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Chapter 9Neurosis(4) Somatoform Disorders

Zhonghua Su, P.h D & MD

Jining Medical University

Introduction (1)

According to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the somatoform disorders are distinguished by physical symptoms suggesting a medical condition, yet the symptoms are not fully explained by the medical condition, by substance use, or by another mental disorder. The symptoms are severe enough to cause patients significant distress or impaired social, occupational, or other functioning. The physical symptoms of somatoform disorders are not intentionally produced as are those of factitious disorders and malingering, but no medical condition can fully explain the somatic symptoms. Clinicians must judge that the onset, severity, and duration of symptoms are strongly linked to psychological factors to diagnose a somatoform disorder.

Introduction (2)

In DSM-IV, five specific somatoform disorders are recognized:


somatization disorder, characterized by many physical complaints affecting many organ systems; conversion disorder, characterized by one or two neurological complaints; hypochondriasis, characterized less by a focus on symptoms than by patients' beliefs that they have a specific disease; body dysmorphic disorder, characterized by a false belief or exaggerated perception that a body part is defective; and pain disorder, characterized by symptoms of pain that are either solely related to or significantly exacerbated by psychological factors. DSM-IV also has two residual diagnostic categories for somatoform disorders: Undifferentiated somatoform disorder includes somatoform disorders not otherwise described that have been present for 6 months or longer; and somatoform disorder not otherwise specified is the category for somatoform symptoms that do not meet any of the previously mentioned somatoform disorder diagnoses.

Classification (DSM -IV)


somatization disorder, conversion disorder hypochondriasis body dysmorphic disorder pain disorder Undifferentiated somatoform disorder somatoform disorder not otherwise specified

Introduction (3)
The categories of somatoform disorders are similar in ICD-10 and DSM-IV, except that in ICD-10, body dysmorphic disorder is a subcategory. ICD-10 also stresses that differential diagnosis of somatoform disorders requires that a clinician know the patient well. A patient's "degree of conviction" may be temporarily lessened by a clinician's assurances and by a physical examination, but the disorders are a culturally accepted way of exhibiting physical illness and explaining physical symptoms.

Somatization Disorder

Introduction (1)
characterized by many somatic symptoms; distinguished by "a combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms." ; begins before the age of 30; may continue for years; multiplicity of the complaints and the multiple organ systems (differ from others); associated with significant psychological distress; impairment in social and occupational functioning; excessive medical-help seeking behavior.

Introduction (2)--history

Somatization disorder has been recognized since the time of ancient Egypt. An early name for somatization disorder was hysteria, a condition incorrectly thought to affect only women. (The word hysteria is derived from the Greek word for uterus, hystera.) In the 17th century, Thomas Sydenham recognized that psychological factors, which he called antecedent sorrows, were involved in the pathogenesis of the symptoms. In 1859, Paul Briquet, a French physician, observed the multiplicity of the symptoms and the affected organ systems and commented on the usually chronic course of the disorder. Because of these astute clinical observations, the disorder was called Briquet's syndrome for a time, although the term somatization disorder became the standard in the United States when the third edition of DSM (DSM-III) was introduced in 1980.

Epidemiology (1)
The lifetime prevalence of somatization disorder in the general population is estimated to be 0.1 or 0.2 percent, although several research groups believe that the actual figure may be closer to 0.5 percent. Women with somatization disorder outnumber men 5 to 20 times, but the highest estimates may be due to the early tendency not to diagnose somatization disorder in male patients. Nevertheless, it is not an uncommon disorder. With a 5-to-1 female-to-male ratio, the lifetime prevalence of somatization disorder among women in the general population may be 1 or 2 percent.

Epidemiology (2)

Among patients in the offices of general practitioners and family practitioners, as many as 5 to 10 percent may meet the diagnostic criteria for somatization disorder. The disorder is inversely related to social position and occurs most often among patients who have little education and low income levels. Somatization disorder is defined as beginning before age 30; it most often begins during a person's teenage years. Several studies have noted that somatization disorder commonly coexists with other mental disorders.

