Somatoform disorders for undergraduates

1. Somatoform Disorders
Dr. Mohamed Abdelghani
M.B.B.Ch., M.Sc., M.D. Psych.

2. Definition
A category of psychiatric disorders
characterized by converting emotional
distress into physical symptoms that have
no clear organic cause.

3. What is it?
 Symptoms cannot be related to a physical cause
 Many investigations and medical evaluations are done
to exclude physical illnesses
 Not faking their pain or symptoms, everything they
feel is real
 Don’t tell them their pains are imaginary or symptoms
are psychological
 Runs in families, they tend to come and go over time

4. DSM IV-TR subtypes
1. Somatization disorder
2.Conversion disorder
3.Hypochondriasis
4.Body dysmorphic disorder
5.Pain disorder
6.Undifferentiated somatoform disorder
7.Somatoform disorders not otherwise specified

5. 1.Somatization disorder
 An illness of multiple somatic complaints in multiple
organ systems
 Women ˃ men.
 More in people with little education and low
incomes.
 Usually starts before age 30.

6. Etiology
 Genetics:
• Tends to run in families.
• Occurs in 10 to 20 percent of the first-degree female
relatives of patients.
 Biological Factors:
 Faulty perception of somatosensory inputs.
 Psychosocial Factors:
• Some patients come from unstable homes and have been
physically abused.

7. Diagnosis according to DSM VI TR
 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.
 B. Each of the following criteria must have been met:
 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)
 One sexual symptom: a history of at least one sexual or reproductive symptom other
than pain (e.g. 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,)
 C. 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
 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
 D. The symptoms are not intentionally produced or feigned

8. Treatment
 Psychotherapy:
 Both individual and group psychotherapy.
 Patients are helped to cope with their symptoms, to
express underlying emotions, and to develop alternative
strategies for expressing their feelings.
 Pharmacotherapy:
• Only in comorbid mood or anxiety disorder.

9. 2.Conversion Disorder
 Symptoms or deficits that affect voluntary motor or
sensory functions, which suggest another medical
condition, but that is judged to be caused by
psychological factors (preceded by conflicts or other
stressors).
 The symptoms are not intentionally produced.
 Female ˃ male.
 Common age: from late childhood to early adulthood.

10. Etiology
 Psychoanalytic theory:
 The conflict is between an instinctual impulse (e.g., aggression or
sexuality) and the prohibitions against its expression.
 Learning Theory:
 A classically conditioned learned behavior; learned in childhood
as a means of coping with an impossible situation.
 Biological Factors:
 Hypometabolism of the dominant hemisphere.
 Hypermetabolism of the nondominant hemisphere.

11. TR Diagnostic Criteria for-IV-DSM
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).
 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.

12. Treatment
 Resolution of the conversion disorder symptom is usually
spontaneous.
 Psychotherapy:
o Insight-oriented supportive or behavior therapy.
o Hypnosis and behavioral relaxation exercises.
 Pharmacotherapy :
o Anxiolytics and antidepressants especially in comorbid cases.
Telling such patients that their symptoms are imaginary often
makes them worse.

13. 3.Hypochondriasis
 Preoccupation with non dellusional fear of having a serious
disease.
 Men and women are equally affected.
 Commonly appears in persons 20 to 30 years old .
 About 3% of medical students, are complaining of
hypochondrial symptoms, but they are generally transient.

14. Etiology
 Faulty cognition:
 A misinterpretation of bodily symptoms or augmentation of their somatic
sensations.
 Social learning model:
 The sick role offers an escape from usual duties and obligations.
 Variant form of other mental disorders:
 About 80% of patients with hypochondriasis may have underlying
depressive or anxiety disorders.
 The psychodynamic school:
 Aggressive and hostile wishes toward others are transferred (through
repression and displacement) into physical complaints..

15. 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).
 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,OCD, panic disorder, a major depressive episode,
separation anxiety, or another somatoform disorder.

16. Treatment
 Psychotherapy:
 Includes psychoeducation, Group psychotherapy, behavior
therapy, cognitive therapy, and hypnosis may be useful.
 Pharmacotherapy:
 If hypochondriacal symptoms only are associated with
underlying psychiatric condition, such as an anxiety disorder
or major depressive disorder.

17. 4- Body Dysmorphic Disorder
(Dysmorphophobia)
 A preoccupation with an imagined defect in appearance
that causes clinically significant distress or impairment in
important areas of functioning.
 Patients are more likely to go to dermatologists, internists,
or plastic surgeons than to psychiatrists.
 Most common age of onset is15-30 years.
 Women ˃ men.

19. Etiology
Unknown
 Biological:
o The high comorbidity with depression, and OCD, and responsiveness
to SSRIs indicate that, in some patients, may involve serotonin.
 Psychosocial :
o Stereotyped concepts of beauty emphasized in certain families and
within the culture may significantly affect patients.
 Psychodynamic:
o Seen as reflecting the displacement of a sexual or emotional conflict
onto a nonrelated body part.

20. DSM-IV-TR Diagnostic Criteria for
Body Dysmorphic Disorder
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).

22. Treatment
 Treatment of patients with surgical, dermatological, dental,
and other medical procedures to address the alleged
defects is mostly unsuccessful.
 Pharmacotherapy:
• Tricyclic drugs, monoamine oxidase inhibitors (MAOIs), pimozide
and serotonin-specific drugs e.g., fluoxetine.
• The coexisting depressive or anxiety disorders should be treated
with the appropriate pharmacotherapy and psychotherapy.

23. 5.Pain Disorder
 A pain disorder is characterized by the presence of
pain in one or more body sites and is sufficiently
severe to come to clinical attention.
 Psychological factors are necessary in the genesis,
severity, or maintenance of the pain.
 The associated psychiatric disorders may precede,
co-occur with or result from the pain disorder, may co-
occur with it, or may result from it.

24. Etiology
 Psychodynamic Factors:
• Patients may be symbolically expressing an intrapsychic conflict through the body.
 Behavioral Factors:
• Pain behaviors are reinforced when rewarded and are inhibited when ignored or
punished.
 Interpersonal Factors:
• Intractable pain has been conceptualized as a means for manipulation and
gaining advantage in interpersonal relationships.
 Biological Factors:
• The cerebral cortex can inhibit the firing of afferent pain fibers.
 Serotonin is probably the main neurotransmitter in the descending inhibitory pathways, and
endorphins also play a role in the central nervous system modulation of pain.

25. The DSM-IV-TR diagnostic criteria for
pain disorder
 Pain in one or more anatomical sites is the predominant focus of the
clinical presentation and is of sufficient severity to warrant clinical
attention.
 The pain causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
 Psychological factors are judged to have an important role in the onset,
severity, exacerbation, or maintenance of the pain.
 The symptom or deficit is not intentionally produced or feigned (as in
factitious disorder or malingering).
 The pain is not better accounted for by a mood, anxiety, or psychotic
disorder and does not meet criteria for dyspareunia.

26. Treatments
 Therapists must fully understand that the patient's experiences of pain
are real.
 Help the patient to find psychological factors behind the condition,
which make their pain worse.
 Pharmacotherapy:
 Analgesic medications do not generally benefit most patients with pain
disorder.
 SSRI and TCA are beneficial.
 Psychotherapy:
 Psychodynamic psychotherapy
 Biofeedback can be helpful in the treatment of pain disorder e.g., muscle
tension states.

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