Unexplained Symptoms that do not have medical explanations.......and could be of psychological problems

1. BY
Emmanuel , Godwin
5th Year Medical Student
University of Nigeria , Enugu Campus

2. •INTRODUCTION
•LIST OF CATEGORIES OF CONSTITUTE
DISORDERS;ICD-10,DSM-IV TR
•SOMATIZATION DISORDER
Introduction
Risk factors/ Etiology
Epidermiology
Diagnostic Criteria
Course and Prognosis
Physical and Psychiatric Presenting Symptoms
Treatment
Differential Diagnosis

3. The term somatoform derives from the Greek
‘’soma’’ which means body,
Somatoform disorders are a broad group of
disorders characterized by the presentation of
physical symptoms with no medical
explanation(s). The symptoms are severe
enough to interfere with the patient’s ability to
function in social or occupational activities.

4.  Symptoms cannot be explained fully by a general medical
condition or by the direct effect of a substance, and are not
attributed to another mental disorder eg panic disorder.
 The symptoms of a somatoform disorder are considered to
be due to a hard wiring problem within the brain where
thoughts are sent down into the body through the
Autonomic Nervous System to become symptoms instead
of being sent up into the conscious area of the brain.
 Medical test results are either normal or do not explain the
person’s symptoms ,and history and physical examination
do not indicate the presence of a medical condition that
could cause them

5.  Patients with this disorder often become worried
about their health because doctors are unable to find a
cause for their symptoms. This may cause severe
distress.
 Somatoform disorders are not the result of conscious
malingering (fabricating or exaggerating symptoms for
secondary motives) or factitious disorders
(deliberately producing, feigning, or exaggerating
symptoms) – sufferers perceive their plight as real.

6.  Additionally, a somatoform disorder should not be
confused with the more specific diagnosis of a
somatization disorder
 . Various laboratory tests, physical examinations, and
surgeries on these individuals show no evidence
supporting the idea that these exaggerating symptoms
are present.
 Somatoform disorder is difficult to diagnose and treat
since doing so requires psychiatrists to work with
neurologists on patients with this disorder.

7. DSM-IV TR
CATEGORIES

8.  Seven somatoform disorders are listed in the revised
fourth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV-TR) of the American
Psychiatric Association as follow:

9.  1)Somatisation disorder , a disorder characterized by
multiple physical complaints which do not have a
medical explanation before age 30;
 (2) Conversion disorder, a somatoform disorder
involving the actual loss of bodily function which
includes blindness , paralysis, and numbness due to
excessive anxiety or characterized by one or two
neurological complaints
 3) Hypochondriasis, characterized less by a focus on
symptoms than by patients' beliefs that they have a
specific disease

10.  4) Body dysmorphic disorder, characterized by a
false belief or exaggerated perception that a body part
is defective;
 (5) Pain disorder, characterized by symptoms of pain
that are either solely related to, or significantly
exacerbated by, psychological factors

11.  6) Undifferentiated somatoform disorder, which
includes somatoform disorders not otherwise
described that have been present for 6 months or
longer; and
 (7) Somatoform disorder not otherwise
specified, which is the category for somatoform
symptoms that do not meet any of the somatoform
disorder diagnoses mentioned above

12. ICD-10 CATEGORIES
 Somatisation disorder, characterised be at least two
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year history of medically unexplained symptoms
Undifferentiated somatoform disorder
Hypochondriacal disorder
Persistent Somatoform Pain disorder
Somatoform autonomic dysfunction
Hypochondriacal-dysmorphophobia
Neurasthenia

13.  The ICD-10 classified conversion disorder as a
dissociative disorder

14. ADDITIONAL PROPOSED
SOMATOFORM DISORDERS ARE;
 Abridged somatization disorder- at least 4
unexplained somatic complaints in men and 6 in
women
 Multisomatoform disorder –at least 3 unexplained
somatic complaints from the Primary Care Evaluation
of Mental Disorders(PRIME-MD) scale for at least
2years of active symptoms.

15. Somatization Disorder

17. INTRODUCTION
 By Definition, it is a disorder consisting of multiple
symptoms affecting multiple organs.
 A.K.A. Briquet’s syndrome or hysteria.
 Is a somatoform disorder.
 Is an illness of multiple somatic complaints in multiple
organ systems that occurs over a period of several years
and results in significant impairment or treatment
seeking, or both. a

18. • Characterised by
recurring, multiple, clinically significant
complaints about
pain, gastrointestinal, sexual and
pseudoneurological symptoms.
• Complaints must begin before individual
turns the age of 30 (usually during the
person’s teenage years)and could last for
several years, resulting in either treatment
seeking behavior or significant treatment.