Etiology

Psychosocial Factors

interpretations of the symptoms as social communication

avoid obligations express emotions symbolize a feeling or a belief

the symptoms substitute for repressed instinctual impulses A behavioral perspective characteristic attention and cognitive impairments decreased metabolism in the frontal lobes and in the nondominant hemisphere genetic components Research into cytokines

Biological Factors

Clinical Features (1)


many somatic complaints and long, complicated medical histories most common symptoms :nausea and vomiting, difficulty in swallowing, pain in the arms and legs, shortness of breath unrelated to exertion, amnesia, and complications of pregnancy and menstruation Patients frequently believe that they have been sickly most of their lives.

Clinical features -2

Psychological distress and interpersonal problems are prominent; anxiety and depression are the most prevalent psychiatric conditions. Suicide threats are common, but actual suicide is rare. If suicide does occur, it is often associated with substance abuse. Patients' medical histories are often circumstantial, vague, imprecise, inconsistent, and disorganized. Patients classically but not always describe their 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.

Clinical features - 3
Somatization disorder is commonly associated with other mental disorders, including major depressive disorder, personality disorders, substance-related disorders, generalized anxiety disorder, and phobias. The combination of these disorders and the chronic symptoms results in an increased incidence of marital, occupational, and social problems.

Diagnosis criteria -1

A. A history of many physical complaints that occur over a period of several years and result in treatment being sought or significant impairment in functioning beginning before age 30 B. Each of the following must have been met, with individual symptoms occurring at any time during the course of the disturbance:

4 pain symptoms 2 gastrointestinal symptoms 1 sexual symptom 1 pseudoneurological symptom

Diagnosis criteria -2

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, 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., sexual indifference, 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, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucination, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting

Diagnosis criteria -3
C. Either 1 or 2: 1. After appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known GMC or substance 2. When there is a related GMC, 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 (as in Factitious Disorder or Malingering)

Differential diagnosis - 1

nonpsychiatric medical conditions

multiple sclerosis, myasthenia gravis, systemic lupus erythematosus, acquired immune deficiency syndrome (AIDS), acute intermittent porphyria, hyperparathyroidism, hyperthyroidism, and chronic systemic infections.

Many mental disorders

major depressive disorder, generalized anxiety disorder, and schizophrenia panic disorder
hypochondriasis, conversion disorder, and pain somatization disorder,

other somatoform disorders

Differential diagnosis - 2

Clinicians must always rule out nonpsychiatric medical conditions that may explain a patient's symptoms. Several medical disorders often show nonspecific, transient abnormalities in the same age group. These medical disorders include multiple sclerosis, myasthenia gravis, systemic lupus erythematosus, acquired immune deficiency syndrome (AIDS), acute intermittent porphyria, hyperparathyroidism, hyperthyroidism, and chronic systemic infections. The onset of multiple somatic symptoms in patients older than 40 should be presumed to be caused by a nonpsychiatric medical condition until an exhaustive medical workup has been completed.

Differential diagnosis - 3

Many mental disorders are considered in the differential diagnosis, which is complicated by the observation that at least 50 percent of patients with somatization disorder have a coexisting mental disorder. Patients with major depressive disorder, generalized anxiety disorder, and schizophrenia may all have an initial complaint that focuses on somatic symptoms. In all these disorders, however, the symptoms of depression, anxiety, or psychosis eventually predominate over the somatic complaints. Although patients with panic disorder may complain of many somatic symptoms related to their panic attacks, they are not bothered by somatic symptoms between panic attacks.

Differential diagnosis - 4
Among the other somatoform disorders, hypochondriasis, conversion disorder, and pain somatization disorder, patients with hypochondriasis falsely believe that they have a specific disease, whereas those with somatization disorder are concerned with many symptoms. The symptoms of conversion disorder are limited to one or two neurological symptoms rather than to the wide-ranging symptoms of somatization disorder. Pain disorder is limited to one or two complaints of pain symptoms.

Course and prognosis


chronic and often debilitating begun before age 30 and have been present for several years more than a year without seeking medical attention an association between periods of increased stress and the exacerbation of somatic symptoms.

Treatment

regularly scheduled visits Additional laboratory and diagnostic procedures be avoided. emotional expressions Psychotherapy, both individual and group

decreases personal health care expenditures (50%) decreasing their rates of hospitalization. helped to cope with their symptoms to express underlying emotions to develop alternative strategies for expressing their feelings

Giving psychotropic medications with coexisting mental disorders Medication must be monitored

Hypochondriasis

Introduction

In DSM-IV, hypochondriasis is defined as a person's preoccupation with the fear of contracting, or the belief of having, a serious disease. This fear or belief arises when a person misinterprets bodily symptoms or functions. The term hypochondriasis is derived from the old medical term hypochondrium, ("below the ribs") and reflects the common abdominal complaints of many patients with the disorder. Hypochondriasis results from patients' unrealistic or inaccurate interpretations of physical symptoms or sensations, even though no known medical causes can be found. Patients' preoccupations result in significant distress to them and impair their ability to function in their personal, social, and occupational roles.

