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Behavioral Medicine II o 1 pseudoneurological symptom

SOMATOFORM DISORDERS o Cannot be fully explained by physical and

laboratory examination
Broad group of illnesses and have bodily signs Clinical features
and symptoms o Impaired coordination or balance
Encompass mind-body interactions o Paralysis or localized weakness
Symptoms are not under voluntary control and o Difficulty swallowing or lump in throat
complaints are not imaginary o Aphonia
o Urinary retention
5 Specific somatoform disorders: o Hallucination
o Loss of touch or pain sensation
Somatization disorder o Double vision
- Many physical complaints affecting many o Blindness
organ systems
o Deafness
- Recurrent, chronic
o Seizures
Conversion Disorder
o Loss of consciousness
- One or two neurological complaints
- Acute, motor or sensory o Anxiety and depression
Hypochondriasis Course and Prognosis
- Focus on symptoms than by patients belief o Chronic and often debilitating
that they have a specific disease Treatment
- Disease concern / preoccupation o Best treated with 1 physician = patient have
Body Dysmorphic Disorder increased opportunities to express somatic
- False belief or exaggerated perception that complaints.
a body part is defective o Group and individual psychotherapy
- Subjective feeling of ugliness or concern Help cope with symptoms
with body defect Develop alternative strategies for
Pain disorder expressing their feelings
- Symptoms of pain that are either solely
related to or significantly exacerbated by
psychological factors CONVERSION DISORDER
- Pain syndrome stimulated
Affect voluntary motor and sensory functions
(neurological / general medical condition)
SOMATIZATION Monosymptomatic
o Motor symptoms ( paralysis, gait
Polysymptomatic disturbance)
Chronic o Sensory deficits ( anesthesia & paresthesia)
Associated with significant psychological o Visceral symptoms (urinary retention,
distress, impaired social and occupational diarrhea and pseudocyesis)
functioning and excessive medical help seeking Acute
behavior Caused by psychological factors preceeded by
Epidemiology stress
o F > M 5-20:1 Epidemiology
o Before 30 / teenage years o F > M (2-10:1)
o 0.2-2% general population o Men = associated with military accidents or
o Little education and low incomes occupational accidents
o Associated with personality disorder: o Common in adolescents and young adult
avoidant, paranoid, self defeating, OC o Rural populations
Etiology o Little education,low IQ, low socioeconomic
o Psychosocial factors groups
o Biological factors Comorbididty
Attention and cognitive impairements = o Depressive disorders
faulty perception and assessment of o Anxiety disorders
somatosensory inputs o Somatization disorder
Excessive distractability o Personality disorder
Inability to habituate to repetitive o Schizophrenia (rare)
stimuli Etiology
Grouping of cognitive constructs on an o Psychoanalytic factors
impressionable basis Repression of unconscious intrapsychic
Partial and circumstantial association
conflict and conversion anxiety into a
Lack of selectivity physical symptom
Decreased metabolism in the frontal The symptoms allow partial expression
love and the nondominant hemisphere of the forbidden wish oror urge to
Diagnosis disguise it so the patient can avoid
o 4 pain symptoms consciously confronting their
o 2 GI symptoms unacceptable impulses (vaginismus =
o 1 sexual symptom (irregular menses, protects patient from sexual wishes)
erectile dysfunction, irregular bleeding
Allow patient to communicate = they o Parenteral amobarbital or lorazepam
need special attention o Spontaneous
Coping with impossible or difficult o Psychotherapy issues of stress and coping
situation o Hypnosis, anxiolytics and behavioral
Manipulate others relaxation
o Learning theory o Longer duration of patient sick role more
regressed more difficult to treat

