SOMATOFORM DISORDERS

Maria L.A. Tiamson, MD

Asst. Professor, Psychiatry
New York Medical College

SOMATIZATION, the concept

Poorly understoodcrocks..turkeys..
hysterics..worried well
the tendency to express and communicate
psychological distress in the form of
somatic symptoms for which they seek
medical help
one of medicines blind spots

Psychosomatic Illnesses

Asthma
Ulcerative colitis
Rheumatoid arthritis
Eczematous disorders
Irritable bowel syndrome

Forms of Somatization
Medically unexplained symptoms
Hypochondriacal somatization
Somatic presentation of psychiatric
disorders (ie., depressive equivalents)

Most common presenting

symptoms

Abdominal pain
chest pain
dyspnea
headache
fatigue

Cough
back pain
nervousness
dizziness

Infectious Diseases

Lyme disease
AIDS
Infectious mononucleosis
Syphilis
Chronic Fatigue Syndrome
Post-infection syndromes

SOMATIZATION, the cost

10% of total direct healthcare costs with the

potential to bankrupt the healthcare financing
system
Somatizers have 9x more total charges, 6x
more hospital charges, 14x more MD services
Somatizers are sick in bed an average of 7
days a month vs. 0.48 days for the general
population

SOMATIC COMPLAINTS

Patients who experience their symptoms but

do not deliberately produce them
(SOMATOFORM DISORDERS)
Patients who knowingly create symptoms in
themselves, either for material gain
(MALINGERING), or for more subtle
benefits, such as gratification of the patient
role (FACTITIOUS DISORDERS)

Pathophysiological Mechanisms

Physiological Mechanisms

autonomic arousal
muscle tension
hyperventilation
vascular changes
cerebral information processing
physiological effects of inactivity
sleep disturbance

Pathophysiological Mechanisms

Psychological Mechanisms

perceptual factors
beliefs
mood
personality factors

Interpersonal Mechanisms
reinforcing actions of relatives and friends
health care system
disability system

DSM-IV Somatoform Disorders

A group of disorders that include medical
symptoms and complaints FOR WHICH
AN ADEQUATE MEDICAL
EXPLANATION CANNOT BE FOUND.
Not intentionally produced
Onset, severity and duration of symptoms
are strongly linked to psychological factors

DSM-IV Somatoform Disorders

Somatization Disorder
Conversion Disorder
Hypochondriasis
Body Dysmorphic Disorder
Somatoform Pain Disorder
Undifferentiated Somatoform Disorder
Somatoform Disorder, NOS

Somatization Disorder

hysteria, Briquets Syndrome

multiplicity of somatic complaints
involving multiple organ systems
female predominance
before age 30
chronic
excessive medical help-seeking behavior

Somatization Disorder
Cannot be fully explained by any known
GMC or substance use
if GMC is present, physical complaints or
impairment are in excess of what could be
expected
significant impairment in functioning

Somatization Disorder
Four pain symptoms
One sexual symptom
One pseudoneurological symptom
Two GI symptoms

Somatization Disorder

Complaints described in colorfiul,

exaggerated terms but lack specific factual
information
prominent anxiety and depressive symptoms
10-20% female 1st degree relatives of SD
women, increased ASPD and SUD in male
rrelatives

Conversion Disorder

Monosymptomatic (one or more neurological

symptoms)
Most common in

adolescents, young adults

rural populations
low education and low IQ
low socioeconomic group
military personnel exposed to combat

Conversion Disorder
Symptom has a symbolic relation to the
unconscious conflict
la belle indifference

Conversion Disorder

Impaired coordination, balance

paralysis, weakness
aphonia, difficulty swallowing, lump in the
throat
urinary retention
loss of touch/pain, double vision, blindness
deafness, seizures

Conversion Disorder
Symptoms do not conform to known
anatomical pathways and physiological
mechanisms
often inconsistent
DDX: multiple sclerosis, myasthenia gravis,
dystonias

Conversion Disorder
Dramatic or histrionic
suggestible
sx are self-limited and do not lead to
physical changes/disability
associated with dissociative disorders,
MDD, histrionic, antisocial and dependent
personality disorders

Hypochondriasis
Preoccupation with the fear of contracting,
or the belief of having, a serious disease
Usually with co-morbid depression, anxiety
Misinterpretation of physical symptoms and
sensations
Request for admission to the sick role,
which offers an escape

Hypochondriasis

Preoccupation is with any of the ff: bodily

functions, minor physical abnormalities, vague
and ambiguous physical sensations
medical history is presented in great detail and
length
doctor shopping
associated with serious illness in childhood, past
experience with disease in a family member

Body Dysmorphic Disorder

Preoccupation with an imagined defect or
an exaggerated distortion of a minimal or
minor defect in physical appearance
dysmorphophobia
Comorbid with major depression (90%),
anxiety disorder (70%), psychotic disorder
(30%)

Body Dysmorphic Disorder

Marked distress over supposed deformity

frequent mirror checking and checking in
other reflecting surfaces
excessive grooming behavior
use of special lighting or magnifying
glasses
avoidance of usual activities

Somatoform Pain Disorder

Presence of pain that is the predominant

focus of clinical attention
Not fully accounted by a nonpsychiatric
medical or neurological condition
The symbolic meaning of body disturbances
relate to atonement for perceived sin, to
expiation of guilt, or to suppressed
aggression

Nonspecific Somatoform
Disorders

Undifferentiated somatoform disorder

unexplained physical effects that last for at least
six months

Somatoform Disorder, NOS

residual category

Relation of Depression and

Somatization
Patients with SD have a high prevalence of
depression (48-94%)
Patients with MDD have substantial levels
of somatization (63-84%)
Depression can be treated successfully
when it coexists with SD

Smith, 1992

Relation of Depression and Pain

Patients with chronic pain have a significant
current prevalence of depressive disorders
More than half of patients with MDD
complain of pain
Pain is reduced with the treatment of
depression

Smith, 1992

Baron Karl Friedrich

Hieronymus
von Munchausen

Factitious Disorders

Psychological symptoms
Physical symptoms
Munchausens syndrome, pseudologica
fantastica, peregrination
usually co-morbid with psychiatric conditions
intentional production of symptoms but goal
is intangible and psychologically complex

ALERTALERTALERT...

Numerous surgical scars, usually in the

abdominal area
Patient is truculent and evasive
Personal and medical history were fraught with
acute and harrowing adventures
History of many hospitalizations, malpractice
claims, insurance claims
Involved in the healthcare profession

Symptom Types
Total fabrications
Exaggerations
Simulations of the disease
Self-induced disease

A Physical Diagnosis is more

likely if.

Symptoms do not meet DSM-IV criteria.

Premorbid social history is unremarkable.
There is an ABRUPT change in personality,
mood, or ability to function.
There are RAPID fluctuations in mental status.
There is lack of response to usual biologic or
psychologic interventions.

Principles of Management

Emphasize explanation
Arrange for regular follow-up
Treat mood/anxiety disorder
Minimize polypharmacy and multiple
diagnostic tests
Provide specific treatment when indicated

Remember.
Reassurance that nothing is wrong does
NOT help.
The patient does not want symptom relief
but rather a RELATIONSHIP and
understanding.
Little is to be gained by saying that its all
in your head.

Remember...
You should acknowledge the patients
plight, avoid challenging the patient.
A positive organic diagnosis will not cure
the patient.
SOMATIZATION MAY CO-EXIST WITH
ANY PHYSICAL ILLNESS AND MAY
INITIALLY MASK THE ILLNESS.

Malingering

Intentional fabrication of symptoms to

achieve a secondary gain, usually material
benefits