SOMATOFORM DISORDERS

CHAIRPERSONS:-
PROFESSOR DR.T. KUMANAN MD DPM

ASST PROFESSOR DR. SHANMUGAPRIYA MD

PRESENTOR DR.D. GOTHANDARAMAN 3rd YEAR PG

INTRODUCTION
• Universal tendency to experience and communicate
psychological distress in form of physical symptoms and seek
medical attention for these symptoms.

• Often these symptoms are poorly explained and are associated

with increased medical visits, unnecessary medical tests and
procedures resulting in iatrogenic complications.

• Most distinctive characteristic of patients with somatic

symptom disorders isn’t symptoms patients complain about
but the way in which they present with and interpret them.
HISTORY
• Ancient origin but waxed and waned periodically.

• Thomas Sydenham attributed pain, convulsions, diarrhea and dropsy

due to disturbance of mind.

• Michel Foucault included hysteria and hypochondria among four

classic syndromes in psychopathology

• German Berrios- “History of mental symptoms”, discarded somatic

symptoms as nonspecific.

• Kurt Schneider- somatically labile/somatopaths individuals

completely focused their attention on their bodies, fatigued easily and
suffered from somatic symptoms.
• Karl Jaspers- Majority of physical suffering is due to psychological
reflection and not due to manifested physical disease.

• Eugene Bleuler- Somatic phenomena considered to be outside

endogenous realm

• Henry Ey viewed hysteria as somatic hyper expressivity of

unconscious ideas, images and affects.

• Juan Jose Lopez Ibor proposed antidepressant treatments as

early in 1960s to somatic component of anxiety and depression.

• Pierre Briquet- Syndrome with multiple motor and sensory

symptoms which led to separation of somatization from
conversion phenomena.
• Wilhelm Stekel- Somatization as bodily expression of a deep somatic
neurosis.

• Lipowski- Somatization as tendency to experience, conceptualize or

communicate psychological states or contents as body sensations,
functional changes or somatic metaphors.

• St. Louis criteria - To diagnose hysteria presence of atleast 15 individual

symptoms distributed over atleast nine of ten groups of possible
symptoms.

• Feighner criteria - Threshold for hysteria diagnosis increased to atleast

25 symptoms distributed in nine of ten possible groups and also
required should start prior to age of 30 years.

• Robert Spitzer- Coined “somatoform” to group among research

diagnostic criteria (RDC) and published in DSM III.
 SOMATOFORM DISORDER IS DSM 5 AND ICD 10
DSM-5 ICD-10
Somatic symptom disorder Somatization disorder, undifferentiated
somatoform disorder, persistent
somatoform pain disorder

Conversion disorder (functional

Dissociative (conversion)
neurological symptom disorder) 
Illness anxiety disorder Hypochondriacal disorder

Factitious disorder
Somatoform disorder NEC Somatoform autonomic dysfunction,
other somatoform disorders, somatoform
disorder unspecified.
Psychological factors affecting
another medical condition
COMPARATIVE NOSOLOGY
• Conversion reaction in DSM-I (1951) and hysterical neurosis
conversion type in DSM-II (1968).
• DSM-III established somatization disorder as direct descendant
of hysteria/Briquet syndrome.
• DSM-III included briquet’s hysteria as somatization disorder
and hysterical conversion as conversion disorder.
• In DSM-IV to qualify as symptoms of somatoform disorder
somatic symptoms should remain medically unexplained
although exaggerations of ordinarily expected symptoms of
coexisting physical disease also considered in symptom count.
• DSM-III-R recognized factitious disorder with physical
symptoms and factitious disorder with psychological
symptoms.
• DSM-IV defined single category factitious disorder with three
types with predominantly psychological signs and symptoms,
with predominantly physical signs and symptoms and with
combined psychological and physical signs and symptoms.

• In DSM-III pain disorder as psychogenic pain, DSM-III R as

somatoform pain disorder, DSM-IV as pain disorder.

• In DSM-5 somatic symptom and related disorders was

introduced.

• DSM-5 added attitudinal and behavioral requirements and no

longer requires symptoms be medically unexplained.