Epidemiology and etiology

One recent study reported a 6-month prevalence of hypochondriasis of 4 to 6 percent in a general medical clinic population. Men and women are equally affected by hypochondriasis. Although the onset of symptoms can occur at any age, the disorder most commonly appears in people 20 to 30 years of age. Some evidence indicates that the diagnosis is more common among blacks than among whites, but social position, education level, and marital status do not appear to affect the diagnosis.

Clinical features-1

Patients with hypochondriasis believe that they have a serious disease that has not yet been detected, and they cannot be persuaded to the contrary. They may maintain a belief that they have a particular disease; as time progresses, they may transfer their belief to another disease. Their convictions persist despite negative laboratory results, the benign course of the alleged disease over time, and appropriate reassurances from physicians. Yet their beliefs are not so fixed as to be delusions. Hypochondriasis is often accompanied by symptoms of depression and anxiety and commonly coexists with a depressive or anxiety disorder.

Clinical features-2

Although DSM-IV specifies that the symptoms must be present for at least 6 months, transient hypochondriacal states can occur after major stresses, most commonly the death or serious illness of someone important to the patient, or a serious (perhaps life-threatening) illness that has been resolved but that leaves the patient temporarily hypochondriacal in its wake. Such states that last fewer than 6 months should be diagnosed as somatoform disorder not otherwise specified. Transient hypochondriacal responses to external stress generally remit when the stress is resolved, but they can become chronic if reinforced by people in the patient's social system or by health professionals.

Diagnostic criteria-1

The DSM-IV diagnostic criteria for hypochondriasis require that patients be preoccupied with the false belief that they have a serious disease and that the false belief be based on a misinterpretation of physical signs or sensations . The belief must last at least 6 months, despite the absence of pathological findings on medical and neurological examinations. The diagnostic criteria also stipulate that the belief not have the intensity of a delusion (more appropriately diagnosed as delusional disorder) and that it not be restricted to distress about appearance (more appropriately diagnosed as body dysmorphic disorder). The symptoms of hypochondriasis must be of an intensity that causes emotional distress or impairs the patient's ability to function in important areas of life. Clinicians may specify the presence of poor insight; patients do not consistently recognize that the concerns about disease are excessive.

DSM-IV diagnosis criteria for ochondriasis


A. B. C.

D. E. F.

Preoccupation with fears of having, or the idea that one has, a serious disease based on the person-misinterpretation of bodily symptoms The preoccupation persists despite appropriate medical evaluation and reassurance. 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). The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The duration of the disturbance is at least 6 months. 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.

Differential diagnosis-1
Hypochondriasis must be differentiated from nonpsychiatric medical conditions, especially disorders that show symptoms that are not necessarily easily diagnosed. Such diseases include AIDS, endocrinopathies, myasthenia gravis, multiple sclerosis, degenerative diseases of the nervous system, systemic lupus erythematosus, and occult neoplastic disorders.

Differential diagnosis-2

Hypochondriasis is differentiated from somatization disorder by the emphasis in hypochondriasis on fear of having a disease and emphasis in somatization disorder on concern about many symptoms. A subtle distinction is that patients with hypochondriasis usually complain about fewer symptoms than do patients with somatization disorder. Somatization disorder usually has an onset before age 30, whereas hypochondriasis has a less specific age of onset. Patients with somatization disorder are more likely to be women than are those with hypochondriasis, which is equally distributed among men and women.

Differential diagnosis-3

Hypochondriasis must also be differentiated from the other somatoform disorders. Conversion disorder is acute and generally transient and usually involves a symptom rather than a particular disease. The presence or absence of la belle indifference indifference is an unreliable feature with which to differentiate the two conditions. Pain disorder is chronic, as is hypochondriasis, but the symptoms are limited to complaints of pain. Patients with body dysmorphic disorder wish to appear normal but believe that others notice that they are not, whereas those with hypochondriasis seek out attention for their presumed diseases.

