1. 1

2. Somatoform disorders
Somatoform disorders are a group of disorders in which
patients are convinced that their sufferings come from
undetected and untreated bodily derangements.
They include:
Somatization disorder
Conversion & Dissociation disorder
Pain disorder
Hypochondriasis
Body dysmorphic disorders
2

3. Somatization disorder
The patient has multiple medically unexplained
symoptoms that can not be explained as organic pathology
or on any known patholophysiological mechanism .
Somatization 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.
The complaints are multiple, chronic and affect multiple
organ systems.
3

4. Somatization disorder
The disorder is an expression of the basic mechanism by
which patients respond to their stressors and express
them as somatic symptoms.
The disorder is associated with significant psychological
distress, impaired social and occupational functioning,
and excessive medical-help-seeking behavior
The condition was previously called hysteria.
4

5. Somatization disorder
Epidimiology
Male/female ratio is ½ to 1/6 and it varies in various
studies.
Affects 1% of the general population and (1-6)% of primary
care attendants and inpatients
Onset is from early childhood to 40 years.
the disorder is inversely related to social position and
occurs most often among patients who have little
education and low incomes.
Co morbidity occurs in 50% of cases mostly with
personality disorder and learning Disability.
5

6. Somatization disorder
Etiology:
symptoms substitute for repressed instinctual impulses
Psychosocial Factors
Predisposing factors include physical and sexual abuse and
parental complaints of unexplained poor physical health
in childhood.
Social, cultural, and ethnic factors may also be involved in
the development of symptoms.
Biological factors
Hypersensitivity of the limbic system towards bodily stimuli was
suggested.
6

7. Somatization disorder
Clinical features
The symptoms may refer to any part or system of the
body. They depend on the patient’s sociocultural
background and life experience.
Nausea and vomiting (other than during pregnancy),
difficulty swallowing, pain in the arms and legs, shortness
of breath unrelated to exertion, amnesia, and
complications of pregnancy and menstruation are among
the most common symptoms.
Patients frequently believe that they have been sickly most
of their lives.
7

8. Somatization disorder
Neurological symptoms include
incoordination, weakness, paralysis, dysphagia, lump in
the throat, aphonia, urinary retention, anesthesia,
hallucination, diplopia, blindness, pseudoseizures and
coma.
8

9. Somatization Disorder
Suicide threats are common, but actual suicide is rare. If
suicide does occur, it is often associated with substance
abuse.
complaints in a dramatic, emotional, and exaggerated
fashion, with vivid and colorful language; they may
confuse temporal sequences and cannot clearly distinguish
current from past symptoms
Female patients with somatization disorder may dress in
an exhibitionistic manner.
Patients may be perceived as dependent, self-centered,
hungry for admiration or praise, and manipulative.
9

10. Somatization Disorder
Management
Good history and physical examination are necessary
for the diagnosis. Once certain of the diagnosis, we
should avoid excessive and unnecessary
investigations.
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.
10

11. Somatization Disorder
management
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
11

12. Somatization Disorder
management
British Journal of Psychiatry (1993), 162, 472—480
The Management of Chronic Somatisation
Somatisation' is a process in which there is inappropriate focus
on physical symptoms and psychosocial problems are denied.
In some patients this process becomes chronic (in excess
of six months). Special skills and strategies are required by non-
psychiatrists to manage these patients, for whom the acceptance
of psychiatric treatment should be facilitated. When taking the
history,
doctors should be aware of psychosocial cues; there after they
should be consistent and unambiguous in their management.
12

13. Somatoform disorders in general practice
Prevalence, functional impairment and comorbidity with anxiety and depressive disorders†
Margot W. M. De Waal, MSc,
Ingrid A. Arnold, MD and
Just A. H. Eekhof, PhD
Department of General Practice and Nursing Home Medicine, Leiden University Medical Centre
Albert M. Van Hemert, PhD
+Author Affiliations
Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
M.W.M. de Waal, LUMC Department of General Practice and Nursing Home Medicine, PO Box 2088, 2301 CB Leiden, The
Netherlands. Tel: +31 71 5275318; fax: +31 71 5275325; e-mail: M.W.M.de_Waal@lumc.nl
General practitioners play a pivotal part in the recognition and
treatment of psychiatric disorders.
21.9%.Comorbidity of somatoform disorders and anxiety/depressive
disorders was 3.3 times more likely than expected by chance.
 In patients with comorbid disorders, physical symptoms,
depressive symptoms and functional limitations were additive.
Conclusions
Our findings underline the importance of a comprehensive
diagnostic approach to psychiatric disorders in general practice.
The British Journal of Psychiatry (2004)184: 470-
476doi:10.1192/bjp.184.6.470
13

