DR ZARINA ZAINAN ABIDIN

Content 1.Somatizationdisorder 2.Conversion disorder Not classified under somatoform disorder in ICD10. 3.Hypochondriasis 4.Body dysmorphic disorder 5.Pain disorder

Somatization disorder
Characterized by many somatic symptoms that cannot be explained adequately on the basis of physical or lab examinations. Onset usually before 30 years old May continue for years. (Is usually a chronic disorder)

Multiple complaints which involve multiple systems. Associated with significant distress

Diagnosis (DSM-IV-TR)
A.A history of many physical complaint beginning before age 30 & result in significant impairment in function. B. Each of the criteria must have been met. a. 4 pain symptoms: At least 4 different sites b. 2 GI symptoms c. 1 sexual symptom d. 1 pseudo-neurological symptoms

C. Either (1) or (2): (1) After appropriate investigation, each of the symptoms in (B) cannot be explained by a known medical condition. (2) When there is related medical condition, the physical complains or impairment are in excess of what would be expected from the history, PE or lab findings. D. The symptoms are not intentionally feigned or produced

Commonly associated with: Major depressive disorder Personality disorders (avoidant, paranoid Obsessive compulsive features) Substance related disorders Generalized anxiety disorder Phobias

Treatment Best treated when the patient has a single identified physician as primary caretaker. Primary physician should see patients during regularly scheduled visit Additional lab and diagnostic procedure should be avoided.

Increase patients awareness of the possibility that psychological factors are involved in the symptoms.

In psychotherapy, patients are helped to cope with their symptoms, to express underlying emotions & to develop alternative strategies for expressing their feelings.

Conversion disorder Characterized by the presence of neurological symptoms that cannot be explained by a known neurological or medical disorder.

Diagnosis A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other medical condition. B. Psychological factors are judged to be associated with the symptoms or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflict or other stressors. C. The symptoms or deficit is not intentionally produced of feigned.

D. The symptoms cannot, after appropriate investigation be fully explained by medical condition or by direct effect of substance. E. The symptoms cause clinically significant distress or impairment or warrant medical evaluation. F. The symptom is not limited to pain or sexual dysfunction, does not occur during somatization disorder.

Clinical features Paralysis, blindness & mutism are the most common symptoms. Most commonly associated with passiveaggressive, dependent, antisocial & histrionic personality disorder. Sensory symptoms: Anaesthesia, paraesthesia.

The disturbance is inconsistent with central or peripheral neurological disease. May involve organ of special sense which lead to deafness, blindness and tunnel vision May involve unilateral or bilateral motor dysfunction; but intact sensory pathway.

 Motor symptom: Abnormal movement, gait disturbances, weakness and paralysis. Movement worsen when attention is given. Pseudo-seizure: Normally, patients are less likely to bite the tongue, have urinary incontinence & injure after falling down.

Psychological symptoms in conversion disorder

Primary gain: Relief of anxiety as a result of unconscious psychological conflict. Immediate gain. Secondary gain: the patient get the benefits as a result of being sick, such as being excused from duty.

La belle indifference: the patient seems to be unconcerned about what appears to be a major impairment. Identification: The patient may unconsciously model their symptoms in those of someone important to them.

Differential diagnosis
Medical disorder Dementia Brian tumour Myasthenia gravis Polymyositis Myopathy Multiple sclerosis Optic neuritis Periodic paralysis AIDS

 Somatizationdisorder Hypochondriasis Factitious disorder Intentional producing symptom, assume sick role, no external incentives

Treatment Resolution of the conversion d/o symptom is usually spontaneous although probably facilitated by insight-oriented psychotherapy. Hypnosis, anxiolytics and relaxation exercise are effective in some cases. Psychoanalytic and insight-oriented psychotherapy is helpful.

Hypochondriasis A person preoccupation with the fear of contacting, or the belief of having, a serious disease. The fear arises when a person misinterprets bodily symptoms or functions. Result in significant distress & impair the ability to function.

Diagnosis A. Preoccupation with fears of having a serious disease based on the persons misinterpretation of bodily symptoms. B. The preoccupation persists despite appropriate medical evaluation and reassurance. C. The belief is not of delusional intensity or about body appearance.

D. It causes significant distress & impairment of function. E. The duration is at least 6 months. F. Not better accounted for by GAD, OCD, Panic, MDD, separation anxiety or other somatoform disorder.

Clinical features

Patients believe that they have a serious illness that has not yet been detected & cannot be persuaded to the contrary. May maintain to have a particular disease, as time progresses, they may transfer the belief to another disease. The conviction persist despite negative lab result. May accompanied by symptoms of depression & anxiety.

Differential diagnosis Somatizationdisorder Conversion disorder Factitious disorder

Treatment
Patient with hypochondriasis are usually resistance to psychiatric treatment. Group psychotherapy focus on stress reduction & education in coping with chronic illness. Psychosocial support & social interaction seem to reduce the patients anxiety.

 Frequent, regularly scheduled PE are useful to reassure patients that their physician are not abandoning them. Invasive procedures should only be undertaken when they are really needed.

Body dysmorphic disorder

Preoccupation with an imagined defect in appearance or an exaggerated distortion of a minimal or minor defect in physical appearance. Cause significant distress or impairment of function. It is not better accounted for by another mental disorder (ex. dissatisfaction with body shape & size in anorexia nervosa).

Treatment

Treatment with surgical or medical procedures is almost invariably unsuccessful. Serotonin specific drugs (Clomipramine & Fluoxetine) are effective in reducing symptoms in 50% if patients.

Pain disorder Pain d/o is defined as the presence of pain that is the predominant focus of clinical attention. Psychological factors play an important role in the d/o. The primary symptom is pain, in one or more sites, which is not fully accounted for by a medical or neurological condition. The symptom is associated with emotional distress or emotional impairment.

Treatment

It may not be possible to reduce the pain, the treatment approach must address rehabilitation. Clinician must discuss the issue of psychological factors early in treatment. Therapist should explain how various pain circuits that are involve with emotion (limbic system) may influence the sensory pain pathways.

Pharmacotherapy: Analgesic are not generally helpful Substance abuse & dependence are often major problems for pt receiving analgesic treatment. Sedative & anti-anxiety are frequently misuse & abuse. Anti-depressant such as TCA & SSRI are useful.

 Behavioral therapy. Hypnosis Transcutaneous nerve stimulation & dorsal column stimulation have been used. Nerve block and surgical ablation procedure are ineffective as pain returns after 6 to 18 months.

 First step is to develop a solid therapeutic alliance by empathizing with the patients suffering. A useful entry point into the emotional aspects of the pain is to examine its interpersonal ramifications in the patients life.

Cognitive therapy has been used to alter ve thoughts and to foster a +ve attitude.

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