Differential diagnosis-4

Hypochondriacal symptoms can also occur in patients with depressive disorders and anxiety disorders. If a patient meets the full diagnostic criteria for both hypochondriasis and another major mental disorder, such as major depressive disorder or generalized anxiety disorder, the patient should receive both diagnoses, unless the hypochondriacal symptoms occur only during episodes of the other mental disorder. Patients with panic disorder may initially complain that they are affected by a disease (for example, heart trouble), but careful questioning during the medical history usually uncovers the classic symptoms of a panic attack. Delusional hypochondriacal beliefs occur in schizophrenia and other psychotic disorders but can be differentiated from hypochondriasis by their delusional intensity and by the presence of other psychotic symptoms.

In addition, schizophrenic patients' somatic delusions tend to be bizarre, idiosyncratic, and out of keeping with their cultural milieus.

Differential diagnosis-5

Hypochondriasis is distinguished from factitious disorder with physical symptoms and from malingering in that patients with hypochondriasis actually experience and do not simulate the symptoms they report.

Course and prognosis


The course of hypochondriasis is usually episodic; the episodes last from months to years and are separated by equally long quiescent periods. There may be an obvious association between exacerbations of hypochondriacal symptoms and psychosocial stressors. Although well-conducted large outcome studies have not yet been reported, an estimated one third to one half of all patients with hypochondriasis eventually improve significantly. A good prognosis is associated with a high socioeconomic status, treatment-responsive anxiety or depression, the sudden onset of symptoms, the absence of a personality disorder, and the absence of a related nonpsychiatric medical condition. Most children with hypochondriasis recover by late adolescence or early adulthood.

Treatment-1
Patients with hypochondriasis are usually resistant to psychiatric treatment although some accept this treatment if it takes place in a medical setting and focuses on stress reduction and education in coping with chronic illness. Among such patients, group psychotherapy is the modality of choice, in part because it provides the social support and social interaction that seem to reduce their anxiety. Individual insight-oriented psychotherapy may be useful, but is generally unsuccessful.

Treatment-2
Frequent, regularly scheduled physical examinations are useful to reassure patients that their physicians are not abandoning them and that their complaints are being taken seriously. Invasive diagnostic and therapeutic procedures should only be undertaken, however, when objective evidence calls for them. When possible, the clinician should refrain from treating equivocal or incidental physical examination findings.

Treatment-3
Pharmacotherapy alleviates hypochondriacal symptoms only when a patient has an underlying drug-responsive condition, such as an anxiety disorder or major depressive disorder. When hypochondriasis is secondary to another primary mental disorder, that disorder must be treated in its own right. When hypochondriasis is a transient situational reaction, clinicians must help patients cope with the stress without reinforcing their illness behavior and their use of the sick role as a solution to their problems.

Body dysmorphic disorder

Introduction-1
DSM-IV defines body dysmorphic disorder as a preoccupation with an imagined defect (for example, a misshapen nose) or an exaggerated distortion of a minimal or minor defect in physical appearance. To be considered a mental disorder, the preoccupation must cause patients significant distress or be associated with impairment in the patient's personal, social, or occupational life.

Introduction-2

The disorder was recognized and named dysmorphophobia more than 100 years ago by Emil Kraepelin, who considered it a compulsive neurosis; Pierre Janet called it obsession de la honte du corps (obsession with shame of the body). Freud wrote about the condition in his description of the WolfMan, who was excessively concerned about his nose. Although dysmorphophobia was widely recognized and studied in Europe, it was not until the publication of DSM-III in 1980 that dysmorphophobia, as an example of a typical somatoform disorder, was specifically mentioned in the United States diagnostic criteria. In DSM-IV, the condition is known as body dysmorphic disorder, because the DSM editors believed that the term dysmorphophobia inaccurately implied the presence of a behavioral pattern of phobic avoidance.

Epidemiology

The cause of body dysmorphic disorder is unknown. The high comorbidity with depressive disorders, a higher-than-expected family history of mood disorders and obsessive-compulsive disorder, 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. Stereotyped concepts of beauty emphasized in certain families and within the culture at large may significantly affect patients with body dysmorphic disorder. In psychodynamic models, body dysmorphic disorder is seen as reflecting the displacement of a sexual or emotional conflict onto a nonrelated body part.

