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Somatoform Disorders
- 2. Why? • Interesting • Easily confused • High incidence – 20% of new patients in GP surgeries are ‘somatisers’ • Expandable – an area where more research is needed!
- 3. Contents • What is Somatization • Somatoform Disorders – What they are – Aetiology – A little history – Key Words – Somatisation Disorder vs Conversion Disorder vs Hypochondriasis – Pain Disorders – Vignettes
- 4. Somatization • Somatization = “a tendency to experience and communicate somatic distress in response to psychosocial stress and to seek medical help for it” * I.e. Psychosomatic symptoms • Many diseases! *Lipowski ZJ (1988). "Somatization: the concept and its clinical application". Am J Psychiatry 145 (11): 1358–68.
- 5. What are the somatoform disorders? • “Physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder. The physical symptoms must be serious enough to interfere with the patient's employment or relationships, and must be symptoms that are not under the patient's voluntary control ” Somatoform Disorders can include: •Somatization Disorder •Hypochondriasis •Conversion / Dissociative Disorder •Pain Disorder •Conversion / Dissociative Disorders •Body Dysmorphic Disorder •Chronic Fatigue Syndrome •IBS Other names: - “Functional Disorders” - “Psychosomatic Disorders” - “Neurotic, stress-related and somatoform disorders” – ICD 10 (F40-F48)
- 6. Aetiology • Uncertain!!! - Unsatisfactory classification of somatoform disorders confusion • Conflicting views and evidence • Generally agreed upon: – Female > Male – Childhood illnesses – Knowledge of symptoms and diseases, including media coverage
- 7. Shlomo
- 8. • Repression • Primary gain • Secondary gain Key Words
- 9. • Repression – An unconscious psychological mechanism in which painful or unacceptable ideas, memories, or feelings are removed from conscious awareness or recall. • Primary gain • Secondary gain Key Words
- 10. • Repression – An unconscious psychological mechanism in which painful or unacceptable ideas, memories, or feelings are removed from conscious awareness or recall. • Primary gain – The immediate relief from guilt, anxiety, or other unpleasant feelings that a patient derives from a symptom. • Secondary gain Key Words
- 11. • Repression – An unconscious psychological mechanism in which painful or unacceptable ideas, memories, or feelings are removed from conscious awareness or recall. • Primary gain – The immediate relief from guilt, anxiety, or other unpleasant feelings that a patient derives from a symptom • Secondary gain – The social, occupational, or interpersonal advantages that a patient derives from symptoms. A patient's being relieved of his or her share of household chores by other family members would be an example of secondary gain. Key Words
- 12. Pain Disorder • Persistent, Severe and Distressing pain, associated with emotional or psychosocial problems, which cannot be explained fully by a physiological process. Tension Headaches ? Proctalgia Fugax Globus Hystericus Facial Pain -Temporomandibular Dysfunction -Atypical Facial Pain Atypical Chest Pain Psychogenic Itch
- 13. Proctalgia Fugax • F>M • Backside Pain • ASSociated with sexual activity Globus Hystericus
- 14. What separates the main Somatoform Disorders? • Somatization Disorder • Conversion Disorder • Hypochondriasis
- 15. What separates the big’ns? • Somatization Disorder - Symptom Orientated e.g. Pain - GI, nervous, cardiopulmonary or reproductive systems. • Conversion Disorder • Hypochondriasis
- 16. What separates the big’ns? • Somatization Disorder - Symptom Orientated e.g. Pain - GI, pseudoneurological, cardiopulmonary or reproductive systems. • Conversion Disorder - Motor and sensory symptoms - Symptoms tend to be deficits e.g. Loss of sensation - La Belle Indifference • Hypochondriasis
- 17. What separates the big’ns? • Somatization Disorder - Symptom Orientated e.g. Pain - GI, nervous, cardiopulmonary or reproductive systems. • Conversion Disorder - Motor and sensory symptoms - Tends to be loss of symptoms e.g. Paralysis • Hypochondriasis - Diagnosis Orientated e.g. Cancer
- 18. Vignettes • Case 1 – A 40 year old woman complains of a deep root pain waking her up, which can only be relieved by straddling the bath tub and putting pressure her perineum. The pain normally last for around an hour. She is wondering if there is anything else she can do to help.
