somatoform disorders are prevalent mental disorders that present as physical disease

1. SOMATOFORM DISORDERS
PRESENTERS – LARRY OMONDI
– MUDEGU LUMWAMU
FACILITATOR: PROF. GAKINYA

2. Defination
• These are a group of disorders that include
physical symptoms for which an adequate
medical explanation cannot be found.
• broad group of illnesses that have bodily signs
and symptoms as a major component.
• They appear to be medical but are due to
psychosocial factors

3. Somatoform disorders as per DSM-
IV-TR

4. Related disorders
• Malingering -Deliberate faking of physical
symptoms to avoid an unpleasant situation,
such as military duty, exams e.t.c
• Factitious Disorder/muchausen syndrome-
Deliberate faking of physical illness to gain
medical attention

5. General principles of somatoform
disorders.
• Patient complains of physical symptoms not
explained by general medical conditions.
• Objective testing is normal.
• Symptoms interfere with patients quality of life.
• Frequently, comorbid anxiety disorder is present.
• Mostly idiopathic
• Slightly more common in women.
• Diagnosis of exclusion.
• Management tends to be psychotherapy.

6. Somatization disorder
• 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.

7. Epidemiology
• Sex ratio (F:M) - 5: 1
• lifetime prevalence in the general population -
0.2% -2 % in women and 0.2% in men.
• Inversely related to social position.
• Onset after 30 years is extremely rare
• somatization disorder commonly coexists with
personality disorders characterized by avoidant,
paranoid, self-defeating, and obsessive-
compulsive features.

8. Etiology.
A. PSYCHOSOCIAL
Interpretation of symptoms as social
communication whose results is to:
a. to avoid obligation( eg job)
b. to express emotions e.g anger to spouse
c. to symbolize a feeling or belief

9. B. Biological factors
• Attention and cognitive impairment such as excessive distractibility,
inability to habituate to repetitive stimuli, grouping of cognitive
constructs on an impressionistic basis and lack of selectivity result
in faulty perception and assessment of somatosensory inputs .
• Some brain imaging studies have reported decreased metabolism in
the frontal lobes and in the dominant hemisphere.
• Genetic data indicate that Somatization disorder tends to run in
families and occurs in 10 to 20% of the first-degree female relatives
of probands of patients with somatization disorder.
• concordance rate of 29 % in monozygotic twins and 10 % in
dizygotic twins
• Cytokines-abnormal regulation of the cytokine system may result in
some of the symptoms seen in somatoform disorders

10. Diagnosis: DSM IV TR CRITERIA
A. 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.

11. B. Each of the following criteria must have been met, with individual
symptoms occurring at any time during the course of the
disturbance:
1. 4 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)
2. 2 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)

12. 3. 1 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)
4. 1 pseudo neurological 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)

13. C. Either (1) or (2):
1. 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)
2.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

14. D. The symptoms are not intentionally produced
or feigned (as in factitious disorder or
malingering).

15. CLINICAL FEATURES:
• Many somatic complaints.
• Long, complicated medical histories: circumstantial,
vague, inconsistent; disorganized.
• Patients frequently believe that they have been sickly
most of their lives despite negative results on
laboratory tests.
• Psychological distress and interpersonal problems are
prominent;
• anxiety and depression are the most prevalent
psychiatric conditions
• Suicide threats are common

16. • Physical examination is essentially normal
• May reveal some skin lesions or scars that
resulted from previously performed surgeries

17. Differential diagnosis
• Medical conditions - multiple sclerosis, brain tumour,
hyperparathyroidism, hyperthyroidism, lupus
erythematosus
• Affective (depressive) and anxiety disorders-1or2
symptoms of acute onset and short duration
• Hypochondriasis - patient´s focus is on fear of disease
not focus on symptoms
• Panic disorder - somatic symptoms during panic episode
only

