PSYCHOLOGY

EXIMIUS
Psychosomatic Medicine
Dr. Pagaddu November 2019
Psychosomatic Medicine
— Greek: soma for body, psyche for soul
— increased understanding of the relationship of medical
illness to psychiatric illness, and the greater appreciation
of mind and body as one
Major conceptual trends in the history of Psychosomatic Medicine
I. Psychoanalytic
Sigmund Freud (1900): Somatic involvement occurs in
conversion hysteria, which is psychogenic in origin-e.g., paralysis of
an extremity. Conversion hysteria always has a primary psychic cause
and meaning; i.e., it represents the symbolic substitutive expression
of an unconscious conflict. It involves organs innervated only by the
voluntary neuromuscular or the sensorimotor nervous system.
Psychic energy that is dammed up is discharged through physiological
outlets. Sandor Ferenczi (1910): The concept of conversion hysteria is
applied to organs innervated by the autonomic nervous system; e.g.,
the bleeding of ulcerative colitis may be described as representing a
specific psychic fantasy. Georg Groddeck (1910): Clearly organic
diseases, such as fever and hemorrhage, are held to have primary
psychic meanings; i.e., they are interpreted as conversion symptoms
that represent the expression of unconscious fantasies. Franz
Alexander (1934, 1968): Psychosomatic symptoms occur only in
organs innervated by the autonomic nervous system and have no
specific psychic meaning (as does conversion hysteria) but are end
results of prolonged physiological states, which are the physiological
accompaniments of certain specific unconscious repressed conflicts.
Presented first conceptualization of the biopsychosocial model. Helen
Flanders Dunbar (1936): Specific conscious personality pictures are
associated with specific psychosomatic diseases, an idea similar to
Meyer Friedman's 1959 theory of the type A coronary type. Peter
Sifneos, John C. Nemiah (1970): Elaborated the concept of
alexithymia. Developmental arrests in the capacity and the ability to
express conflict-related affect result in psychosomatic symptom
formation. Concept of "alexithymia" modified later by Stoudemire,
who advocated the term "somatothymia" emphasizing cultural
influences on use of somatic language and somatic symptom to
express affective distress.
2021
rearing, anxiety transmission. Thomas Holmes, Richard Rahe (1975):
Correlated the severity and the number of recent stressful life events
with the likelihood of disease.
IV. Systems theory
Adolph Meyer (1958): Formulated the psychobiological
approach to patient assessment that emphasizes the integrated
assessment of developmental, psychological, social, environmental,
and biological aspects of the patient's condition. Basic concept of the
biopsychosocial model is implicit in his approach. Zbigniew Lipowski
(1970): A total approach to psychosomatic disease is necessary.
External (ecological, infectious, cultural, environmental), internal
(emotional), genetic, somatic, and constitutional factors as well as
past and present history are important and should be studied by
investigators working in the various fields in which they are trained.
George Engel (1977): Coined the term "biopsychosocial" derived from
general systems theory and based on conceptual ideas introduced
much earlier by Alexander and Meyer. Leon Eisenberg (1995):
Contemporary psychiatric research demonstrates that the mind-brain
responds to biological and social vectors while being jointly
constructed of both. Major brain pathways are specified in the
genome; detailed connections are fashioned by, and consequently
reflect, socially mediated experience in the world.
