and size in anorexia nervosa).
Treatment Treatment of patients with surgical, dermatological, dental,and other medical procedures to address the allegeddefects is mostly unsuccessful. Pharmacotherapy:• Tricyclic drugs, monoamine oxidase inhibitors (MAOIs), pimozideand serotonin-specific drugs e.g., fluoxetine.• The coexisting depressive or anxiety disorders should be treatedwith the appropriate pharmacotherapy and psychotherapy.
5.Pain Disorder A pain disorder is characterized by the presence ofpain in one or more body sites and is sufficientlysevere to come to clinical attention. Psychological factors are necessary in the genesis,severity, or maintenance of the pain. The associated psychiatric disorders may precede,co-occur with or result from the pain disorder, may co-occur with it, or may result from it.
Etiology Psychodynamic Factors:• Patients may be symbolically expressing an intrapsychic conflict through the body. Behavioral Factors:• Pain behaviors are reinforced when rewarded and are inhibited when ignored orpunished. Interpersonal Factors:• Intractable pain has been conceptualized as a means for manipulation andgaining advantage in interpersonal relationships. Biological Factors:• The cerebral cortex can inhibit the firing of afferent pain fibers. Serotonin is probably the main neurotransmitter in the descending inhibitory pathways, andendorphins also play a role in the central nervous system modulation of pain.
The DSM-IV-TR diagnostic criteria forpain disorder Pain in one or more anatomical sites is the predominant focus of theclinical presentation and is of sufficient severity to warrant clinicalattention. The pain causes clinically significant distress or impairment in social,occupational, or other important areas of functioning. Psychological factors are judged to have an important role in the onset,severity, exacerbation, or maintenance of the pain. The symptom or deficit is not intentionally produced or feigned (as infactitious disorder or malingering). The pain is not better accounted for by a mood, anxiety, or psychoticdisorder and does not meet criteria for dyspareunia.
Treatments Therapists must fully understand that the patients experiences of painare real. Help the patient to find psychological factors behind the condition,which make their pain worse. Pharmacotherapy: Analgesic medications do not generally benefit most patients with paindisorder. SSRI and TCA are beneficial. Psychotherapy: Psychodynamic psychotherapy Biofeedback can be helpful in the treatment of pain disorder e.g., muscletension states.
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