14. ISSN: 0033-3174
Copyright (C) 2011 by American Psychosomatic Society
Issue: Volume 73(8) pgs. 637-722 October 2011
Abuse History, Depression, andSomatization Are Associated With Gastric Sensitivity and Gastric Emptying in Functional
Dyspepsia
Lukas Van Oudenhove, MD, PhD, Joris Vandenberghe, MD, PhD, Rita Vos, MSc, Benjamin Fischler, MD, PhD,
Koen Demyttenaere, MD, PhD and Jan Tack, MD, PhD
 Abstract
 Objective Gastric sensitivity testing relies on subjective reporting and may therefore be
influenced by psychosocial factors and somatization. Furthermore, psychological processes
may affect gastric motor function (accommodation to a meal emptying) through efferent
brain-gut pathways. This study sought to determine the association of abuse history,
psychiatric comorbidity, andsomatization with gastric sensorimotor function.
 Methods In 201 patients with functional dyspepsia, gastric sensitivity and accommodation
were studied with a barostat. Gastric emptying of solids was studied using a breath test.
Sexual and physical abuse history, psychiatric comorbidity (depression and panic disorder),
and somatization were assessed using validated questionnaires. Multiple linear regression
models were used to identify patient characteristics independently associated with gastric
sensitivity and emptying.
 Results Age (p = .02), sexual abuse history (p < .001), physical abuse history (p= .004),
and somatization (p < .001) were independently associated with gastric discomfort
threshold (R2
= 0.30); a significant depression-by-sexual abuse interaction effect was also
found (p = .003). None of the factors studied were associated with gastric accommodation to
a meal. Physical abuse history (p = .003) and somatization (p = .048) were independently
associated with gastric emptying (R2
= 0.19).
 Conclusions These results demonstrate the complex relationship among abuse history,
psychiatric comorbidity, somatization, and gastric sensorimotor (dys)function. Although
the psychobiological mechanisms underlying these relationships remain to be determined,
the autonomic nervous, stress hormone, and immune systems may be involved.
14

15. Military deployment to the Gulf War as a risk
factor for psychiatric illness among US troops
NANCY FIEDLER, GOZDE OZAKINCI,WILLIAM HALLMAN,
DANIELWARTENBERG, NOEL T. BREWER, DRUE H. BARRETT
and HOWARD M. KIPEN
 Gulf War veterans had a significantly higher prevalence of
Psychiatric diagnoses, with twice the prevalence of anxiety disorders
and depression.
Lower rank, female gender and divorced or single marital status were
significant independent predictors of Psychiatric disorder.
Conclusions
 Deployment to the Gulf War is associated with a range of mental
health outcomes more than 10 years after deployment.
The British Journal of Psychiatry (2006)
Volume: 188, Pages: 453-459
15

16. Conversion & Dissociation
Disorder
Conversion and dissociation disorder is an illness of
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 because the illness is preceded by conflicts or other
stressors.
The symptoms or deficits of conversion & dissociation
disorder are not intentionally produced, are not caused by
substance use, are not limited to pain or sexual symptoms,
and the gain is primarily psychological and not social,
monetary, or legal.
It was originally combined with the syndrome known
as somatization disorder and was referred to as
hysteria, conversion reaction, or dissociative 16

17. Conversion & Dissociation Disorder
History
conversion disorders were understood to be conditions in
which a psychological conflict occurred to which the
patient could not consciously admit. According to Freud,
there was at least one motive which could be allowed to
emerge into consciousness. For example, a woman may
develop hysterical symptoms because a forbidden Oedipal
wish—to be closer to a man who, to her, represents her
father—is in conflict with unconscious feelings of guilt
that she is thereby displacing her mother in such a
relationship. The resolution of both these unconscious
wishes with a symptom like a paralysis which prevented a
man from courting her would constitute the primary gain
of her illness.
17

18. Conversion & Dissociation Disorder
History cont’d
This notion of primary gain is basic to the Freudian
dynamic theory. It should not be confused with
secondary gain which is more often mentioned and
which represents the advantages that follow from the sick
role (e.g. the loss of the use of a limb), with such benefits
as extra attention, nursing, special consideration, and
perhaps financial reward in compensation cases.
According to this theory, secondary gain is an important
part of the reinforcing mechanisms in the maintenance of
hysterical symptoms—a rather common-sense idea.
However, primary gain is part of the causal system.
18

19. Conversion & Dissociation Disorder
In both ICD-10 and DSM-IV dissociative
symptoms are regarded as arising from emotional
conflict.
In ICD-10 , ‘in the dissociative disorders it is
presumed that ... ability to exercise a conscious
and selective control is impaired .
DSM-IV adopts a different approach. Conversion
disorders are classified under ‘somatoform
disorders', in which the common feature of all
conditions is the presence of physical symptoms
that suggest a general medical condition. The
symptoms are required to cause clinically
significant distress or impairment in social,
occupational, or other areas of functioning.
19

