Somatoform disorders

Somatoform
Disorders
Jayesh Patidar
www.drjayeshpatidar.blogspot.com

Objectives: Somatoform disorders
 Identify the diagnostic features of the most
common somatoform disorders
 List characteristics differentiating somatoform
disorders from malingering and factitious
disorders
 Outline management strategies for patients with
somatoform disorders.
By the conclusion of the presentation, the student
will be able to:

Somatoform disorders
 Context and definitions
 Epidemiology
 Social and medical cost

Ms. A
Ms. A is a 43 year old divorced woman who
complains of abdominal pain. She describes
a searing pain that usually follows meals, and
localizes it by pointing to an area just above
her umbilicus. She insists that antacids and
ranitidine are of no help. She is insistent on
having an endoscopy right away.
Ms. A’s chart is now on its third volume. She
has made frequent visits to the practice over
about 20 years, sometimes for this complaint
and sometimes for others. She has had
multiple diagnostic procedures, and many
trials of therapy. None has brought definitive
diagnosis or effective resolution of symptoms.www.drjayeshpatidar.blogspot.com

Somatoform disorders
 Somatization disorder
 Hypochondriasis
 Pain disorder
 Body dysmorphic disorder
 Conversion disorder

Somatization disorder
 “Briquet’s syndrome”
 Clinical features
 Epidemiology

 4 pain symptoms
 2 gastrointestinal symptoms
 1 sexual symptom
 1 pseudoneurologic symptom
DSM IV criteria

Screening criteria I - 5 of:
 Abdominal gas
 Diarrhea
 Abdominal pain
 Chest pain
 Pain in extremities
 Weakness
 Nausea
 “Feeling sickly”
 Dizziness
 Fainting spells
 Vomiting

Screening criteria II - 2 of:
 Vomiting
 Pain in extremities
 Dyspnea without exertion
 Amnesia
 Dysphagia
 Burning sensation in sexual organs or rectum
 Painful menstruation

Frequency of common symptoms
in somatization disorder
See Andreasen & Black (4th Ed.), Table 8-3

Ms. A - 2
You remind Ms. A that she had an upper GI
series of X-ray studies less than a year ago,
and an upper endoscopy about six months
ago. The complaints were identical then, and
the results were negative. You begin to make
some recommendations about changes in
eating patterns, when she interrupts.
“I’ve tried all that and it doesn’t work. I know
I have an ulcer and the exams last year were
negative because they missed it. I never had
much faith in that gastroenterologist you
referred me to, anyway. You’ve got to find
someone who can make the diagnosis and
take care of it properly.”

Hypochondriasis
 Generalized fear of or belief in illness
 Prevalence in men = women
 Pervasive disruption of psychosocial
function

Hypochondriasis - clinical
features
 Complaints: GI, pain, cardiovascular
 Chronic, variable
 Preoccupied, disabled
 Attitudes towards physicians

Pain disorder
 Pain in one or more sites
 Psychological factors in
origin and/or
maintenance of pain

Body dysmorphic disorder
 Preoccupation with imagined or
slight imperfection in appearance
– Most commonly: skin, hair, nose
– Also: penis, muscles, breasts,
buttocks
 Men = women
 Some family link to OCD
 SSRIs modestly helpful with
quality of life

Conversion disorder
 Loss of, or alteration in, physical function,
resulting from psychologic need or conflict
 Historical roots

Jean-Marie Charcot

Sigmund Freud

Bertha Pappenheim (“Anna O”)

A. insistence on the presence of a particular illness.
B. large variety of unsubstantiated physical
complaints.
C. persistent complaints of pain with
disproportionate disability.
D. personality style featuring physical manifestations
of psychological problems.
E. sensory or motor symptoms suggesting
neurologic origin.
The defining characteristic of conversion disorder is:

 Sensory or motor symptoms suggesting
neurologic origin
 Positive evidence of psychologic etiology
 See Andreasen & Black (4th Ed.), Table 8-5 for DSM-IV
criteria
Conversion disorder

Differential diagnosis
 Malingering / factitious disorder
 Somatic delusions
 Mood disorder

A. Both are different names for the same condition.
B. Factitious disorder attempts to achieve psychological
benefit, malingering attempts to achieve external
benefit.
C. Factitious disorder is conscious, malingering is primarily
unconscious.
D. Malingering is a much more chronic condition than
factitious disorder.
E. Malingering patients complain of a wider variety of
symptoms.
The chief difference between malingering and
factitious disorder is:

A. Both are different names for the same condition.
B. Factitious disorder attempts to achieve
psychological benefit, malingering attempts to
achieve external benefit.
C. Factitious disorder is conscious, malingering is primarily
unconscious.
D. Malingering is a much more chronic condition than
factitious disorder.
E. Malingering patients complain of a wider variety of
symptoms.
The chief difference between malingering and
factitious disorder is:

Diagnostic algorithm
Suspicious symptoms
or complaints
Conscious attempt
to deceive
No conscious
attempt to deceive
Somatoform disorders, e.g.:
Conversion disorder
Hypochondriasis
Chief goal
psychological
(primary gain)
Factitious
disorder
Chief goal external
(secondary gain)
Malingering

Primary gain Solution to an
internal problem
Secondary gain Environmental
influences that
perpetuate somatization

Factitious Disorder
 Production of symptoms under voluntary
control
− Worsen when observed
− Bizarre or ridiculous
− Wax and wane with environmental events
 Goal is to assume “patient role”
 External incentives absent

Malingering: DSM-IV (V65.2)
Intentional production of
false or grossly
exaggerated symptoms,
motivated by external
incentives such as
obtaining financial
compensation or drugs, or
avoiding work, military
duty, or criminal
prosecution

Malingering
 Symptoms under voluntary control
− Patient acknowledgement
− Direct observation
− Failure to cooperate with treatment
− Rapid remission when incentives removed
 Causal relationship to environmental incentive
− Avoidance of work, punishment, military service
− Financial gain
− Acquisition of drugs
 Cannot be explained by desire to assume
patient role, or by other mental disorder

ALL PAIN
IS REAL

Understanding somatization
 Dimensional characteristic
 Pain and depression

Pain and monoamines
Limbic system
Thalamus
Locus coeruleus
Serotonin
Norepinephrinewww.drjayeshpatidar.blogspot.com

“I thought I had something psychosomatic,
but it turned out to be just my imagination.”

The goal is
MANAGEMENT,
not cure

Keep in
control of the
case

Schedule regular
appointments
Break the cycle of symptoms ↔ attention

Management of somatoform
disorders
 Explain chronic nature of condition
 Explore impact on patient’s life
 Avoid implying “It’s all in your head.”
Explain tension ↔ pain cycle

Management of somatoform
disorders
•Explain chronic nature of condition
•Explore impact on patient’s life
•Avoid implying “It’s all in your head.”
• Explain tension ↔ pain cycle
•Brief physical exam

20 minutes / month
= 4 hours / year

Signs and symptoms of
depression
 Hopelessness
 Guilt
 Irritability
 Diminished interest or pleasure
 Diminished energy
 Sleep or appetite disturbance

Somatoform disorders

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