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Somatoform Disorders

Somatoform (DSM-4) physical symptoms suggesting


a medical condition, yet the symptoms are

not fully explained by the medical disorder,
by substance use, or by another mental
Ramon S. Javier, MD  Physical symptoms are not intentionally
Department of Neurology & Psychiatry
UST Faculty of Medicine & Surgery

Somatoform Disorders Somatoform Disorders

 Pain symptoms:
 (ICD-10) repeated presentation of physical  abdominal pain
symptoms, together with persistent request  back pain
for medical investigation, although patients  joint pain
have been reassured by their physicians that  chest pain
the symptoms have no physical basis.  pains involving the extremities
 pain during menstruation
 pain during sexual intercourse
 pain during urination

Somatoform Disorders Somatoform Disorders

 Gastrointestinal symptoms:  Sexual symptoms:

 nausea  sexual indifference
 dizziness  erectile or ejaculatory dysfunction
 bloating  irregular menses
 vomiting other than during pregnancy,  excessive menstrual bleeding
diarrhea, or intolerance of several different  vomiting throughout pregnancy

Classification of Somatoform
Somatoform Disorders
Disorder (DSM-IV)
 Pseudoneurological symptoms:  Specific somatoform disorder
 Impaired coordination or balance  Somatization disorder
 Paralysis or localized weakness  Conversion disorder
 Dysphagia or lump in throat  Hypochondriasis disorder
 aphonia  Body dysmorphic disorder
 Urinary retention  Pain disorder
 Diplopia  Undifferentiated SD
 Hypoanesthesia  Somatoform disorder not otherwise
 Dissociative symptoms described

Somatization Disorders Somatization Disorders

 many somatic symptoms that cannot be
explained adequately on the basis of
physical and laboratory examinations.  combination of at least
 begins before the age of 30 4 pain symptoms
 chronic and associated with significant
 2 gastointestinal symptoms
psychological distress, impairment of social  1 sexual symptom

and occupational functioning and seek  1 pseudoneurological symptom.

excessive medical help.

Somatization Disorder Etiology:

Epidemiology Psychosocial factor

 lifetime prevalence:  psychoanalytic interpretations of

 0.1% or 0.2% symptoms rest on the hypothesis that
 5-to-1 female to male ratio the symptoms substitute for repressed
 beginning before the age 30 instinctual impulses.
 2/3 have identifiable psychiatric symptoms  behavioral perspective emphasizes that
parental teaching, parental example, and
 1/2 have mental disorder ethnic mores may teach some children to
 commonly assoc. w/ personality disorder. somatize.
 Social, cultural, and ethnic factors.

Etiology: Etiology:
Biological factor Biological factor
 Neuropsychological basis:  Cytokines:
 patients have characteristic attention and
cognitive impairments that result in faulty  help cause some of the nonspecific
perception and assessment of somatosensory symptoms of disease, especially
inputs. infection, hypersomnia, anorexia,
 Brain-imaging study: fatigue, and depression.
 decrease metabolism in the frontal lobes in the
nondominant hemisphere
 occurring in 10 to 20% of the 1st degree female

Conversion Disorder Conversion Disorder

 presence of one or more neurological  paralysis, blindness, and mutism are the
symptoms that cannot be explained by a known most common symptoms.
neurological or medical disorder.
 most commonly associated with passive-
 psychological factors be associated with the
initiation or exacerbation of the symptoms. aggressive, dependent, antisocial, and
 symptom of deficit is not intentionally produced.
histrionic personality disorders.
 symptom or deficit causes significant distress  sensory sx. - anesthesia and paresthesia
or impairment to social, occupational and other  motor sx. - abnormal movements, gait
important areas. disturbances, weakness and paralysis.

Conversion Disorder Etiology:

Epidemiology Psychological factors
 lifetime prevalence:  Repression of unconscious intrapsychic
 22 per 100,000 population conflict and conversion of anxiety into
 most common in adolescent physical symptom.
 ratio of women to men - 5 to 1  Symptoms allow partial expression of
the forbidden wish or urge but disguise it
 in men usually occupational or military
to avoid consciously confronting there
unacceptable impulse.
 most common among rural pop.

Etiology: Hypochondriasis Disorders
Biological factors (DSM-IV)
 Brain-imaging  Preoccupation with the fear of contracting,
or the belief of having a serious disease.
 hypometabolism of the dominant hemisphere
 Usually abdominal complaints.
and hypermetabolism of the dominant
hemisphere.  Unrealistic or inaccurate interpretations of
 Impaired hemispheric communication. physical symptoms or sensations.
 Excessive cortical arousal - sets off negative  No known medical cause.
feedback loops between the cerebral cortex  Preoccupation result in significant distress
and brainstem reticular formation.
and impair their ability to function.

Hypochondriasis Disorder Etiology:

Epidemiology Hypochondriasis

 prevalence:  symptoms reflect a misinterpretation of bodily

 4 to 6% in a general medical clinic symptoms.
population.  request for admission to the sick role made by
a person facing seemingly insurmountable
 occurs at any age > 20 - 30 yrs. and insolvable problems.
 men and women equally affected  coexisting with depression and anxiety
 social position, education level, and disorder,
marital status do not appear to affect the  aggression and hostile wishes are transferred
diagnosis. into physical complaints

Body Dysmorphic Disorder Body Dysmorphic Disorder

(DSM-IV) Epidemiology

 Preoccupation with an imagined defect or  most common age of onset - 15 - 20 yrs.

exaggerated distortion of a minimal or  women are often affected than men
minor defect in physical appearance.  affected patient likely unmarried.
 Preoccupation causes clinically significant  commonly coexist with mental disorders.
distress or impairment in social,  90% experience major depression.
occupational, or other important areas of  70% - anxiety disorder.
 30% - psychotic disorder.
 Preoccupation is not better accounted for
by another mental disorder.

Etiology: Body Dysmorphic Disorder:
Body Dysmorphic Disorder Common location of imaging defects.

 unknown  hair - 63%

 due to high comorbidity with depressive  nose - 50%
disorder serotonin neurotransmitter maybe
involved.  skin - 50%
 psychodynamic models - displacement of  eyes - 27%
sexual or emotional conflict into a  head, face - 20%
nonrelated body part.
 overall body build - 17%
 lips - 17%

Pain Disorder Pain Disorder

(DSM-IV) Epidemiology

 Pain in one or more anatomical sites is the  more common in women.

predominant focus of the clinical presentation  peak ages of onset - 4th and 5th decades
and is of sufficient severity to warrant clinical  most common in blue collared occupation
 Causes significant distress or impairment in  genetic inheritance or behavioral mechanisms
social, occupational or other important areas of are possibly involved in the transmission.
functioning.  assoc. with depressive, anxiety and substance
 Psychological factor plays an important role in abuse disorders.
the onset, severity, exacerbation, or
maintenance of the pain.

Pain Disorder Pain Disorder

Etiology:Psychosocial factor Etiology: Biological factor
 Symbolic expression of intrapsychic conflict
through the body.  Neurotransmitter serotonin maybe
 Unconscious regard of emotional pain as involved in the descending inhibitory
weak and somewhat lacking in legitimacy. pathway for pain.
 Atonement to perceived sin, to expiation of  Role of endorphins in the modulation of
guilt, or to suppressed aggression. pain.
 Means to obtain love.
 Means of manipulation and gaining advantage
in interpersonal relationship.