somatoform disorder in detail with types and clinical cases and its features and management and criteria dsm iv and icd 10 classification

1. SOMATOFORM DISORDERS
DR. SANDEEP SHRESTHA
DR. SUNDAR SHRESTHA
INTERN
PSYCHIATRIC DEPARTMENT

3. Somatoform disorders are mental
illness characterized by the
presentation of physical symptoms
with no medical explanations .The
symptoms are severe enough to
interfere with the patients ability to
function in social or occupational
activities.

4. ICD -10 classification

5. ICD -10 classification
1.Somatisation disorder
2.Hypochondriasis
3.Conversion disorder
3.Somatoform Autonomic dysfunction
4.Persistent somatoform pain disorders
5. Undifferentiated somatoform disorder
6.Others somatoform disorder( Globus
hysterics , psychogenic pruritus,
psychogenic dysmenorrhea, Teeth-
grinding)

7. HYPOTHALAMUS PITUITARY ADRENAL AXIS
 Stress affect immune responses through the
hypothalamus –pituitary-adrenal axis and
sympathetic nervous system.
 Neuropeptides and neurotransmitters
(Serotonin) are released ,triggering various
GI responses , such as GUT dysmotility.

8. SOMATISATION DISORDER
Somatization disorder is characterized by
the following clinical
Features:
Multiple somatic symptoms in absence
of any physical disorder.
The symptoms are recurrent and chronic
(at least 2 year duration is needed for
diagnosis.

10. SOMATIZATION DISORDER: DIAGNOSTIC
CRITERIA( DSM IV-TR)
A. History of physical symptoms:
beginning before 30
occurring over several years
resulting in Treatment being sought or
significant impairment in social,
occupational, or other important areas of
functioning.

11. CONTD…
B. Must meet each of the following criteria during the course of the
disorder:
 4 Pain Sign: a History of pain related to at least 4 different sites
(e.g. head, abdomen, back, joints, chest) or functions (e.g.
menstruation, sexual intercourse, urination)
 2 Gastrointestinal Sign: a History of at least 2 GI Sign other than
pain (e.g. nausea, bloating, vomiting, diarrhea, intolerance of
several foods)
 1 Sexual Sign: a History of at least 1 sexual or reproductive Sign
other than pain (e.g. sexual indifference, erectile or ejaculatory
dysfunction, irregular menses, excessive menstrual bleeding,
vomiting throughout pregnancy)
 1 Pseudoneurological Sign: a History of at least 1 Sign or deficit
suggesting a neurological condition without pain (e.g. impaired
coordination or balance, paralysis, localized weakness, difficulty
swallowing, lump in throat, loss of touch or pain sensation, double
vision, blindness, deafness, seizures, urinary retention)

12. C. Either (1) or (2):
(1) Symptoms not fully accounted for by a
general medical condition or the effects of a
substance
(2) When there is a related medical condition,
the complaints and resulting social or
occupational impairment exceed what would be
expected from the history, physical
examination, or laboratory findings .
D. Symptoms are not intentionally feigned or
produced, as in Factitious Disorder or
Malingering
CONTD…

13. CLINICAL CASE
Diagnosis :Somatisation disorder

14. TREATMENT
PSYCHOTHERAPY
1. Supportive psychotherapy: The treatment of choice is usually
supportive psychotherapy. The first step is to enlist the patient in the
therapeutic alliance by establishing a rapport. It is useful to demonstrate
the link between psychosocial conflict(s) and somatic symptoms, if it is
apparent. In chronic cases, ‘symptom reduction’ rather than
‘complete cure’ might be a reasonable goal.
2. Behaviour modification: After rapport is established, attempts at
modifying behaviour are made, for example, not focusing on the
symptoms per se, and positively reinforcing normal functioning.
3. Relaxation therapy, with graded physical exercises.

15. PHAMACOTHERAPY
Drug therapy: Antidepressants and/or
benzodiazepines can be given on a short-term
basis for associated depression and/or anxiety.
Benzodiazepines should be used with great
caution, as the risk of dependence and misuse is
high in these patients

20. Hypochondriasis
( Hypochondriacal Disorder)
Hypochondriasis is defined as a persistent preoccupation
with a fear (or belief) of having one (or more) serious
disease(s), based on person’s own interpretation of normal
body function or a minor physical abnormality.