o Biological factors
Hypometabolism of the dominant
Excessive cortical arousal leading to
negative feedback HYPOCHONDRIASIS
Inc. corticofugal output = inhibit
patient awareness of bodily sensation Pre-occupation with fears of contracting or the
(observe sensory deficits) belief of having a serious disease significant
Clinical features stress impair ability to function in their
o Paralysis, blindness and mutism most personal, social and occupational roles
common Misinterpret body symptoms or functions
o Commonly associated with Common abdominal complaints hypochondrium
Passive-aggressive below the ribs
Dependent Unrealistic or inaccurate interpretation of
Anti-social physical symptoms or sensations
Historionic personality disorder Epidemiology
Depression and anxiety o Atleast 6 months
o Sensory symptoms o 4-6% in general population
anesthesia and paresthesia o 3% medical students in their 1st 2 years
stocking and glove anesthesia of the o M=F
hands and feet or hemianesthesis from o 20-30 yearsold
midline Etiology
Involve special senses (deafness, o Misinterpretation of bodily symptoms
blindness, tunnel vision) unilateral or o Augment and amplify somatic sensation
bilateral o Low threshold for pain
o Motor symptoms o Sick roles offer an escape (excused to
Abnormal movements usual duties, avoid noxious obligations)
Gait disturbance o Aggressive and hostile wishes towards
Weakness others are transferred through
Paralysis repression and displacements into
Movements worsen when you call their physical complaints
attention o Deserved punishment
Astasia-abasia wildly ataxic,
staggering gait, jerky Differential diagnosis
truncalmovements, thrashing and o AIDS, endocrinopathies, myasthenia gravis,
waving arms movements SLE, multiple schlerosis, degenerative
o Seizure symptoms disease or nervous system, occult neoplastic
Pseudoseizure (tongue biting and disorders
urinary incontinence) Course and prognosis
o Other associated features o Episodic months to years and are
Primary gain symptoms have separated with equally long quiescent
symbolic meaning period
Secondary gain accrue tangible o Fewer symptom compared to somatization
advantages and benefits as a resultof disorder
being sick (excused from obligations) o Good prognosis:
La belle indifference unconcerned Upper socioeconomic status
about what appears to be major Response to treatment
Identification model their symptoms Sudden onset
on those of someone important to them Absence of personality disorder
Course and prognosis Absence of related non psychiatric
o Later may have neurological disorder medical condition
o 90-100% resolve in a few days or less than Most children recover by late
a month adolescence and early adulthood
o Good prognosis: Treatment
Sudden onset o Psychotherapy
Easily identifiable stressor o Frequent regular scheduled PE
Good premorbid judgement Take complaints seriously
No comorbidity
No ongoing litigation
Manipulation and gaining advantage in
Preoccupation with an imaged defect in interpersonal relationships
appearance o Biological factors
Causes significant distress or impairment in Cerebral cortex can inhibit firing of
important areas of functioning afferent pain fibers
Epidemiology Serotonin is the main neurotransmitter
o 15-30 yearsold in the descending inhibitory pathways
o F>M Endorphins play a role in CNS
o Unmarried individual modulation of pain = dec. Endorphin
o 90% MDD augment incoming sensory stimuli
o 70% anxiety disorder Most prominent symptoms
o 30% psychotic disorder o Anergia, anhedonia, dec. Libido, insomnia,
Etiology irritability, diurnal variation, weight loss
o Unknown Course and prognosis
o Serotonin o Begin abruptly
o Stereotype concept of beauty family and o Inc. saeverity for a few weeks or months
culture Treatment
o Displacement of sexual and emotional o Nerve block 6-8 months repeat
conflict nonrelated body part o Psychotherapy
Clinical feature Biofeedback esp. Migraine, myofacial
o Concerns involve facial flaws (nose) pain and tension headache
o Commonly assoc. symptoms Develop solid therapeutic alliance by
Frank delusions of reference empathizing with patients suffering
Excessive mirror checking / avoidance Acknowledge reality of pain
of reflective surface (make up and Alter negative thoughts and foster a
clothing) positive attitude
Attempts to hide presumed deformity o Pharmacotherapy
o Avoid social and occupational exposure SSRI and TCA
Comorbidity Amphetamine adjunct to SSRI
o Anxiety disorder
o Narcisstic personality disorder
Differential diagnosis
o Anorexia nervosa, gender identity disorder,
brain damage neglect syndrome
o Psychotherapy
o Pharmacotherapy
SSRI (Clomipramine and Fluoxetine)


Pain in 1 or more body site

Associated with emotional distress and
functional impairement
o F > M 2:1
o 4th and 5th decades
o Blue collar occupations job related injuries
o Genetic inheritance and behavioral
mechanism transmission
o Depressive disorder, anxiety disorder,
substance abuse common in families with
pain disordered patient
o Psychodynamic factors
Symbolically expressing an intrapsychic
conflict (alexithymia unable to
articulate showed through their body)
Method of obtaining love, punishment
for wrong doing, expiating guilt,
o Behavioral factors
Reinforced when rewarded
Inhibited when ignored or punished
o Interpersonal factors