- 19. Vignettes • Case 2 37 year old son of local GP, presenting with abdo pain, bloatedness, and mass in left lower quadrant. He tests stools weekly for occult blood and palpates abdomen daily. X-ray, colonoscopy, gastroscopy and oesophagoscopy are normal. He is never relieved by negative findings. *Adapted from lecture notes
- 20. Vignettes • Case 3 49 year old female with a history of stroke 9 years ago, demonstrating partial hemiplegia of left side of the body (she sometimes counts with her fingers of both hands). No evidence of pathology on CT. declined physiotherapy rehab. *Adapted from lecture notes
- 21. You should now be able to • Understand what is meant by Somatoform Disorders • Recognise the contentious nature of the aetiology of Somatoform Disorders • Understand the common presentations of Somatization Disorder, Conversion Disorder, Hypochondriasis and Pain Disorder
- 22. References • http://www.healthatoz.com • Kumar & Clarke. Clinical Medicine (6th Ed.). Edinburgh, UK • American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC. • Owen W; ABC of the upper gastrointestinal tract. Dysphagia.; BMJ. 2001 Oct 13;323(7317):850-3 • B Olsen. Proctalgia fugax – a nightmare drowned in enema. Colorectal Disease. 10(5); 522-523 • http://www.patient.co.uk/showdoc/40024692/ • Noyes R, Stuart S, Watson DB, Langbehn DR (2006). Distinguishing between hypochondriasis & somatization disorder: a review of the existing literature. Psychother Psychosom 75 (5): 270–81
Editor's Notes
- Somatisation is the process behind somatoform disorders.
- A working definition of somatoform disorders is “Physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, drugs or another mental disorder. The symptoms must be serious enough to interfere with the patients employment or relationships and must be symptoms that are not under the patient’s voluntary control.” However, as with everything in psychiatry, nothing is straight forward. There are several different names, definitions and several different classification systems by which Somatoform Disorders are called, defined and classified. Different names and different classifications come into and out of vogue with little change in evidence or research. In the ICD-10 Somatoform Disorders come under the umbrella of “F40-F48 Neurotic, stress-related and somatoform disorders”. Some doctors even believe all functional disorders to be different manifestations of “one functional syndrome” which is indicative of a somatization process. However, it is more important that you can identify the common features of the different somatoform disorders rather than worrying about which classification system to use. Some of the main individual illnesses which are generally thought to be “somatoform” are (read box). In this session I’m hoping to teach you the main differences between Somatization Disorder, Hypochondriasis and Conversion Disorder, as these are easily confused. I’ll also introduce a couple of the more interesting presentations of Pain Disorder. As a group of disorders they are difficult to diagnose due to the patient’s long medical and surgical histories and due to the fact they aren’t lying to you. Often they will have some organic symptoms due to the side effects of drugs which they have been given to relieve the psychosomatic symptoms.
- The reason that classification of somatoform disorders are unsatisfactory is that we do not know their exact cause. We do know that they tend to affect women more than men and are associated with knowledge and experience, especially childhood experiences, of symptoms and illneses. Although the discrepancies over classification can be annoying it also means that this field is pretty exciting as it could change enormously with more insight.
- Shlomo or Sigmund Freud to you, thought that hysterical patient's symptoms resulted from dissociated thoughts or memories re-emerging through bodily functions or trance states. And this is where we first gained the broad category of Somatoform Disorders. Ironically Psychoanalysis, where you delve into the patient’s subconscious to and bring out repressed fears, which Freud believed to be the best treatment for Hysteria, the old name for Somatoform Disorders, is not recommended in most cases.