21. HYPOCHONDRIASIS
CAUSES:
 Faulty interpretation of bodily cues and
sensations as evidence of physical illness
 Enhanced sensitivity to, & over-focusing on,
physical sensations and illness cues
 Stressful life events
 Disproportionate incidence of disease in family
during childhood
 Secondary gains associated with the sick role:
decreased responsibility and increased attention

22. HYPOCHONDRIASIS:
DIAGNOSTIC CRITERIA(DSM IV – TR)
A. Preoccupation with fear of having or belief that one has a
serious illness, based on misinterpretation of bodily Sign or
functions
B. Preoccupation persists despite appropriate medical
evaluation, reassurance, and the person’s not developing
the feared disease
C. Preoccupation lasts at least 6 months
D. Preoccupation causes clinically significant distress or
impairment in important areas of functioning
E. Preoccupation is not better accounted for by other
disorders, such as GAD, OCD, Panic Disorder, Major
Depression, Separation Anxiety, or another Somatoform
Disorder

23. CLINICAL CASE
DIAGNOSIS:Hypochondriasis

24. 1. Supportive psychotherapy.
2.Pharmacotherapy
Antidepressant
benzodiazepam
Treatment:
The treatment of hypochondriasis is often
difficult. It basically consist of:

26. CONVERSION DISORDER
A disoder in which the individual experiences
one or more neurological symptoms that
cannot be explained by any medical or
neurological disorder.

27. CONVERSION DISORDER
 More common in:
 rural populations
 lower SES
 less medically/psychologically sophisticated
 women than men (2-10x)
 In women, sign are much more common on
the left than right side of the body
 Onset: late childhood through early
adulthood; rarely before 10 or after 35

28. CONVERSION DISORDER:
DIAGNOSTIC CRITERIA (DSM IV – TR)
A. One or more Sign or deficits affecting voluntary motor or
sensory functioning and indicative of a neurological or other
medical condition
B. Psychological factors are associated with the Sign – the
initiation or exacerbation of Sign is preceded by conflicts or
stressors
C. The Sign is not intentionally feigned or produced, as in
Factitious Disorder or Malingering
D. The Sign cannot be fully explained by a general medical
condition, the effects of a substance, or a culturally sanctioned
behavior or experience
E. Sign cause significant distress or impairment in functioning or
warrant medical attention
F. The Sign is not limited to pain or sexual dysfunction, does not
occur exclusively in the course of Somatization Disorder, and is
not better accounted for by another mental disorder

29. CLINICAL CASE
DIAGNOSIS:CONVERSION DISORDER

30. CONVERSION DISORDER
 Presentaion
 With Motor Sign or Deficits – e.g. impaired
coordination or balance, paralysis, localized
weakness, difficulty swallowing, lump in throat,
urinary retention
 With Sensory Sign or Deficits – loss of touch or
pain sensation, double vision, blindness,
deafness, hallucinations
 With Seizures or Convulsions
 With Mixed Presentation

31. CONVERSION DISORDER:
ASSESSMENT
 Assess the following:
 physical sign, medical conditions, medications, abused
substances, psychiatric symptoms, and stressors and
conflicts
 the person’s level of medical knowledge
 whether the person may be intentionally feigning
symptoms
 manner of presenting symptoms – dramatic and
histrionic or la belle indifference
 R/O underlying neurological or general medical
conditions by referral for a thorough neuorological
examination: 5-10% have real medical problems

32. CONVERSION DISORDER:
TREATMENT CONSIDERATIONS
A.PSYCHOTHERAPY
 Identify and attend to the traumatic or stressful life event
 Address current psychosocial stressors with environmental
manipulation, support, advice, and coping skills
 Reduce any reinforcing or supportive consequences from the
conversion Sign
 Insight-oriented therapies usually aren’t indicated or helpful
 For acute Sign: positive expectation for recovery; a face-saving
way for the patient to recover, e.g. physical therapy
 For chronic Sign: physical rehabilitation, suggestion, &
psychotherapy
 Work closely with a medical doctor and psychiatrist

33. Somatoform Autonomic Dysfunction
According to ICD-10, in this disorder, symptoms
are presented by the patient as if they were due to
a physical disorder of an organ system that is predominantly
under autonomic control, e.g. heart and cardiovascular system
(such as palpitations), upper gastro intestinal tract (such as
aerophagy, hiccough), lower gastrointestinal tract (such as
flatulence, irritable bowel syndrome), respiratory system
(such as hyperventilation), genitourinary system (such as
dysuria), or other organ systems.

34. There is preoccupation with, and distress regarding,
the possibility of a serious (but often unspecified)
disorder of the particular organ system. Physical
examination and investigations do not however show
presence of any significant abnormality. The
preoccupation persists despite repeated assurances and
explanations.