Summary of Clinical Problems in Psychosomatic Medicine
Type of Clinical Problem Example
Psychiatric symptoms Delirium, dementia
secondary to a medical
condition
Psychiatric symptoms as a Anxiety related to
reaction to medical condition chemotherapy, depression
or treatments related to limb amputation
Psychiatric complications of Depression secondary to
medical conditions and interferon treatment
treatments

II. Psychophysiological Psychological factors Somatoform disorders

Walter Cannon (1927): Demonstrated the physiological precipitating medical
concomitants of some emotions and the important role of the symptoms
autonomic nervous system in producing those reactions. The concept
is based on Pavlovian behavioral experimental designs. Harold Wolff Medical complications of Neuroleptic malignant
(1943): Attempted to correlate life stress to physiological response, psychiatric conditions or syndrome, acute withdrawal
using objective laboratory tests. Physiological change, if prolonged, treatment from alcohol or other substance
may lead to structural change. He established the basic research
paradigm for the fields of psychoimmunology, psychocardiology, and Co-occurring medical and Recurrence of depressive
psychoneuroendocrinology. Hans Selye (1945): Under stress, a psychiatric conditions disorder in setting of cancer
general adaptation syndrome develops. Adrenal cortical hormones treatment (conditions occur
are responsible for the physiological reaction. Meyer Friedman independently); schizophrenia in
(1959): Theory of type A personality as a risk factor for cardiovascular a patient with end-stage renal
disease. The basic concept was introduced by Helen Flanders Dunbar disease
as early as 1936. Robert Ader (2007): Beginning in the 1970s,
established the basic concepts and the research methods for the field Psychiatric/Psychosocial Capacity evaluation; evaluation
of psychoneuroimmunology assessment prior to organ transplantation

Ill. Sociocultural
Karen Horney (1939), James Halliday (1948): Emphasized
the influence of the culture in the development of psychosomatic
illness. They thought that culture influences the mother, who, in turn,
affects the child in her relationship with the child-e.g., nursing, child

TRANSCRIBERS Group 6 1
 PSYCHOLOGY
Psychosomatic Medicine
Dr. Pagaddu November 2019
TREATMENTS
• Specific consideration must be given to medical illness and
treatments when making recommendations for
psychotropic medications
• Psychotherapy also plays an important role
• Psychopharmacologic recommendations need to consider
several important factors
• In addition to targeting a patient's active symptoms,
considering the history of illness and treatments, and
weighing the particular side-effect profile of a particular
medication
• It is critical to evaluate potential drug-drug interactions and
contraindications to the use of potential psychotropic
agents
• awareness of liver function is important
• general appreciation of side effects, such as weight gain,
risk of development of diabetes, and cardiovascular risk,
must be considered in the choice of medications
• The use of psychosocial interventions also requires
adaptation when used in this population
Somatic Symptom Disorder
ú also known as hypochondriasis
ú characterized by 6 or more months of a general and
nondelusional preoccupation with fears of having, or
the idea that one has, a serious disease based on the
person's misinterpretation of bodily symptoms.
ú preoccupation causes significant distress and
impairment in one's life; it is not accounted for by
another psychiatric or medical disorder
ú a subset of individuals with somatic symptom disorder
has poor insight about the presence of this disorder
§ Epidemiology
ú prevalence of this disorder is 4 to 6 percent, but it may
be as high as 15 percent
ú M=F
ú onset of symptoms can occur at any age, the disorder
most commonly appears in persons 20-30 y/o
ú more common among blacks than among whites
ú social position, education level, and marital status do
not appear to affect the diagnosis
ú Hypochondriacal complaints reportedly occur in about
3 percent of medical students, usually in the first 2
years, but they are generally transient
§ Etiology
§ persons with hypochondriasis augment and amplify their
somatic sensations; they have low thresholds for, and low
tolerance of, physical discomfort
§ hypochondriasis is understandable in terms of a social learning
model
o viewed as a request for admission to the sick role made
by a person facing seemingly insurmountable and
insolvable problems which offers an escape that allows
a patient to avoid noxious obligations, to postpone
unwelcome challenges, and to be excused from usual
duties and obligations
§ a variant form of other mental disorders, depressive disorders
and anxiety disorders are most frequently included
§ Psychodynamic: aggressive and hostile wishes toward others are
transferred (through repression and displacement) into physical
complaints
TRANSCRIBERS Group 6
EXIMIUS
2021
o the anger of patients with hypochondriasis originates
in past disappointments, rejections, and losses, but the
patients express their anger in the present by soliciting
the help and concern of other persons and then
rejecting them as ineffective
o viewed as a defense against guilt, a sense of innate
badness, an expression of low self-esteem, and a sign
of excessive self-concern
o means of atonement and expiation (undoing) and can
be experienced as deserved punishment for past
wrongdoing (either real or imaginary) and for a
person's sense of wickedness and sinfulness
DSM-5 Diagnostic Criteria for Somatic Symptom Disorder
A. One or more somatic symptoms that are distressing or result
in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviors related to the
somatic symptoms or associated health concerns as manifested
by at least one of the following:
1 . Disproportionate and persistent thoughts about the
seriousness of one's symptoms.
2. Persistently high level of anxiety about health or
symptoms.
3. Excessive time and energy devoted to these
symptoms or health concerns
C. Although any one somatic symptom may not be continuously
present, the state of being symptomatic is persistent (typically
more than 6 months).