• Pain disorder in DSM-V is considered as specifier in somatoform

disorder.
• DSM-5 recognized factitious disorder by proxy by dividing
general category of factitious disorders into factitious disorder
imposed on self and factitious disorder imposed on another.

• In DSM-V hypochondriasis is renamed as illness anxiety

disorder.

• Body dysmorphic disorder in DSM-IV moved to OCD in DSM-V.

• Factitious disorder and psychological factors affecting other

medical condition included in DSM-V.
Functional Somatic Syndromes across Medical Specialties
 Absence of gold standard against which a specific diagnosis can
be confirmed or ruled out.

 No consistent explanation emanating from physical and

laboratory assessments.

 Absence of clearly articulated pathophysiology.

 Simultaneous presence of multiple unexplained physical

symptoms originating from several different organ systems.

 Higher levels of psychiatric symptoms and comorbidities and

comparable responses to psychological and pharmacologic
interventions.
SOMATIC SYMPTOM DISORDER
• DSM-5 - Present with one or more somatic complaints that result
in significant functional impairment and must be anxious about
their symptoms or preoccupied with them.

• In ICD-10- No evidence for underlying medical cause for disorder

and DSM-5 doesn’t require.

• DSM 5 specifies symptoms must be present for at least 6 months

but transient manifestations can occur.
• Subjective symptoms – (e.g. pains and paraesthesia)

• Objective symptoms- (e.g. haematuria and icterus)

• Provoked findings - symptoms or signs (e.g. soreness

resulting from pressure or sensory impairment ).

• EPIDEMIOLOGY- Prevalence of 4-6%. Men and women are

equally affected. Commonly occurs in age group 20-30 years.
ETIOLOGY
• Multifactorial including biological, physiological, psychological,
social, cultural and iatrogenic factor.

• Patients augment and amplify their somatic sensations, have low

thresholds and low tolerance of physical discomfort.

• Focus on bodily sensations, misinterpret them and become

alarmed by them because of faulty cognitive scheme.

• Somatic presentations of mental disorders are conceptualized

using biopsychosocial model.
• Environmental and cultural factors - Idiopathic physical
symptoms common among individuals from lower
socioeconomic status, patients from developing countries and
certain ethnic groups.
• Ataque de nervios among Puerto Ricans - Ataques typically
occur immediately after or within a day of stressor.
• Symptoms of ataque are dramatic including emotional and
physical symptoms such as screaming uncontrollably, crying,
trembling, nervousness, anger, violence and breaking things.
• Seen in cultural and social frames where psychological suffering
is considered more stigmatizing than medical disorders.
• Social learning model - symptoms are viewed as request for
admission to sick role made by a person facing seemingly
insurmountable and insolvable problems.
• Sick role offers an escape that allows a patient to avoid noxious
obligations, to postpone unwelcome challenges and to be
excused from usual duties and obligations.
• Psychological theories - medically unexplained physical
symptoms develop as a reaction to repression of unacceptable
wishes or instinctual impulses and internal psychic conflicts.
• Defence against feeling of emptiness individual becomes
directed on outside world and on physical stimuli.
• Biological factors- Neurophysiological dysfunction in attention
process. Reduced corticofugal inhibition in diencephalon and
brainstem of afferent bodily stimuli resulting in insufficient filtering of
irrelevant bodily stimuli.

• Hypersensitivity of limbic system towards bodily stimuli.

• Stimulus entrapment - individual becomes addicted to stimuli to his or

her thought that are aggressive and hostile wishes toward others are
transferred (through repression and displacement) into physical
complaints.

• Somatoform disorder viewed as defense against guilt, sense of innate

badness, low self esteem and excessive self concern.
• Course of somatic symptom disorder is episodic.

• Episodes last from months to years and separated by long

quiescent periods.

• Association between exacerbations of somatic symptoms and

psychosocial stressors is present.