18. Differential diagnosis
• Conversion disorder - only one or two
• Pain disorder - one or two unexplained pain
complaints, not a lifetime history of multiple
complaints
• Delusional disorders - schizophrenia with somatic
delusions or depressive disorder with hypochondriac
delusions, bizzare, psychotic sy.
• Undifferentiated somatization disorder - short
duration (e.g. less than 2 years) and less striking
symptoms

19. Treatment
– Have a single identifiable physician as the primary doctor
(reduce opportunities to express complaints)
– Avoid ordering multiple laboratory investigation
– Individual and group psychotherapy beneficial-patients are
helped to cope with their symptoms, to express underlying
emotions, and to develop alternative strategies for
expressing their feelings
– Treat any comorbid mental or physical illness

20. Course and Prognosis
 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.
 Somatization disorder is a chronic,
undulating, and relapsing disorder that rarely
remits completely.

21. Conversion disorder.
• An illness of symptoms that affect voluntary
motor or sensory functions, which suggest
another medical condition, but that is judged to
be caused by psychological factors because the
illness is preceded by conflicts or other
stressors.

22. Epidemiology.
• Make up 5 - 30% of psychiatry consultations in general
hospitals
• M:F / 1: 10 with higher rates among younger girls
• Men with conversion disorder have often been involved in
occupational or military accidents.
• Onset - any age
• Common in rural populations, uneducated, low intelligence
& social economic status, military personnel.
• Symptoms are more common on the left than on the right
side of the body in women

23. Comorbidity
• Neurological disorders more frequently found in these
patients .
• Among axis I condition - depressive disorder, anxiety
disorders, somatization disorder .
• Personality disorders frequently accompany conversion
disorders i.e. histrionic 20%, passive dependant 40%.
• Clinical features include both motor and sensory modalities
and even seizures.

24. Associated features
• Primary Gain- Achieved by keeping internal conflicts outside their
awareness; they represent an unconscious psychological conflict.
• Secondary Gain- Patients accrue tangible advantages and benefits as a
result of being sick; for example, being excused from obligations
• La Belle indifference- patient's inappropriately cavalier attitude toward
serious symptoms; that is, the patient seems to be unconcerned about what
appears to be a major impairment.
• Identification -Patients with conversion disorder may unconsciously model
their symptoms on those of someone important to them.

25. Common Symptoms of Conversion
Disorder
• Motor Symptoms
Involuntary movements
Tics
Blepharospasm
Torticollis
Opisthotonos
Seizures
Abnormal gait
Falling
Astasia-abasia
Paralysis
Weakness
Aphonia
• Sensory Deficits
Anesthesia, especially of
extremities
Midline anesthesia
Blindness
Tunnel vision
Deafness
•
Visceral Symptoms
Psychogenic vomiting
Pseudocyesis
Globus hystericus
Swooning or syncope
Urinary retention
Diarrhea

26. DSM-IV-TR Diagnostic Criteria for
Conversion Disorder
A. One or more symptoms or deficits affecting voluntary
motor or sensory function that suggest a neurological or
other general medical condition.
B. Psychological factors are judged to be associated with
the symptom or deficit because the initiation or
exacerbation of the symptom or deficit is preceded by
conflicts or other stressors.
C. The symptom or deficit is not intentionally produced or
feigned (as in factitious disorder or malingering).

27. D. The symptom or deficit cannot, after appropriate investigation, be
fully explained by a general medical condition, or by the direct
effects of a substance, or as a culturally sanctioned behavior or
experience.
E. The symptom or deficit causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning or warrants medical evaluation.
F. The symptom or deficit is not limited to pain or sexual dysfunction,
does not occur exclusively during the course of somatization
disorder, and is not better accounted for by another mental disorder.

28. Treatment
• Resolution is usually spontaneous .
• Insight oriented psychotherapy (supportive or
behavioral) .
• Hypnosis, anxiolytics and behavioural
relaxation exercises may be used

29. Prognosis
• A good prognosis -acute onset, presence of clearly
identifiable stressors at the time of onset, a short
interval between onset and the institution of
treatment, and above average intelligence.
• Paralysis, aphonia, and blindness are associated
with a good prognosis, whereas tremor and
seizures are poor prognostic factors

30. Hypochondriasis
• 6 months or more of a general and non
delusional preoccupation with fears of having,
or the idea that one has, a serious disease
based on the person's misinterpretation of
bodily symptoms.