35. Treatment
The treatment consists of:
1. Supportive psychotherapy.
2. Drug treatment: The symptoms of anxiety
and/or
depression usually respond to short-term use of
benzodiazepines and antidepressants.

37. PERSISTENT SOMATOFORM PAIN
DISORDER
A disorder in which the presence of pain is the patients
main complaint.

38. PAIN DISORDER:
DIAGNOSTIC CRITERIA (DSM IV – TR)
A. Pain in one or more anatomical sites is the
predominant focus of clinical presentation and is of
sufficient severity to warrant clinical attention.
B. Psychological factors are judged to have an
important role in the onset, severity, exacerbation, or
maintenance of the pain.
C. Pain causes clinically significant distress or
impairment in important areas or functioning or
warrants medical attention.
D. Pain is not intentionally feigned or produced, as in
Factitious Disorder or Malingering.
E. Pain is not better accounted for by a Mood, Anxiety,
or Psychotic Disorder.

39. 3 TYPES OF PAIN DISORDER
 Pain Disorder Associated with Psychological
Factors: psychological factors have a major role
in the onset, severity, exacerbation, or
maintenance of pain
 Pain Disorder Associated with a General Medical
Condition: GMC or site of pain is coded on Axis
III, e.g. low back, sciatic, pelvic, headache, chest,
joint, abdominal, throat, urinary
 Pain Disorder Associated with Both Psychological
Factors and a General Medical Condition: most
common

40. PAIN DISORDER: SPECIFIERS
 Acute: duration less than 6 months
 Chronic: duration 6 months or longer

41. PAIN DISORDER:
TREATMENT CONSIDERATIONS
 Collect info regarding physical Sign, medical
conditions, medications, abused substances,
psychiatric symptoms, stressors and conflicts
 Distinguish from Factitious Disorder or
Malingering
 Target both the physical and psychological
aspects of chronic pain
 Validate the person’s pain, rather than
challenging or insight
 Enlist the person’s cooperation in developing
strategies for dealing with pain

42. PAIN DISORDER:
TREATMENT CONSIDERATIONS
 Pain management: teach techniques for coping with pain;
use of analgesic, anti-inflammatory, and antidepressant
medications
 Cognitive behavioral techniques: distraction, stress
management, cognitive restructuring, activity pacing, sleep
management, logging activities attempted and level of pain
associated with each
 Attend to factors that influence recovery: acknowledging
pain; giving up unproductive efforts to control pain;
participating in regularly scheduled activities despite pain;
recognizing and treating comorbid disorders; adapting to a
potentially chronic condition; not allowing the pain to
become the determining factor in one’s lifestyle

43. BODY DYSMORPHIC DISORDER
A disorder characterized by the belief that
some part is abnormal ,defective ,or
misshapen.

46. BODY DYSMORPHIC DISORDER:
DIAGNOSTIC CONSIDERATIONS(DSM IV – TR)
A. Preoccupation with an imagined defect in
appearance or markedly excessive concern
about a slight physical anomaly
B. The preoccupation causes clinically
significant distress or impairment in important
areas or functioning
C. The preoccupation is not better accounted
for by another mental disorder, such as
distorted body image in Anorexia Nervosa

47. CLINICAL CASE
DIAGNOSIS:BODY DISMORPHIC
DISORDER

48. BODY DYSMORPHIC DISORDER:
COMMON FEATURES
 Constant and excessive use of mirrors
 Avoidance of mirrors
 Lots of time spent grooming
 Lots of grooming rituals
 Attempts to hide parts of body
 Constantly seeking reassurance about looks,
while discounting feedback
 Anxiety or depression about one’s appearance

49. BODY DYSMORPHIC DISORDER:
FACTS & FIGURES
 People with BDD often seek help from
dermatologists and plastic surgeons (rates of
BDD in these settings is 6-15%)
 BDD is under-recognized & under-diagnosed
in nonpsychiatric settings
 BDD is infrequent in mental health settings
 Onset: adolescence and young adulthood

50. BODY DYSMORPHIC DISORDER: TREATMENT
 There is little to no research on treatments for BDD
 Distinguish BDD from normal concerns about
appearance or overvaluing of appearance (resistant to
reality testing and reassurance; cause significant
distress or impairment; delusional)
 Pharmacotherapy: SSRI’s at higher doses & for longer
duration
 CBT strategies: exposure and response prevention,
self-esteem building, modifying distorted thinking, and
coping strategies

52. FACTITIOUS DISORDER

53. CLINICAL CASE
DIAGNOSIS:FACTITIOUS DISORDER