• Good prognosis - high socioeconomic status, treatment

responsive anxiety or depression, sudden onset of symptoms,
absence of a personality disorder, absence of childhood
adversity and absence of a related nonpsychiatric medical
condition.
 SOMATIC SYMPTOM DISORDER SOMATIZATION DISORDER
(DSM-5) (ICD-10)
 
Duration ≥6 months ≥2 years

Symptoms Preoccupied with symptoms and Recurring symptoms

their potential seriousness.
Frequently change symptoms
Anxious about symptoms and Prolonged involvement with
medical system
health
Higher use of healthcare
Increased time and energy
services
devoted to symptoms

Distress or impairment Social, interpersonal and familial

Psychosocial impact disruption

With predominant pain

Symptom specifiers
DIFFERENTIAL DIAGNOSIS
• Somatic symptom disorder from nonpsychiatric medical
conditions.

• Somatic symptom disorder is differentiated from illness anxiety

disorder by emphasis on fear of having a disease rather than a
concern about many symptoms.

• Patients with body dysmorphic disorder wish to appear normal

but believe that others notice that they aren’t whereas patients
with somatic symptom disorder seek out attention for their
presumed disease.

• Somatic symptom disorder is distinguished from factitious

disorder and malingering by patients with somatic symptom
disorder experience and don’t simulate the symptoms they
report.
ASSESSMENT
• Before the meeting with the patient Review medical records
and other relevant material.
• Examination
• Attitude towards referral and treatment. Physical complaints
- Chronology, intensity, provoking / relieving factors.
• Triggering factors - Physical trauma or disease, Psychosocial
stressors.
• Current and previous emotional and behavioural complaints.
Social, funtional level, strain and coping.
• Patient’s illness belief and perception of symptoms.
Expectations to treatment and investigation –
Physical/Psychiatric.
• Past medical, surgical and psychological history. Physical
examination. Diagnostic tests if not already done.
TREATMENT
TERM MODEL

• Understanding- Full history of symptoms, explore emotional

clues, enquire directly about symptoms of anxiety and
depression, life events, stress and other external factors, explore
functional level, health beliefs, expectations to treatment,
focused physical examination.

• Physician’s expertise and acknowledgement of illness- Provide

feedback on results of physical examination, acknowledge reality
of symptoms, make it clear that there is no indication for further
examination of nonpsychiatric treatment.
• Negotiating a new model of understanding

 Simple explanations- Physical symptoms are common

reactions, depression lowers threshold of pain, muscular
tension in anxiety and nervousness causes pain.
 Demonstrations- Practical establishment of association
between physical discomfort, emotional reactions and life
events.
 Severe cases- known phenomenon with somatization, cause is
unknown, nothing indicates a hidden physical disease,
individual symptom coping and reactions determine one’s
future well being.
• Negotiating further treatment- Sum up agreements made during
consultation, agree on specific objectives, contents and form for
future course.

 Acute cases: no further appointments.

 Subacute cases: therapy sessions, regular scheduled
appointments.
 Chronic: Status consultation, regular scheduled appointments.
 Consider referral to psychiatrist, psychologist or specialist
service.
SMITH’S CONSULTATION LETTER
• Richard Smith and colleagues at the University of Arkansas.

• Brief “consultation letter” for primary care physicians providing

with “do’s and don’ts” regarding their encounters with patients
with multiple medically unexplained physical symptoms and
briefly instructing them on key management techniques.

• Patients didn’t show significant change in somatic symptom

relief their functional capacity improved significantly and
decrease utilization of health resources that generated
significant cost savings.
CBT
• Cognitive behavioural therapy is the best documented and widely used
therapy. CBT helps to modify thoughts and behaviour associated with
somatization.

 Goal setting - realistic in light of patient’s illness and framework of

therapy.
 Engagement and motivation -systematically engaging patients in
therapy. Discuss illnesses have emotional component and
psychological treatment focusing on emotional component is often
helpful in reducing suffering.
 Psychoeducation- Patient are taught about somatoform disorders and
about body’s normal reactions to stress and how stress expressed in
physical symptoms.
 Physical symptoms and symptom attribution – clarify patient’s
dysfunctional automatic thoughts and basic beliefs about
illness and symptoms.

 Behaviour and coping- tested in patient by homework and at

next session effect is explored. It is important to go slowly for
patient to experience success.

 Links between symptoms and stressors - Patients are unaware

of their patterns of reaction but can be established by careful
registration of variations in symptom intensity and relating to
them.
  Family and social network - Create an alliance with family
to make sure they support the patient and not counteract
therapy.