Such an association occurs through the defense mechanisms of repression, dissociation, distortion, symbolization, and projection.

Clinical features

The most common concerns involve facial flaws, particularly those involving specific parts (for example, the nose).

Sometimes the concern is vague and difficult to understand, such as extreme concern over a "scrunchy" chin.

One study found that, on average, patients had concerns about four body regions during the course of the disorder. The specific body part may change during the time a patient is affected with the disorder.

Common associated symptoms include ideas or frank delusions of reference , either excessive mirror checking or avoidance of reflective surfaces, and attempts to hide the presumed deformity.

The effects on a person's life can be significant; almost all affected patients avoid social and occupational exposure.

As many as one third of the patients may be housebound because of worry about being ridiculed for the alleged deformities, and as many as one fifth attempt suicide.

As previously discussed, comorbid diagnoses of depressive disorders and anxiety disorders are common, and patients may also have traits of obsessive-compulsive, schizoid, and narcissistic personality disorders.

Diagnosis criteria
A.

B.

C.

Preoccupation with an imagined defect in appearance. If a slight physical anomoly is present, the person-concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

Diagnostic Criteria

Preoccupation with an imagined defect in appearance. If a slight physical anomoly is present, the person-concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

Differential diagnosis-1
Distortions of body image occur in anorexia nervosa, gender identity disorders, and some specific types of brain damage (for example, neglect syndromes); body dysmorphic disorder should not be diagnosed in these situations. Body dysmorphic disorder must also be distinguished from a person's normal concern about appearance.

In body dysmorphic disorder, however, a person experiences significant emotional distress and functional impairment because of the concern.

Differential diagnosis-2

Although distinguishing between a strongly held idea and a delusion is difficult, if a patient's preoccupation with the perceived body defect is, in fact, of delusional intensity, the appropriate diagnosis is delusional disorder, somatic type. Other diagnostic considerations are narcissistic personality disorder, depressive disorders, obsessive-compulsive disorder, and schizophrenia.

In narcissistic personality disorder, concern about a body part is only a minor feature in the general constellation of personality traits. In depressive disorders, schizophrenia, and obsessive-compulsive disorder, the other symptoms of these disorders usually evidence themselves in short order, even when the initial symptom is excessive concern about a body part.

Course and prognosis


The onset of body dysmorphic disorder is usually gradual. An affected person may experience increasing concern over a particular body part until the person notices that functioning is being affected. Then the person may seek medical or surgical help to address the presumed problem. The level of concern about the problem may wax and wane over time, although the disorder is usually chronic if left untreated.

Treatment

Treatment of patients with body dysmorphic disorder with surgical, dermatological, dental, and other medical procedures to address the alleged defects is almost invariably unsuccessful. Although tricyclic drugs, monoamine oxidase inhibitors, and pimozide (Orap) have been reported to be useful in individual cases, a larger body of data indicate that serotonin-specific drugs-for example, clomipramine (Anafranil) and fluoxetine (Prozac)-are effective in reducing symptoms in at least 50 percent of patients. In any patient with a coexisting mental disorder, such as a depressive disorder or an anxiety disorder, the coexisting disorder should be treated with the appropriate pharmacotherapy and psychotherapy. How long treatment should be continued when the symptoms of body dysmorphic disorder have remitted is unknown.

Pain disorder

Introduction

In DSM-IV, pain disorder is defined as the presence of pain that is "the predominant focus of clinical attention." Psychological factors play an important role in the disorder. The primary symptom is pain, in one or more sites, which is not fully accounted for by a nonpsychiatric medical or neurological condition. The symptoms of pain are associated with emotional distress and functional impairment. The disorder has been called somatoform pain disorder, psychogenic pain disorder, idiopathic pain disorder, and atypical pain disorder.

Epidemiology
Low back pain has disabled an estimated 7 million people; more than 8 million physician office visits annually; Female : male=2:1; The peak ages of onset are in the fourth and fifth decades; most common in people with blue-collar occupations; genetic inheritance or behavioral mechanisms are possibly involved;

Clinical features-1
Patients with pain disorder do not constitute a uniform group but, instead, are a heterogeneous collection of people 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; to meet a diagnosis of pain disorder, however, the disorder must have a psychological factor that is judged to be significantly involved in the pain symptoms and their ramifications.