31. Epidemiology
• 5% of general medical outpatients .
• Men and women equally affected .
• Commonly appear at ages 20-30 but may occur in
any age.
• 3% of medical students in the first 2 years .

32. DSM-IV-TR Diagnostic Criteria for
Hypochondriasis
A. Preoccupation with fears of having, or the idea that
one has, a serious disease based on the person's
misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical
evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity
(as in delusional disorder, somatic type) and is not
restricted to a circumscribed concern about appearance
(as in body dysmorphic disorder).

33. D. The preoccupation causes clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by
generalized anxiety disorder, obsessive-compulsive
disorder, panic disorder, a major depressive episode,
separation anxiety, or another somatoform disorder.

34. treatment
• Most patients resist psychiatric treatment
(unless in a general medical setting).
• Frequent, regular scheduled physical
examinations are useful to reassure patients
that they are not being abandoned.
• Group psychotherapy often benefits such
patients

35. Course and prognosis
• Course is episodic and good prognosis is
associated with high social economic status.
• sudden onset of symptoms, absence of
personality disorder or a related medical
condition & treatment responsive anxiety or
depression associated with good prognosis.

36. Body Dysmorphic Disorder
• Patient has a pervasive subjective feeling of
ugliness of some aspect of their appearance
despite a normal or nearly normal appearance.

37. • The core of this disorder is the person's strong
belief or fear that he or she is unattractive or
even repulsive.

38. Epidemiology
• Poorly studied partly because patients see different
specialists e.g. dermatologist, internists, plastic
surgeons etc.
• Onset 15 - 30 years affecting men more than women
(often unmarried) .
• 90% of patient has had episode of depression, 70%
anxiety and 30% a psychotic disorder.
• women are affected somewhat more often than men

39. Aetiology
• Etiology unknown but probably due to stereotype
concepts of beauty emphasized in certain families &
cultures.
• The high comorbidity with depressive disorders, a
higher-than-expected family history of mood disorders
and obsessive-compulsive disorder (OCD), and the
reported responsiveness of the condition to serotonin-
specific drugs indicate that, in at least some patients,
the pathophysiology of the disorder may involve
serotonin and may be related to other mental disorders.

40. Clinical Features
• The most common concerns involve facial flaws,
particularly those involving specific parts e.g. the
nose.
• Other body parts of concern are hair, breasts, and
genitalia.
• As many as one third of the patients may be
housebound because of worry about being
ridiculed for the alleged deformities, and
approximately one fifth attempt suicide.

41. DSM-IV-TR Diagnostic Criteria for
Body Dysmorphic Disorder
A. A Preoccupation with an imagined defect in
appearance. If a slight physical anomaly is present, the
person's concern is markedly excessive.
B. The preoccupation causes clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
C. The preoccupation is not better accounted for by
another mental disorder (e.g., dissatisfaction with body
shape and size in anorexia nervosa).

42. Treatment
• Attempt to address defects surgically, by
dermatologist or internist is always unsuccessful.
• clomipramine (Anafranil) 25mg PO qD. and
fluoxetine (Prozac) 20mg PO qD- reduce
symptoms in at least 50 %of patients
• Supportive psychotherapy important in treatment.

43. Course
• Onset is gradual with waxing and waning
overtime.
• Chronic if untreated.

44. Pain Disorder
• Presence of pain that is the predominant focus
of clinical attention.
• Pain is prominent complaint.
• Pain does not respond to analgesics.
• Pain is in one or more sites and is not fully
accounted for by a non-psychiatric medical or
neurological condition.
• symptoms cause emotional distress and
functional impairment.