Specify if: With predominant pain (previously pain disorder): This
specifier is for individuals whose somatic symptoms
predominantly involve pain.
Specify if: Persistent: A persistent course is characterized by
severe symptoms, marked impairment, and long duration (more
than 6 months).
Specify current severity:
• Mild: Only one of the symptoms specified in Criterion B
is fulfilled.
• Moderate: Two or more of the symptoms specified in
Criterion B are fulfilled.
• Severe: Two or more of the symptoms specified in
Criterion B are fulfilled, plus there are multiple somatic
complaints (or one very severe somatic symptom).
Clinical Features
• Believe that they have a serious disease that has not yet
been detected, and they cannot be persuaded to the
contrary
• or as time progresses, they may transfer their belief to
another disease.
• convictions persist despite negative laboratory results, the
benign course of the alleged disease over time, and
appropriate reassurances from physicians.
• commonly coexists with a depressive or anxiety disorder
• transient somatic symptom disorder responses to major
stresses generally remit when the stress is resolved, but
they can become chronic if reinforced by persons in the
patient's social system or by health professionals
2
 PSYCHOLOGY
Psychosomatic Medicine
Dr. Pagaddu November 2019
• believe that they have a serious disease that has not yet
been detected, and they cannot be persuaded to the
contrary
• or as time progresses, they may transfer their belief to
another disease.
• convictions persist despite negative laboratory results, the
benign course of the alleged disease over time, and
appropriate reassurances from physicians.
• commonly coexists with a depressive or anxiety disorder
• transient somatic symptom disorder responses to major
stresses generally remit when the stress is resolved, but
they can become chronic if reinforced by persons in the
patient's social system or by health professionals
Differential Diagnosis
• AIDS, endocrinopathies, myasthenia gravis, MS,
degenerative diseases of the nervous system, systemic
lupus erythematosus, and occult neoplastic disorders
• somatization disorder - concern about many symptoms;
have more complaints, onset before age 30, more likely to
be women
• conversion disorder- acute and generally transient and
usually involves a symptom rather than a particular disease
Course and Prognosis
• usually episodic; the episodes last from months to years and
are separated by equally long quiescent periods.
• an obvious association between exacerbations of
hypochondriacal symptoms and psychosocial stressors
• good prognosis: high socioeconomic status, treatment-
responsive anxiety or depression, sudden onset of
symptoms, the absence of a personality disorder, and the
absence of a related nonpsychiatric medical condition
Treatment
• usually resist psychiatric treatment
• in a medical setting and focuses on stress reduction and
education in coping with chronic illness
• Group psychotherapy
• individual insight-oriented psychotherapy, behavior
therapy, cognitive therapy, and hypnosis may be useful
• frequent, regularly scheduled physical examinations
• Invasive diagnostic and therapeutic procedures should only
be undertaken, however, when objective evidence calls for
them
• Pharmacotherapy - anxiety disorder or MDD
Illness anxiety disorder
— applies to those persons who are preoccupied with being
sick or with developing a disease of some kind
— a variant of somatic symptom disorder (hypochondriasis)
— somatic symptom disorder is diagnosed when somatic
symptoms are present, whereas in illness anxiety disorder,
there are few or no somatic symptoms and persons are
"primarily concerned with the idea they are ill."
— may also be used for persons who do, in fact, have a
medical illness but whose anxiety is out of proportion to
their diagnosis and who assume the worst possible
outcome imaginable
TRANSCRIBERS Group 6
EXIMIUS
2021
Epidemiology
— prevalence is unknown aside from using data that
relate to hypochondriasis
— prevalence of 4 to 6 percent in a general
medical clinic population
— diagnosed more frequently in older rather than
younger persons
— no evidence to date that the diagnosis is more
common among different races or that gender,
social position, education level, and marital status
affect the diagnosis
Etiology
— Unknown
— social learning model described for somatic
symptom disorder may apply to this disorder as
well
— the fear of illness is viewed as a request to play
the sick role
— psychodynamic school of thought is also similar
to somatic symptom disorder
DSM-5 Diagnostic Criteria for Illness Anxiety Disorder
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are
only mild in intensity. If another medical condition is
present or there is a high risk for developing a medical
condition (e.g., strong family history is present), the
preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the
individual is easily alarmed about personal health status.