Clinical features-2

Patients with pain disorder often have long histories of medical and surgical care.

They visit many physicians, request many medications, and may be especially insistent in their desire for surgery. Indeed, they can be completely preoccupied with their pain and cite it as the source of all their misery.

Such patients often deny any other sources of emotional dysphoria and insist that their lives are blissful except for their pain. Their clinical picture can be complicated by substance-related disorders, because these patients attempt to reduce the pain through the use of alcohol and other substances.

Clinical features-3

At least one study has correlated the number of pain symptoms to the likelihood and severity of symptoms of somatization disorder, depressive disorders, and anxiety disorders.

Major depressive disorder is present in about 25 to 50 percent of all patients with pain disorder, and dysthymic disorder or depressive disorder symptoms are reported in 60 to 100 percent of the patients.

Some investigators believe that chronic pain is almost always a variant of a depressive disorder, a masked or somatized form of depression.

The most prominent depressive symptoms in patients with pain disorder are anergia, anhedonia, decreased libido, insomnia, and irritability; diurnal variation, weight loss, and psychomotor retardation appear to be less common symptoms.

Diagnostic criteria

The DSM-IV diagnostic criteria for pain disorder require the presence of clinically significant complaints of pain . The complaints of pain must be judged to be significantly affected by psychological factors, and the symptoms must result in a patient's significant emotional distress or functional impairment (for example, social or occupational). DSM-IV requires that the pain disorder be associated primarily with psychological factors or with both psychological factors and a general medical condition. DSM-IV further specifies that pain disorder associated solely with a general medical condition be diagnosed as an Axis III condition and also allows clinicians to specify whether the pain disorder is acute or chronic, depending on whether the duration of symptoms has been 6 months or more.

DSM-IV diagnosis criteria for pain disorder


A.

B.

C.

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.

A.

B.

C.

DSM-IV diagnosis criteria for pain disorder


D.

E.

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.

D.

E.

Differential diagnosis-1

Purely physical pain can be difficult to distinguish from purely psychogenic pain, especially because the two are not mutually exclusive.

Physical pain fluctuates in intensity and is highly sensitive to emotional, cognitive, attentional, and situational influences. Pain that does not vary and is insensitive to any of these factors is likely to be psychogenic. When pain does not wax and wane and is not even temporarily relieved by distraction or analgesics, clinicians can suspect an important psychogenic component.

Differential diagnosis-2

Pain disorder must be distinguished from other somatoform disorders, although some somatoform disorders can coexist. Patients with hypochondriacal preoccupations may complain of pain, and aspects of the clinical presentation of hypochondriasis, such as bodily preoccupation and disease conviction, can also be present in patients with pain disorder. Patients with hypochondriasis tend to have many more symptoms than do patients with pain disorder, and their symptoms tend to fluctuate more than do the symptoms of patients with pain disorder. Conversion disorder is generally short lived, whereas pain disorder is chronic. In addition, pain is, by definition, not a symptom in conversion disorder. Malingering patients consciously provide false reports, and their complaints are usually connected to clearly recognizable goals.

Course and prognosis


The pain in pain disorder generally begins abruptly and increases in severity for a few weeks or months. The prognosis varies, although pain disorder can often be chronic, distressful, and completely disabling. When psychological factors predominate in pain disorder, the pain may subside with treatment or after the elimination of external reinforcement. The patients with the poorest prognoses, with or without treatment, have preexisting characterological problems, especially pronounced passivity; are involved in litigation or receive financial compensation; use addictive substances; and have long histories of pain.

Treatment (1)

General consideration

discuss the issue of psychological factors early in treatment; explain how various brain circuits that are involved with emotions; fully understand that the patient's experiences of pain are real.
Analgesic medications are not generally helpful; Sedatives and antianxiety agents are not especially beneficial; Antidepressants (TCA, SSRIs) are useful; Amphetamine used as an adjunct to SSRIs.

Pharmacotherapy

Treatment (2)

Behavioral therapy

Biofeedback can be helpful; Hypnosis, transcutaneous nerve stimulation, and dorsal column stimulation have been used; Nerve blocks and surgical ablative procedures are ineffective
develop a solid therapeutic alliance; not confront somatizing patients; examine its interpersonal ramifications in the patient's life; Cognitive therapy

Psychotherapy

Treatment (3)

Pain control programs

Multidisciplinary pain units use many modalities; physical therapy and exercise; offer vocational evaluation and rehabilitation; Concurrent mental disorders are diagnosed and treated; dependent on analgesics and hypnotics are detoxified.