45. Epidemiology
• Onset 40 - 50 years .
• Common in persons with blue collar jobs perhaps due to the
high likelihood of injuries.
• Common among first degree relatives .
• Depression, anxiety & substance use common among
family members .
• Actual figure not known but definitely very high.

46. Aetiology
• Patients who experience bodily aches and pains without identifiable
and adequate physical causes may be symbolically expressing an
intrapsychic conflict through the body.
• also function as a method of obtaining love, punishment for wrong
doing expiating guilt and atoning for wrongdoing.
• Pain behaviours are reinforced when rewarded and inhibited when
ignored or punished.
• Pain may also be a means of manipulating and gaining advantage in
interpersonal relationships
• There could be a deficiency of endophines in the CNS.

47. Clinical Features
• Patients with pain disorder are not a uniform
group, but a heterogeneous collection of
persons with low back pain, headache, atypical
facial pain, chronic pelvic pain, and other
kinds of pain.
• A patient's pain may be posttraumatic,
neuropathic, neurological, iatrogenic, or
musculoskeletal

48. DSM-IV-TR Diagnostic Criteria for
Pain Disorder
A. Pain in one or more anatomical sites is the
predominant focus of the clinical presentation and is
of sufficient severity to warrant clinical attention.
B. The pain causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
C. Psychological factors are judged to have an important
role in the onset, severity, exacerbation, or maintenance
of the pain.

49. D. The symptom or deficit is not intentionally
produced or feigned (as in factitious disorder
or malingering).
F. The pain is not better accounted for by a
mood, anxiety, or psychotic disorder and does
not meet criteria for dyspareunia.

50. Treatment
• Because it is not possible to reduce the pain,
treatment approach must address rehabilitation.
• Psychogenicity of the pain should be explained to
the patient without forgetting that the pain is real.
• Medication: - antidepressant often helpful while
amphetamines benefit some patients.

51. Course and prognosis
• Begins abruptly and increase in severity.
Prognosis is variable and may be chronic,
distressful and completely disabling
• Patient with worst prognosis (with or without
treatment) have pre-existing character logical
problems e.g. pronounce passivity, involvement in
litigation or receive financial compensation, use
addictives, have long history of pain.

52. DSM-IV-TR Diagnostic Criteria for
Undifferentiated Somatoform
Disorder
A. One or more physical complaints (e.g., fatigue, loss of appetite,
gastrointestinal or urinary complaints).
B. Either (1) or (2):
1. after appropriate investigation, the symptoms 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)
2. when there is a related general medical condition, the physical
complaints or resulting social or occupational impairment is in excess
of what would be expected from the history, physical examination, or
laboratory findings

53. C. The symptoms cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
D. The duration of the disturbance is at least 6
months.

54. E. The disturbance is not better accounted for by
another mental disorder (e.g., another
somatoform disorder, sexual dysfunction,
mood disorder, anxiety disorder, sleep
disorder, or psychotic disorder).
F. The symptom is not intentionally produced or
feigned (as in factitious disorder or
malingering).

55. Somatoform Disorder Not Otherwise
Specified
• a residual category for patients who have symptoms
suggesting a somatoform disorder, but do not meet
the specific diagnostic criteria for other somatoform
disorders
• e.g., pseudocyesis

56. A. Pseudocyesis: a false belief of being pregnant that is
associated with objective signs of pregnancy, which may
include abdominal enlargement (although the umbilicus
does not become everted), reduced menstrual flow,
amenorrhea, subjective sensation of fetal movement,
nausea, breast engorgement and secretions, and labor
pains at the expected date of delivery. Endocrine changes
may be present, but the syndrome cannot be explained by
a general medical condition that causes endocrine
changes (e.g., a hormone-secreting tumor).
B. A disorder involving nonpsychotic hypochondriacal
symptoms of less than 6 months' duration.
C. A disorder involving unexplained physical complaints (e.g.,
fatigue or body weakness) of less than 6 months' duration
that are not due to another mental disorder.