D. The individual performs excessive health-related
behaviors (e.g., repeatedly checks his or her body for
signs of illness) or exhibits maladaptive avoidance (e.g.,
avoids doctor appointments and hospitals).
E. Illness preoccupation has been present for at least 6
months, but the specific illness that is feared may change
over that period of time.
F. The illness-related preoccupation is not better explained
by another mental disorder, such as somatic symptom
disorder, panic disorder, generalized disorder, body
dysmorphic disorder, obsessive-compulsive disorder, or
delusional disorder, somatic type.
Specify whether:
Care-seeking type: Medical care, including physician
visits or
undergoing tests and procedures, is frequently used.
Care-avoidant type: Medical care is rarely used.
Differential Diagnosis
• too often these patients are dismissed as "chronic
complainers" and careful medical examinations are not
performed
• patients with illness anxiety disorder usually complain
about fewer symptoms than patients with somatic
symptom disorder
3
 PSYCHOLOGY
EXIMIUS
Psychosomatic Medicine 2021
Dr. Pagaddu November 2019
• Somatic symptom disorder usually has an onset before age Common symptoms of conversion disorder
30, whereas illness anxiety disorder has a less specific age — Motor Symptoms
of onset Involuntary movements
• conversion disorder is acute, generally transient, and Tics
usually involves a symptom rather than a particular disease. Blepharospasm
• Pain disorder is chronic, but the symptoms are limited to Torticollis
complaints of pain Opisthotonos
• can also occur in patients with depressive and anxiety Seizures
disorders Abnormal gait
• patients with panic disorder may initially complain that they Falling
are affected by a disease (e.g., heart trouble Astasia-abasia
• delusional beliefs occur in schizophrenia and other Paralysis
psychotic disorders Weakness
• Obsessive-compulsive disorder by the singularity of their Aphonia
beliefs and by the absence of compulsive behavioral traits; — Sensory Deficits
but there is often an obsessive quality to the patients fear Anesthesia, especially of extremities
Midline anesthesia
Course and Prognosis Blindness
• there are no reliable data about the prognosis Tunnel vision
• usually episodic; the episodes last from months to years and Deafness
are separated by equally long quiescent periods — Visceral Symptoms
Psychogenic vomiting
• a good prognosis is associated with high socioeconomic
Pseudocyesis
status, treatment-responsive anxiety or depression, sudden
Globus hystericus
onset of symptoms, the absence of a personality disorder,
Swooning or syncope
and the absence of a related nonpsychiatric medical
Urinary retention
condition
Diarrhea
Treatment
Epidemiology
• usually resist psychiatric treatment
— W:M = 2:1 to 10:1
• although some accept this treatment if it takes place in a
— among children a higher predominance is seen in girls
medical setting and focuses on stress reduction and
— L>R side of women
education in coping with chronic illness
— Women: more likely to develop somatization disorder if
• Group psychotherapy may be of help especially if the
with conversion disorder
group is homogeneous
— Men: association exists between conversion disorder and
• Other forms of psychotherapy, such as individual insight- ASPD
oriented psychotherapy, behavior therapy, cognitive — Onset: late childhood to early adulthood; rare before 10
therapy, and hypnosis, may be useful y/o or after 35 y/o
• Invasive diagnostic and therapeutic procedures should — in children younger than 10 y/o: limited to gait problems or
only be undertaken when objective evidence calls for seizures
them. — most common: rural populations, with little education, with
• Pharmacotherapy may be of help in alleviating the anxiety low IQs, in low socioeconomic groups, and military
generated by the fear that the patient has about illness, personnel who have been exposed to combat situations
especially if it is one that is life-threatening; but it is only — commonly associated with: MDD, anxiety disorders,
ameliorative and cannot provide lasting relief schizophrenia
— increased frequency in relatives of probands with
conversion disorder
FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER (Conversion — increased risk in monozygotic, but not dizygotic, twin
disorder)
— an illness of symptoms or deficits that affect voluntary Comorbidity
motor or sensory functions, which suggest another medical • Medical and, especially, neurological disorders occur
condition, but that is judged to be caused by psychological frequently among patients with conversion disorders
factors because the illness is preceded by conflicts or other • depressive disorders, anxiety disorders, and somatization
stressors disorders ; rare: schizophrenia
— Symptoms are NOT intentionally produced, are NOT caused
• PDs : histrionic, PA
by substance use, are NOT limited to pain or sexual
symptoms, and the gain is primarily psychological and NOT
social, monetary, or legal
Etiology
— originally combined with the syndrome known as
• Psychoanalytic Factors
somatization disorder and was referred to as hysteria,
• caused by repression of unconscious intrapsychic conflict
conversion reaction, or dissociative reaction
and conversion of anxiety into a physical symptom
• conflict is between an instinctual impulse (e.g., aggression
or sexuality) and the prohibitions against its expression

TRANSCRIBERS Group 6 4
 PSYCHOLOGY
Psychosomatic Medicine
Dr. Pagaddu November 2019
• symptoms allow partial expression of the forbidden wish or
urge but disguise it, so that patients can avoid consciously
confronting their unacceptable impulses; that is, the
conversion disorder symptom has a symbolic relation to the
unconscious conflict (i.e., vaginismus protects the patient
from expressing unacceptable sexual wishes.