Neurasthinia

Introduction-1
The term neurasthenia was introduced in the 1860s by the American neuropsychiatrist George Miller Beard, who applied it to a condition characterized by chronic fatigue and disability. The term neurasthenia ("nervous exhaustion") is not now used frequently, but it does appear in psychiatric literature and remains a diagnostic entity in the 10th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10).

Introduction-2
In ICD-10, neurasthenia is classified as one of the neurotic disorders. According to current nosology in the United States, the disorder is not considered a distinct diagnosis. In the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), neurasthenia is categorized as undifferentiated somatoform disorder.

Introduction-3

The disorder is a prime example of cultural differences influencing the classification and manifestations of diseases. Neurasthenia is an accepted condition in Europe and Asia, where it is characterized by fatigue, headache, insomnia, and other vague somatic complaints and is thought to result from chronic stress rather than from unconscious psychological conflicts. In many cultures (especially China), in which people resist being categorized as having a mental disorder, neurasthenia is a preferred diagnosis. Thus, the disorder is most commonly diagnosed in eastern Asia.

Epidemiology-1
Difficulties in investigating the epidemiology of neurasthenia stem from the fact that it occurs in connection with other conditions, such as anxiety, depression, and somatoform disorders, and it has not been sufficiently studied as an independent disorder. Beard considered neurasthenia one of the most frequently observed conditions in the 19th century United States, although no statistics were available to support his observation. A 1994 study in Switzerland showed a prevalence rate (using ICD-10) of 12 percent in that country.

Epidemiology-2

Studies have indicated that the major symptoms-fatigue and heightened concerns with bodily symptoms-are most commonly appear in people who are socially and economically deprived, although the disorder is no more prevalent in this group than in others and may, in fact, occur more frequently in higher socioeconomic groups. Precursors of neurasthenia in the form of "growing pains," fatigue, and sleep disturbances appear in children. Beard believed childhood to be one of the peak periods for the onset of the disorder, the other being middle age (adults 40 to 65 years of age).

Diagnostic criteria-1

According to ICD-10, neurasthenia is not used as a diagnostic category in all countries. In the United States, for example, many of the cases so diagnosed would meet the criteria for depressive disorder, somatoform disorder, or anxiety disorder. Some patients, however, have such varied symptoms that neurasthenia is the preferred diagnosis. These patients may be diagnosed using the ICD-10 diagnostic criteria, or they may receive a diagnosis of undifferentiated somatoform disorder according to the DSM-IV criteria.

Diagnostic criteria-2
Neurasthenia is characterized by a wide variety of signs and symptoms. The most common findings are chronic weakness and fatigue, aches and pains, and general anxiety or "nervousness." Beard, Freud, and others described a plethora of patients' reported complaints. The symptoms are real to patients. As Beard stated: "They are not imaginary. They have a real objective existence and cannot be willed away."

Diagnostic criteria-3

ICD-10 describes two types of the disorder, with substantial overlap between them. In one type, the main feature is a complaint of increased fatigue after mental effort, often associated with some decrease in occupational performance or coping efficiency in daily tasks. The mental fatigability is typically described as an unpleasant intrusion of distracting associations or recollections, difficulty in concentrating, and generally inefficient thinking. In the other type, the emphasis is on feelings of bodily or physical weakness and exhaustion after only minimal effort, accompanied by muscular aches and pains and inability to relax. In both types, other unpleasant physical feelings, such as dizziness, tension headaches, and a sense of general instability, are common. Worry about decreasing mental and bodily well-being, irritability, anhedonia, and varying degrees of both depression and anxiety may be present. Sleep is frequently disturbed in its initial and middle phases, but hypersomnia may also be prominent.

Diagnostic criteria-4
If the DSM-IV criteria are used, neurasthenia would be associated with one of the two forms of undifferentiated somatoform disorders, that is, with the group of physical complaints including chronic fatigue and loss of appetite.

