Case example

D, a ten-year-old, arrived in the eye clinic complaining his vision was deteriorating. He was a bright boy and his family looked worried. He had thorough medical assessments, and was found to have reduced distance vision (6/18 in both eyes). No medical cause for this sight loss was found.
He attended the eye clinic with his mother and father. It transpired his parents were divorced and had remarried. D lived with the stepfather he did not care for, and a new baby half-sister. Towards the end of the consultation, the mother volunteered that her father had a neurological disease. On airing these difficult emotional issues, D then said I see better. He left the clinic with his vision normal and ageappropriate.
1

OUTLINE
Somatoform disorder - Pain disorder - Undifferentiated somatoform disorder - Somatoform disorder not otherwise specific (NOS)

Psychosomatic disorder
By: Siti Nurulismah
2

PAIN DISORDER
Definition: Preoccupation with pain in the absence of physical disease. The pain doesnt follow a neuroanatomic distribution. [1]
Epidemiology: 1 month prevalence is 0.15-1.26%, >Female [2]

behavioral

Pain can escape from dislike activity

interpersonal Etiology biological

Pain stabilize relationship

Pain threshold

psychodynamics

Emotional pain body pain

4

DSM IV diagnostic criteria for pain disorder

A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. D. The symptom or deficit is not intentionally produced or feigned. E. The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria for Dyspareunia.
5

Treatment:
Antidepressant Analgesia Psychoeducation Cognitive behavioral therapy Massage

Biological

Psychosocial

UNDIFFERENTIATED SOMATOFORM DISORDER

D S M I V
7

SOMATOFORM DISORDER NOS

Cannot be classified in any category
Duration is <6 months Examples:
- Pseudocyesis - Fatigue or body weakness in less than 6 months and not due to other mental illness

PSYCHOSOMATIC DISORDER
Definition Psyche (mind) & Soma (body) Prevalence 12.5% [3]

Treatment

Etiology

Classification

Diagnosis

1. Psychological factor medical condition 2. Physical illness emotional/ mental disorder

9

Physical condition affected by psychological factors

Hypertension
- Psychological theories: inhibit anger, guilt over hostile impulse, need to gain approval from authority - Acute stress, chronic stress - Hormonal changes

10

Medical problems that present with psychiatric symptoms

Disease

Psychiatric symptoms

Impaired performance and behavior Dementia Myxedema madness; Delusional Paranoid Aggressive behavior Inability to function during attack

AIDS Hypothyroidism

Depression Anxiety Thought disorder Somatic delusion Hallucinations

Pheochromocytoma

Anxiety Panic Trembling

11

Diagnosis
DSM IV criteria for psychological factor affecting medical condition:

12

 Examples:
- MDD delaying recovery from MI - Anxiety exacerbating asthma - Pathological denial of the need of surgery in cancer patient - Stress related exacerbation of ulcer

13

Etiology
B. Neurotransmitter response Catecolamines, serotonin, dopamine

A. Stress factors Prolonged stress + organ that genetically vulnerable to stress

C. Endocrine response Cortisol

D. Immune response Cytokines increase glucocorticoids

E. Physiological factors General adaption syndrome; stress affect HPA axis

14

Treatment
Collaborative approach Biological Psychosocial
Supportive psychotherapy Dynamic insight oriented psychotherapy Group therapy Family therapy Cognitive behavioral therapy

15

Case example
D, a ten-year-old, arrived in the eye clinic complaining his vision was deteriorating. He was a bright boy and his family looked worried. He had thorough medical assessments, and was found to have reduced distance vision (6/18 in both eyes). No medical cause for this sight loss was found.
He attended the eye clinic with his mother and father. It transpired his parents were divorced and had remarried. D lived with the stepfather he did not care for, and a new baby half-sister. Towards the end of the consultation, the mother volunteered that her father had a neurological disease. On airing these difficult emotional issues, D then said I see better. He left the clinic with his vision normal and ageappropriate.
16

SUMMARY
Pain disorder
- Preoccupation with pain in the absence of physical disease. Biological - Treatment
Psychosocial

Undifferentiated somatoform disorder (6 months) vs. somatoform disorder NOS (<6 months)

Psychosomatic disorder
Mind & body

17

References:
1. KAPLAN & SADOCK; Pocket Handbook of Clinical Psychiatry 5th Edition

2.

LIU, L., BI, B., QIN, X., WEI, S., WANG, W., LI, Y., JIN, Q., AI, L., PHILLIPS, M. R. & DONG, G. 2012. The prevalence of somatoform disorders in internal medicine outpatient departments of 23 general hospitals in Shenyang, China. General Hospital Psychiatry
HIDAYAT, D., INGKIRIWANG, E., ANDRI, A., ASNAWI, E., WIDYA, R. S. & SUSANTO, D. H. 2011. The Usage of Two Minutes Method (M2M) to Determine Mental Disorder Prevalence in Primary Care. Journal of the Indonesian Medical Association, 60. DSM IV TR

3.

4.

THANK YOU
18