• allow patients to communicate that they need special
consideration and special treatment
— Learning Theory
— a conversion symptom can be seen as a piece of
classically conditioned learned behavior;
symptoms of illness, learned in childhood, as a
means of coping with an otherwise impossible
situation
— Biological Factors
— brain-imaging studies have found
hypometabolism of the dominant hemisphere
and hypermetabolism of the nondominant
hemisphere and have implicated impaired
hemispheric communication in the cause of
conversion disorder
— may be caused by an excessive cortical arousal
that sets off negative feedback loops between the
cerebral cortex and the brainstem reticular
formation
— cerebral impairments in verbal communication,
memory, vigilance, affective incongruity, and
attention
Diagnosis
• The DSM-5 limits the diagnosis of conversion disorder to
those symptoms that affect a voluntary motor or sensory
function, that is, neurological symptoms
• Physicians cannot explain the neurological symptoms
solely on the basis of any known neurological condition.
• The diagnosis of conversion disorder requires that
clinicians find a necessary and critical association
between the cause of the neurological symptoms and
psychological factors, although the symptoms cannot
result from malingering or factitious disorder.
• The diagnosis of conversion disorder also excludes
symptoms of pain and sexual dysfunction and symptoms
that occur only in somatization disorder.
• DSM-5 allows specification of the type of symptom or
deficit seen in conversion disorder, for example, with
weakness or paralysis, with abnormal movements, or
with attacks or seizures.
Clinical Features
• Most common: paralysis, blindness, and mutism
• affected patients are at risk for suicide
• Sensory Symptoms;
o Common: anesthesia and paresthesia of the
extremities
o stocking-and-glove anesthesia of the hands or
feet or the hemianesthesia of the body
o deafness, blindness, and tunnel vision
o unilateral or bilateral
o neurological evaluation reveals intact sensory
pathways
TRANSCRIBERS Group 6
EXIMIUS
2021
• Motor Symptoms
§ include abnormal movements, gait disturbance,
weakness, and paralysis
§ gross rhythmical tremors, choreiform
movements, tics, and jerks
§ movements generally worsen when attention is
called to them
§ astasia-abasia, which is a wildly ataxic, staggering
gait accompanied by gross, irregular, jerky truncal
movements and thrashing and waving arm
movements
§ reflexes remain normal, electromyography
findings are normal
• Seizure Symptoms
§ Pseudoseizures are another symptom
§ Tongue-biting, urinary incontinence, and
injuries after falling can occur in
pseudoseizures
§ Pupillary and gag reflexes are retained after
pseudoseizure, and patients have no
postseizure increase in prolactin
concentrations
• Primary Gain
§ by keeping internal conflicts outside their
awareness.