 Treatment and help seeking behaviour and physicians

handling.

• Group psychotherapy benefits patients because it provides

social support and social interaction that reduce their anxiety.

• Individual insight-oriented psychotherapy.

PHARMACOTHERAPY
 Pharmacotherapy alleviates somatic symptom disorder only
when a patient has an underlying drug responsive condition
such as coexisting anxiety disorder or depressive disorder.

 Antidepressants are the first choice medication and tricyclic

antidepressants are most effective.

 Lower dosage is usually recommended and dosage is increased

gradually in order to avoid side effects.

 Benzodiazepines avoided.
ILLNESS ANXIETY DISORDER
• Patients are preoccupied with false belief that they have or will
develop a severe disease in the presence of few physical signs or
symptoms.

• Convictions persist despite negative laboratory results, benign course

of alleged disease and appropriate reassurances from physicians.

• Essential features- fear of disease, disease conviction, bodily

preoccupation, somatic symptoms, reassurance seeking.

• Associated features- fear of aging and death, overvaluation of

health, low self esteem and sense of vulnerability to illness.
• Addicted to internet searches about their feared illness and seek
excessive reassurance about their health.

• Preoccupation with illness interferes with their interaction with

family, friends and coworkers.

EPIDEMIOLOGY
• Prevalence of 4-6 percent and more frequently in older >
younger persons.
 ILLNESS ANXIETY DISORDER HYPOCHONDRIACAL
(DSM-5) DISORDER (ICD-10)
Duration ≥6 months -
Symptoms Preoccupied with having or Preoccupied with having a
getting a serious illness serious medical illness
without good reason. Anxiety
Anxious about belief Somatic complaints
Excess health related Concerns about
behaviors related to belief appearance
(care seeking), maladaptive Distressed
behaviors or avoidance
behaviors
Body dysmorphic disorder
is included as subtype
ETIOLOGY
• Personality- Positive correlation between neuroticism and
hypochondriacal concerns present.

• Persons with neuroticism are prone to find bodily sensations

noxious and interpret them as signs of serious illness.

• Developmental factors - early adversity, childhood experience of

illness, over solicitous parents create a sense of physical
vulnerability in susceptible individuals.

• Children model exaggerated illness behaviour displayed by

parents.
• Life events- Events involving illness and death have specific
role as symptoms of hypochondriacal patients resemble
those of been ill or died.

• Cognitive and perceptual factors- Faulty attribution of

innocuous sensations is central defect and focus attention
on amplifying symptoms.

• Misinterpretation arise from cognitive schemata with earlier

experience of illness.

• Have constitutionally lowered threshold for physical

symptoms or have heightened attentional focus and
increased physiological arousal.
• Interpersonal factors- Form of care eliciting behaviour with
expression in physical complaints.

• Through unexplained somatic symptoms and expressions of

illness worry patients seek emotional and interpersonal support
from family members and physicians.

• Social and cultural factors- Somatic distress gains attention of

family and community since it signals impairment in functioning.

• Individuals socially isolated or lacking social support manifest

care eliciting behaviour resulting in hypochondriasis.
• Social learning model - fear of illness viewed as request to play
sick role by facing insurmountable and insolvable problems. Sick
role offers escape for patient to be excused from usual duties
and obligations.

• Psychodynamic theory - Aggressive and hostile wishes toward

others are transferred into minor physical complaints or fear of
physical illness.

• Fear of illness is a defense against guilt, sense of innate badness,

expression of low self esteem and sign of excessive self concern.

• Feared illness seen as punishment for past either real or

imaginary wrongdoing.
MEASURES FOR ASSESSMENT OF HYPOCHONDRIASIS

SELF RATED QUESTIONNAIRES

• Whiteley index.
• Illness worry scale.
• Illness attitude scales.
• Health anxiety questionnaire.
• Health anxiety inventory.
• Multidimensional inventory of hypochondriacal traits.
• Psychiatric diagnostic screening questionnaire.
STRUCTURED INTERVIEWS
• Structured diagnostic interview for hypochondriasis.
• Structured clinical interview for DSM IV.
• Composite international diagnostic interview.
• Schedules for clinical assessment in neuropsychiatry.