20. Conversion & Dissociation Disorder
The difference between conversion disorder and
somatization disorder lies in the number of
symptoms and in the fact that conversion
disorders are primarily limited to voluntary motor
or sensory function without pain, but resemble
neurological disease.
In DSM-IV it is assumed that in dissociative
disorder there is a disruption in the integrated
functions of consciousness. Several types are
listed: dissociative amnesia, dissociative fugue,
dissociative identity disorder or depersonalization
disorder, and dissociative disorder not otherwise
specified.
20

21. Conversion disorder
Clinical symptoms
Motor symptoms:
Weakness, paralysis, seizures, aphonia and abnormal
movements, tremor.
Sensory deficits :
Anesthesia, blindness, deafness, peripheral nerve
sensory loss, visual hallucinations.
Visceral symptoms:
Vomiting, diarrhea, urinary retention, pseudocyesis,
globus hystericus.
21

22. Dissociative symptoms
Stupor
is marked by a profound diminution or absence of
voluntary movement, but normal responsiveness to
external stimuli such as light, noise, and touch. There is an
apparent disturbance of consciousness but the patient is
neither asleep nor unconscious.
Amnesia
In amnesia of psychological origin (psychogenic amnesia)
there is a loss of knowledge of personal identity with
preservation of other information, often including
complex learned information or skills. The patient may
not know who he is, but knows who is the President, or his
doctor. 22

23. Dissociative symptoms
Fugue
The main phenomenon is sudden unexpected travel away from home
or a customary place of work. There is also inability to recall their
personal past history. Sometimes a partial or completely new identity
is assumed. The memory for some recent traumatic or stressful event
may be lost, although these matters are discovered when other
informants become available.
Dissociative identity disorder
(formerly multiple personality disorder ) the presence of two or more
distinct identities, or personality states, each with its own relatively
enduring pattern of perceiving, relating to, and thinking about the
environment and self'. At least two of these identities or personality
states must recurrently take control of the person's behaviour. There
should also be inability to recall important personal information that
is too extensive to be explained by ordinary forgetfulness.
23

24. Conversion disorder
Data indicate that conversion disorder is most common
among rural populations, persons with little
education, those with low intelligence quotients,
those in low socioeconomic groups, and military
personnel who have been exposed to combat
situations. It is more in females than males.
24

25. Conversion disorder
 Am J Psychiatry 159:1908-1913, November 2002
© 2002 American Psychiatric Association
 Article
 Childhood Abuse in Patients With Conversion Disorder
 Karin Roelofs, Ph.D., Ger P.J. Keijsers, Ph.D., Kees A.L. Hoogduin, M.D., Ph.D.,
Gérard W.B. Näring, Ph.D., and Franny C. Moene, Ph.D.
 Patients withconversion disorder reported a higher incidence of physical/sexualabuse,
a larger number of different types of physical abuse,sexual abuse of longer duration, and
incestuous experiencesmore often than comparison patients. In addition, within
thegroup of patients with conversion disorder, parental dysfunctionby the mother—
not the father—was associated withhigher scores on the Dissociative Experiences Scale
and theSomatoform Dissociation Questionnaire. Physical abuse was associatedwith a
larger number ofconversion symptoms (Structured ClinicalInterview for DSM-IV Axis
I Disorders).
 The present results provideevidence of a relationship between childhood
traumatizationand conversion disorder.
25

26. Conversion disorder
 Am J Psychiatry 159:1908-1913, November 2002
© 2002 American Psychiatric Association
 Article
 Childhood Abuse in Patients With Conversion Disorder
 Karin Roelofs, Ph.D., Ger P.J. Keijsers, Ph.D., Kees A.L. Hoogduin, M.D., Ph.D.,
Gérard W.B. Näring, Ph.D., and Franny C. Moene, Ph.D.
 RESULTS: Patients withconversion disorder reported a higher incidence of
physical/sexualabuse, a larger number of different types of physical abuse,sexual abuse
of longer duration, and incestuous experiencesmore often than comparison patients. In
addition, within thegroup of patients with conversion disorder, parental
dysfunctionby the mother—not the father—was associated withhigher scores on the
Dissociative Experiences Scale and theSomatoform Dissociation Questionnaire. Physical
abuse was associatedwith a larger number ofconversion symptoms (Structured
ClinicalInterview for DSM-IV Axis I Disorders).
26

27. Conversion disorder
Treatment
Resolution of the conversion disorder symptom is usually
spontaneous, although it is probably facilitated by insight-
oriented supportive or behavior therapy.
The most important feature of the therapy is a
relationship with a caring and confident therapist
Parenteral amobarbital or lorazepam may be helpful in
obtaining additional historic information, especially when
a patient has recently experienced a traumatic event
27