§ symptoms have symbolic value; they represent
an unconscious psychological conflict
• Secondary Gain
§ Patients accrue tangible advantages and benefits
as a result of being sick
§ being excused from obligations and difficult life
situations, receiving support and assistance that
might not otherwise be forthcoming, and
controlling other persons' behavior
• La Belle Indifference
§ a patient's inappropriately cavalier attitude
toward serious symptoms; that is, the patient
seems to be unconcerned about what appears to
be a major impairment
§ not pathonognomonic of conversion disorder
• Identification
§ may unconsciously model their symptoms on
those of someone important to them
§ i.e., during pathological grief reaction, bereaved
persons commonly have symptoms of the
deceased
Differential Diagnosis
• a thorough medical and neurological workup is essential in
all cases
• if the symptoms can be resolved by suggestion, hypnosis, or
parenteral amobarbital or lorazepam, they are probably the
result of conversion disorder
• Neurological disorders : dementia and other degenerative
diseases, brain tumors, and basal ganglia disease
• weakness may be confused with myasthenia gravis,
polymyositis, acquired myopathies, or MS
• Optic neuritis---misdiagnosed as conversion disorder
blindness
• Guillain-Barre syndrome, Creutzfeldt-Jakob disease,
periodic paralysis, and early neurological manifestations of
AIDS
• somatization disorder, hypochondriasis, pain disorder ,
sexual dysfunction, malingering and factitious disorder
5
 PSYCHOLOGY
Psychosomatic Medicine
Dr. Pagaddu November 2019
Distinctive Physical Examination Findings in Conversion Disorder
(see last page)
Course and Prognosis
• Onset is usually acute
• 95 percent of acute cases remit spontaneously, usually
within 2 weeks in hospitalized patients.
• if symptoms (+) for 6 months or longer, the prognosis for
symptom resolution is less than 50 percent and diminishes
further the longer that conversion is present
• Recurrence within 1 year of the first episode; one episode
is a predictor for future episodes
• 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
• Poor prognostic factors: tremor and seizures
Treatment
• resolution is usually spontaneous
• facilitated by insight-oriented supportive or behavior
therapy.
• most important feature of the therapy: a relationship with
a caring and confident therapist
• Hypnosis, anxiolytics, and behavioral relaxation exercises
• Parenteral amobarbital or lorazepam may be helpful
• psychoanalysis and insight-oriented psychotherapy
• brief and direct forms of short-term psychotherapy
Pain Disorder
— characterized by the presence of, and focus on, 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, which causes significant
distress or impairment, or both
— does not have to judge the pain to be inappropriate or in
excess of what would be expected
— the phenomenological and diagnostic focus is on the
importance of psychological factors and the degree of
impairment caused by the pain
— has been called somatoform pain disorder, psychogenic
pain disorder, idiopathic pain disorder, and atypical pain
disorder
— Pain disorder is diagnosed as "Unspecified Somatic
Symptom Disorder" in DSM-5 or it may be designated as a
"specifier" under that heading
Epidemiology
— The 6-month and lifetime prevalence is approximately 5
percent and 12 percent, respectively
— 3 percent of people in a general practice have persistent
pain, with at least 1 day per month of activity restriction
because of the pain
— can begin at any age
— gender ratio is unknown
— associated with other psychiatric disorders, especially
affective and anxiety disorders
— chronic pain: most frequently associated with depressive
disorders
— acute pain: more commonly associated with anxiety
disorders.
TRANSCRIBERS Group 6
EXIMIUS
2021
— depressive disorders, alcohol dependence, and chronic pain
may be more common in relatives of individuals with
chronic pain disorder
— if pain is associated with severe depression and a terminal
illness, there is an increased risk for suicide
Etiology
Psychodynamic Factors
• may be symbolically expressing an intrapsychic conflict
through the body
• if suffering from alexithymia, that is being unable to
articulate internal feeling states in words, feelings are
expressed with the body
• by displacing the problem to the body, the patients may feel
that they have a legitimate claim to the fulfillment of their
dependency needs
• the symbolic meaning of body disturbances may also relate
to atonement for perceived sin, to expiation of guilt, or to
suppressed aggression
• many patients have intractable and unresponsive pain
because they are convinced that they deserve to suffer
• defense mechanisms used by patients with pain disorder
are displacement, substitution, and repression
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
• secondary gain is most important to patients with pain
disorder
Biological Factors
• 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
• Endorphin deficiency seems to correlate with
augmentation of incoming sensory stimuli
Diagnosis and Clinical Features
• 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 judged to be significantly involved in
the pain symptoms and their ramifications
• patients with pain disorder often have long histories of
medical and surgical care
• patients often deny any other sources of emotional
dysphoria and insist that their lives are blissful except for
their pain
• 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.
