Somatoform Disorders - PowerPoint

							Somatoform Disorders
  Somatoform Disorders:
  Key Common Features
Phenomenology:
 Physical symptoms that are
  suggestive of, but can’t be
  fully explained by, medical
  findings or physiological
  mechanisms
  Somatoform Disorders:
  Key Common Features

Pathogenesis:
 Behavioral disturbance in which
  people speak not with words or
  feeling but with their bodies
   Somatoform Disorders:
   Key Common Features
Epidemiology:
  usually with a female preponderance
  occuring frequently in a primary care
   setting
  high psychiatric and medical comorbidity
  onset in adolescence or early adulthood,
   usually with a chronic course
  Somatoform Disorders:
  Key Common Features
Outcomes:
  difficult to diagnose
  difficult to treat
  causes significant distress and
   functional decline
         Somatoform Disorders
•   Somatization Disorder
•   Hypochondriasis
•   Conversion Disorder
•   Body Dysmorphic Disorder
•   Pain Disorder
•   Undifferentiated Somatoform Disorder
         Somatoform Disorders:
          Conversion Disorder
Diagnostic Criteria:
  1. Unexplained symptoms of voluntary motor or
    sensory function
  2. Associated psychological factors
  3. Significant distress or functional decline
  4. Not merely pain or sexual dysfunction
  5. Rule out other conditions
         Somatoform Disorders:
          Conversion Disorder
Course
     many remit within 2 weeks
     25% recur within 1st year
     50% sx-free at 1 year
     80% sx-free at 5 and 15 years
      Somatoform Disorders:
       Conversion Disorder
Prognosis [good signs if…]
      acute onset
      clear precipitant
      early treatment
      intelligence
      good social environment
      no comorbidity
       (psychiatric/medical)
      Somatoform Disorders:
       Conversion Disorder
Epidemiology
     Prevalence 10-300:100K
     15% have conversion sx at times
     1-3% of o/p psych referrals
     5-15% of psych consults
     4% of neuro o/p visits
     onset 10-35yo
     F>M 2-10:1
     Esp. rural, low SEC, “medically naïve”
         Somatoform Disorders
Etiology #1?
• Amplification of bodily
  sensations
  – Altered cognitive schema
    (“somatic filter”)
  – negative misinterpretations
    of physical sensations
  – anxiety from automatic
    negative thoughts
         Somatoform Disorders
Etiology #2?
• Need for Sick Role
  – frequent inability of
    somatizing patients to
    express concerns in any
    other way than by being
    physically sick
         Somatoform Disorders
Etiologies 3-9?
  –   unconscious psychological conflict
  –   hysterical identification
  –   social learning
  –   cross-cultural
  –   primary/secondary gain
  –   genetic
  –   neurodevelopmental
        Somatoform Disorders:
            Comorbidity
•   neurological disease or other GMC
•   personality disorders
•   secondary depression
•   secondary anxiety
•   substance use disorders
       Somatoform Disorders:
       Differential Diagnosis
• other somatoform disorders
• factitious/malingering
• psychiatric (mood, anxiety, psychotic,
  personality, dissociative)
• general medical
• substance-induced
• cultural
         Somatoform Disorders:
           Hypochondriasis
• Preoccupation with fears of having a serious
  disease
• triggered by misinterpreted body sensations
• despite reassurance
• M>F
• 4-9% prevalence in primary care
    Somatoform Disorders: BDD
• Preoccupation with imagined defect (or
  excessive concern with minor defect)
• Usually face/head
• ?psychosis
• M=F
• 2% lifetime prevalence
         Somatoform Disorders:
            Pain Disorder
• Pain (unexplained, or greater than would be
  expected)
• Psychological factors important
• F>M
• older age of onset (30-40yo)
• 40% prevalence in chronic pain populations
• 60-100% incidence of comorbid depression
           Somatoform Disorders:
           Somatization Disorder
• Inadequately explained symptoms in four areas:
  –   Pain (four sites)
  –   Gastrointestinal (two non-pain symptoms)
  –   Sexual (one non-pain symptom)
  –   Neurological (one non-pain symptom)
• F>M
• Early onset
     Somatoform Disorders:
     Differential Diagnosis


Illness       Mechanism   Motivation
Somatoform        U           U
Factitious        C           U
Malingering       C           C
       Somatoform Disorders:
       Differential Diagnosis
• other somatoform disorders
• factitious/malingering
• psychiatric (mood, anxiety, psychotic,
  personality, dissociative)
• general medical
• substance use disorder
• cultural
      Somatoform Disorders:
      Presenting the Diagnosis

Physician:   “It’s all in your head”

Patient:     “But it’s NOT in my head;
             it’s in my stomach!”
     Somatoform Disorders:
     Presenting the Diagnosis

• summarizing signs/sx
• good news
• bad news
• seek psychiatrist
• not crazy
• power of suggestion
       Somatoform Disorders:
       Management Strategies
Overall goals:
  – realistic treatment plan (sx reduction)
  – shift focus from body to person
  – insure good communication across treatment
    providers
  – manage countertransference
       Somatoform Disorders:
       Management Strategies

Managing appointments:
  – regular, brief follow-up
  – healthy, supportive relationship
  – briefer exams, more talk
      Somatoform Disorders:
      Management Strategies

What to say:
  – reinforce non-complaining behaviors
  – reassure
  – be empathic
        Somatoform Disorders:
        Management Strategies
What to do/not do:
  –   limit work-up
  –   intervene with benign, time-limited measures
  –   treat comorbidity if present
  –   psychotherapy (group/individual)
  –   skills: relaxation, stress management, etc.
  –   psychotropic medication
  –   complementary treatments