- These are words which are key to understanding the literature on Somatoform Disorders. Does you know what repression is?
- Repression is …. Okay a bit harder, do you know what primary gain is?
- As with the larger heading of somatoform disorders, there are many presentations of Pain Disorder. I’m just going to introduce the most interesting ones. The pain disorders officially include Tension Headaches, Proctalgia Fugax, Globus Hystericus, Facial Pain, Atypical Chest Pain, Psychogenic Itch and many more. Personally I don’t think Tension Headaches should be included as there is a physiological process which can explain them – Adrenaline Muscle Tension in Temporalis + HR increase increased Cerebral Blood Flow. However, it’s over analytical people like me who confuse all the classification systems.
- Now Globus Hystericus or Globus Pharyngitis is another interesting one. The sensation of a lump in the throat where no pathology can be found. It can cause difficulty swallowing. Most commonly this is due to GORD, however, it can also be caused by anxiety. It is just useful to recognise this as a common psychiatric symptom and so know that you don’t have to keep investigating this mysterious symptom after cancer has been ruled out. Empirical PPI is worth trying. Now Proctalgia Fugax is fleeting cramping pain of the backside. It affects females more than males and tends to occur at night, waking the patient up. It normally lasts ~20minutes. In males it’s associated with ejaculation and tense sexual arousal. In terms of treatment, unlike other Somatoform Disorders Reattribution of the pain to psychological symptoms doesn’t help. Warm baths, hot enemas, stretching and massage have been reported to help though. Also, in patients who suffer prolonged attacks salbutamol inhalation has been shown to reduce their duration. But I figure it’s useful to know what to suggest when someone presents with this unusual symptom and not just presume anal sex.
- The most well known of the Somatoform Disorders are Somatization disorder, Conversion Disorder and Hypochondriasis. However, there can be a lot of confusion over the diagnosis of the different disorders as they are all very similar and perhaps should be grouped together. So I’ll give you the first one, Somatization Disorder, and then you have to tell me the differences of the others from Somatization Disorder. Okay. Somatisation Disorder, the patient needs symptoms of pain in at least 4 sites on the body. 2 of these need to be GI, 1 sexual and 1 Pseudoneurological (e.g. fainting). These symptoms need to start before the age of 30. Now I’m not too sure why they need to be below 30 years of age. Ideas on a postcard. Anyway, so what do you think makes Conversion Disorder different in general terms? (Not specific criteria)
- The most famous of the Somatoform Disorders are Somatization disorder, Conversion Disorder and Hypochondriasis. However, there can be a lot of confusion over the diagnosis of the different disorders as they are all very similar and perhaps should be grouped together. So I’ll give you the first one and then you have to tell me the differences of the others from Somatisation Disorder. Okay. Somatisation Disorder. According to the DSM IV criteria, the patient needs symptoms of pain in at least 4 sites on the body. 2 of these need to be GI, 1 sexual and 1 Pseudoneurological (e.g. fainting/blindness). These symptoms need to start before the age of 30. Now I’m not too sure why they need to be below 30 years of age. Ideas on a postcard. Anyway, so what do you think makes Conversion Disorder different in general terms? (Not specific criteria)
- Okay so conversion disorder is different in that it affects different systems. It affects the nervous system causing motor and sensory symptoms and these symptoms tend to be deficits (such as Paralysis or los of sensation). Also, those with conversion disorder may exhibit something called “la belle indifference” – where the patient exhibits a kind of French apathy towards their symptoms. You’re Paralysed. Oui; Tres Bon Tres Bon. In a psychoanalytic way of thinking Conversion disorder is thought to result from a … So what makes Hypochondriasis different to Somatisation and Conversion?
- A hypochondriac will come to the dr with a specific disease in mind, instead of individual symptoms. And they will express concerns about a specific disease. Now the most common diseases in Hypochondriasis that patients get worried about are Cancer Heart Disease And HIV
- Okay so now you know the differences between the disorders I want you to look at the sheet and try to identify which disorder each case has.