Signs and symptoms reported by patients with neurasthenia


General fatigue Exhaustion General anxiety Difficulty concentrating Physical aches and pains Dizziness Headache Intolerance of noise (hyperacusis) or bright lights Chills Indigestion Constipation or diarrhea Flatulence Palpitations Extrasystole Tachycardia Excess sweating Flushing of skin Dysmenorrhea

Sexual dysfunction, eg, erectile disorder, anorgasmia Paresthesia Insomnia Poor memory Pessimism Chronic worry Fear of disease Irritability Feelings of hopelessness Dry mouth or hypersalivation Arthralgias Heat insensitivity Dysphagia Pruritus Tremors Back pain

Differential Diagnosis-1

Neurasthenia must be distinguished from anxiety disorders, depressive disorder, and the somatoform disorders, which include somatization disorder, conversion disorder, hypochondriasis, body dysmorphic disorder, and pain disorder.

Because so many signs and symptoms of neurasthenia overlap with and appear in each of these disorders, differential diagnosis may be exceedingly difficult. For example, patients with anxiety disorder do not uncommonly have depressive symptomatology; patients with hypochondriasis often complain of anxiety; and patients with body dysmorphic disorder can have somatic complaints.

Differential Diagnosis-2

Clinicians must rigorously apply the diagnostic criteria for anxiety, depressive, and somatoform disorders before making a diagnosis of neurasthenia. Hallmarks of neurasthenia are a patient's emphasis on fatigability and weakness and concern about lowered mental and physical efficiency (in contrast to the somatoform disorders, in which bodily complaints and preoccupation with physical disease dominate the picture). If the neurasthenic syndrome develops in the aftermath of a physical illness (particularly influenza, viral hepatitis, or infectious mononucleosis), the diagnosis of the illness should also be recorded. Chronic fatigue syndrome, discussed below, must also be considered.

Course and prognosis-1


Neurasthenia most often occurs during adolescence or middle age. Untreated, the disorder is usually chronic, and patients may become incapacitated by one or more symptoms so that all areas of functioning become impaired. In childhood, difficulties in school functioning, including poor grades and truancy, are likely. In adulthood, work performance deteriorates, or patients may become so disabled that work is impossible. Similarly, social, marital, and interpersonal relationships suffer.

Course and prognosis-2


Beard believed that with treatment (such as it was in the 1860s) "the majority can be relieved or substantially cured." The range of therapeutic options now available is broad, and with treatment the prognosis should be favorable; but the long-term prognosis is unknown. For cases first diagnosed in childhood, the prognosis without treatment is guarded, chronicity of symptoms being the most likely outcome. Sometimes it is difficult to distinguish the prodromal signs of schizophrenia or bipolar disorder from neurasthenia.

Treatment-1

The key concept in the current treatment of neurasthenia is clinicians' understanding that a patient's symptoms are not imaginary. The symptoms are objective and are produced by emotions that influence the autonomic nervous system, which in turn affects body functions. Stress can cause structural change in an organ system, and the result can be life threatening. Therapy must therefore begin with a careful medical workup to determine whether a patient's somatic symptoms are amenable to therapy, and if so, what treatment is likely to produce the best results. Patients should be reassured that the administration of medication (analgesics, laxatives, and so on) to relieve medical symptoms will be successful, but only when combined with concurrent psychotherapeutic intervention. Patients must be helped to recognize the stresses in their lives and the coping mechanisms they use to deal with these stresses, to gain insight into the interaction between mind and body. Without such insight-oriented psychotherapy, the neurasthenic condition is likely to continue unabated.

Treatment-2

The availability of psychopharmacological agents has markedly improved therapeutic options. Serotonergic agents (such as fluoxetine [Prozac]), which have both an antidepressant and an antianxiety effect, are the most useful class of drugs. Newer antidepressants, such as nefazodone (Serzone) and mirtazapine (Remeron), are also effective. Mirtazapine is reported to have distinct sedative properties in addition to being an antidepressant and may be especially useful for neurasthenia. Physicians should take care in prescribing drugs with abuse potential, such as benzodiazepines, because of these patients' predilection for self-medication and drug misuse. Such drugs may be useful, for brief periods and under careful supervision, to deal with overwhelming anxiety, phobias, or insomnia. Similarly, small doses of analeptics, such as amphetamine (Dexedrine) or methylphenidate (Ritalin), may help to treat chronic fatigue and anhedonia. Testosterone replacement can be tried in men with demonstrated testosterone deficiency, but long-term treatment with testosterone is associated with serious adverse side effects, such as prostatic cancer.

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