19. RISK FACTORS/ETIOLOGY
 Affects women more than men
 Is usually begins by the age of 30
 Data suggest that there may be a genetic linkage to the
disorder
 Male relatives tend to have antisocial personality
disorder
 Female relatives tend to have histrionic personality
disorder

20. Epidemiology
• Lifetime prevalence in the general population is
estimated to be 0.2% - 2% in women and 0.2% in
men.
• The disorder is inversely related to social position
and occurs most often among patients who have
little education and low incomes.
• Research has shown comorbidity with other
psychological disorders particularly mood disorders
and anxiety disorders; also between somatization
disorders and personality disorders especially
antisocial, histrionic, avoidant and dependent
personality disorders.

21. • About 10-20% of female first degree
relatives also have somatization disorder,
and male relatives have increased rates of
alcoholism and sociopathy.

22. DSM-IV-TR Diagnostic Criteria for Somatization
Disorder
• A history of many physical complaints beginning before age 30
years that occur over a period of several years and result in
treatment being sought or significant impairment in social,
occupational, or other important areas of functioning.
• Each of the following criteria must have been met, with
individual symptoms occurring at any time during the course of
the disturbance:
– 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, during sexual
intercourse, or during urination)
– two gastrointestinal symptoms: a history of at least two
gastrointestinal symptoms other than pain (e.g., nausea, bloating,
vomiting other than during pregnancy, diarrhea, or intolerance of
several different foods)

23. – one sexual symptom: a history of at least one sexual or
reproductive symptom other than pain (e.g., sexual
indifference, erectile or ejaculatory
dysfunction, irregular menses, excessive menstrual
bleeding, vomiting throughout pregnancy)
– one pseudoneurological symptom: a history of at least
one symptom or deficit suggesting a neurological
condition not limited to pain (conversion symptoms
such as impaired coordination or balance, paralysis or
localized weakness, difficulty swallowing or lump in
throat, aphonia, urinary retention, hallucinations, loss
of touch or pain sensation, double
vision, blindness, deafness, seizures; dissociative
symptoms such as amnesia; or loss of consciousness
other than fainting)

24. • Either (1) or (2):
– after appropriate investigation, each of the symptoms
in Criterion B cannot be fully explained by a known
general medical condition or the direct effects of a
substance (e.g., a drug of abuse, a medication)
– when there is a related general medical condition, the
physical complaints or resulting social or occupational
impairment are in excess of what would be expected
from the history, physical examination, or laboratory
findings
• The symptoms are not intentionally produced or
feigned (as in factitious disorder or malingering).

25. Course and Prognosis
• Somatization disorder is a chronic, undulating, and
relapsing disorder that rarely remits completely. It is
unusual for the individual with somatization
disorder to be free of symptoms for greater than 1
year, during which time they may see a doctor
several times. Research has indicated that a person
diagnosed with somatization disorder has
approximately an 80 percent chance of being
diagnosed with this disorder 5 years later. Although
patients with this disorder consider themselves to be
medically ill, good evidence is that they are no more
likely to develop another medical illness in the next
20 years than people without somatization disorder.

28. Treatment
• Somatization disorder is best treated when the
patient has a single identified physician as primary
caretaker. When more than one clinician is
involved, patients have increased opportunities to
express somatic complaints.
• Once somatization disorder has been diagnosed,
the treating physician should listen to the somatic
complaints as emotional expressions rather than as
medical complaints. Nevertheless, patients with
somatization disorder can also have bona fide
physical illnesses; therefore, physicians must always
use their judgment about what symptoms to work
up and to what extent.

29. Treatment
 Patient should be seen during regularly scheduled
brief monthly visits
 To date, cognitive behavioral therapy (CBT) is the best
established treatment.
 CBT helps with the patient realizing that the ailments
are not as catastrophic and enabling them to slowly get
back to doing activities that they once were able to do
without fear of ‘worsening their symptoms’.


30. • Psychotherapy, both individual and group,
decreases these patients' personal health
care expenditures by 50 percent, largely by
decreasing their rates of hospitalization. In
psychotherapy settings, patients are helped
to cope with their symptoms, to express
underlying emotions, and to develop
alternative strategies for expressing their
feelings.

31. • ECT has been used in treating somatization
disorder among the elderly.
• Psychotherapeutic treatment of coexisting
disorder is indicated.

32. DIFFERENTIAL DIAGNOSIS
 Medical
 Multiple sclerosis
 Myasthenia gravis
 SLE
 AIDS
 Thyroid
 Chronic Systemic infection

33. DIFFERENTIAL DIAGNOSIS
 Psychiatric
 Major Depression
 Generalised Anxiety Disorder
 Schizophrenia

34. REFERENCES
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35. Thank You