• MDD is present in about 25-50%f patients with pain
disorder, and dysthymic disorder or depressive disorder
symptoms are reported in 60-100% of the patients
• most prominent depressive symptoms in patients with pain
disorder: anergia, anhedonia, decreased libido, insomnia,
and irritability; diurnal variation, weight loss, and
psychomotor retardation appear to be less common
6
 PSYCHOLOGY
EXIMIUS
Psychosomatic Medicine 2021
Dr. Pagaddu November 2019
Differential diagnosis Other Therapies
• Purely physical pain can be difficult to distinguish from o Biofeedback can be helpful in the treatment of
purely psychogenic pain, especially because the two are pain disorder, particularly with migraine pain,
not mutually exclusive myofacial pain, and muscle tension states, such as
• Physical pain fluctuates in intensity and is highly sensitive tension headaches
to emotional, cognitive, attentional, and situational o Hypnosis, transcutaneous nerve stimulation, and
influences dorsal column stimulation also have been used
• Pain that does not vary and is insensitive to any of these o Nerve blocks and surgical ablative procedures are
factors is likely to be psychogenic effective for some patients with pain disorder;
• When pain does not wax and wane and is not even but these procedures must be repeated, because
temporarily relieved by distraction or analgesics, clinicians the pain returns after 6 to 18 months
can suspect an important psychogenic component
• somatoform disorders, although some somatoform Distinctive Physical Examination Findings in Conversion Disorder
disorders can coexist.
• Hypochondriasis Condition Text Conversion Findings
Anesthesia Map Sensory loss does not conform to
• conversion disorder - generally short-lived
dermatomes recognized pattern of distribution
• Malingering
• tension headaches hemianesthesia Check midline Strict half-body split

Course and Prognosis Astasia-abasia Walking, With suggestion, those who cannot
• generally begins abruptly and increases in severity for a few dancing walk may still be able to dance;
weeks or months alteration of sensory and motor
findings with suggestion
• can often be chronic, distressful, and completely disabling
Paralysis, paresis Drop paralyzed Hand falls next to face, not on it
acute pain disorders have a more favorable prognosis than
hand onto face
chronic pain disorders
Hoover test Pressure noted in examiner's hand
• people with pain disorder who resume participation in under paralyzed leg when
regularly scheduled activities, despite the pain, have a more attempting straight leg raising
favorable prognosis than people who allow the pain to Check motor Give-away weakness
become the determining factor in their lifestyle strength
Coma Examiner Resists opening; gaze preference is
Treatment attempts to away from doctor
• the treatment approach must address rehabilitation open eyes
Ocular cephalic Eyes stare straight ahead, do not
• discuss the issue of psychological factors early in treatment maneuver move from side to side
and should frankly tell patients that such factors are Aphonia Request a Essentially normal coughing sound
important in the cause and consequences of both physical cough indicates cords are closing
and psychogenic pain Intractable sneezing Observe Short nasal grunts with little or no
• also explain how various brain circuits that are involved sneezing on inspiratory phase; little
with emotions (e.g., the limbic system) can influence the or no aerosolization of secretions:
sensory pain pathways minimal facial expression; eyes
• therapists must fully understand that the patient's open; stops when asleep; abates
when alone
experiences of pain are rea
Syncope Head up tilt test Magnitude of changes in vital signs
and venous pooling do not explain
Pharmacotheraphy continuing symptoms
• Analgesic medications do not generally benefit
• Sedatives and antianxiety agents are not especially Tunnel vision Visula fields Changing pattern on multiple
beneficial and are also subject to abuse, misuse, and examinations
adverse effects
• Antidepressants, such as tricyclics and SSRIs, are the most Profound monocular Swinging Absence of relative afferent
blindness flashlight sign pupillary defect
effective pharmacological agents
(Marcus Gunn) Sufficient vision in “bad eye”
• Amphetamine, which has analgesic effects, may benefit Binocular visual precludes plotting normal
some patients, especially when used as an adjunct to SSRIs, fields physiological blind spot in good eye
but dosages must be monitored carefully
Severe bilateral “Wiggle your Patient may begin to mimic new
Psychotheraphy blindness fingers, I'm just movements before realizing the slip
• psychodynamic psychotherapy benefits patients with pain testing
coordination”
disorder.
• first step in psychotherapy is to develop a solid therapeutic Sudden flash of Patient flinches
alliance by empathizing with the patient's suffering bright light
• Cognitive therapy has been used to alter negative thoughts “Look at your Patient does not look there
and to foster a positive attitude hand”
“Touch your Even blind patients can do this by
index fingers” proprioception

TRANSCRIBERS Group 6 7
 PSYCHOLOGY
EXIMIUS
Psychosomatic Medicine 2021
Dr. Pagaddu November 2019

TRANSCRIBERS Group 6 8