• Chronic fluctuating course in hypochondriasis.

• Good prognosis with high socioeconomic status, treatment

responsive anxiety or depression, sudden onset of symptoms,
absence of personality disorder and absence of related
nonpsychiatric medical condition.
DIFFERENTIAL DIAGNOSIS
• Illness anxiety disorder and somatic symptom disorder are
differentiated by emphasis on fear of having a disease versus
emphasis on concern about many symptoms.
• Conversion disorder- acute, transient and involves a symptom
rather than a particular disease. La belle indifference is seen
instead of anxiety.
• If patients meet full diagnostic criteria for both illness anxiety
disorder and MDD or GAD patients are diagnosed with both
diagnoses.
• Illness anxiety disorder differentiated from OCD by singularity of
their beliefs and absence of compulsion but there is often an
obsessive quality to patient’s fear.
TREATMENT
MANAGEMENT STRATEGIES FOR HYPOCHONDRIASIS

 Legitimize patient’s symptoms.

 Establish regular schedule of visits.
 Base diagnostic evaluation on objective findings.
 Approach treatment of physical symptoms cautiously.
 Provide a plausible explanation for symptoms.
 Establish a goal of improved functioning.
NON PHARMACOLOGICAL
CBT
• Superior than other psychotherapy in illness anxiety disorder.

 Identifying and challenging dysfunctional thoughts and

formulating realistic beliefs.
 Behavioural procedures involve exposure in vivo with response
prevention. Exposure to feared internal and external stimuli and
prevention of checking and reassurance seeking behaviours.

• Group therapy, individual insight oriented therapy and hypnosis.

PHARMACOLOGICAL
• Pharmacotherapy helpful in alleviating anxiety generated by fear
about illness but only ameliorative and can’t provide lasting
relief.

• Patients with secondary hypochondriasis respond to treatment

for primary disorder.

• After completion of treatment significant reduction in concerns

whose anxiety symptoms had improved with treatment.

• In addition to CBT, fluoxetine conferred a slight added benefit.

CONVERSION DISORDER (FUNCTIONAL NEUROLOGIC
SYMPTOM DISORDER)

• Patients present with symptoms appearing to be neurologic

condition but are incompatible with neurologic conditions.

• Often illness is preceded by conflicts or stressors and associated

with psychological factors.

• Individuals with conversion disorder doesn’t intentionally

produce symptoms or deficits.
EPIDEMIOLOGY
• Prevalence is 5-15 percent of psychiatric consultations in a general
hospital.

• Women to men ratio is from 2:1 to 10:1. Among childrens higher

predominance in girls. Symptoms common on left > right side of
body in women.

• Onset is from late childhood to early adulthood and rare before 10

years of age or after 35 years of age.

• Conversion disorder is common among rural populations, low

education, low intelligence quotients, low socioeconomic groups and
military personnel exposed to combat situations.
• Onset is acute. Deficits are short duration and approximately
95 percent of acute cases remit spontaneously within 2 weeks.
• If symptoms are present for 6 months or longer prognosis for
symptom resolution is less than 50 percent and diminishes
further. Recurrence occurs in 1/4th within 1 year of 1st episode.
1st episode is a predictor for future episodes.
• Good prognosis - acute onset, presence of stressors at time of
onset, short interval between onset and institution of
treatment and above average intelligence.
• Paralysis, aphonia and blindness are associated with good
prognosis whereas tremor and seizures are associated with
poor prognosis.
ETIOLOGY
PSYCHOANALYTIC FACTORS

• Conversion disorder is caused by repression of unconscious

intrapsychic conflict and conversion of anxiety into a physical
symptom.

• Conflict is between an instinctual impulse (aggression or sexuality)

and prohibitions against its expression.

• Conversion symptoms allow partial expression of forbidden wish or

urge but disguise it.

• Conversion symptoms allow patients to communicate need for

special consideration and special treatment.
• LEARNING THEORY- Classically conditioned learned behavior.
Symptoms of illness learned in childhood are called forth as means
of coping with an otherwise impossible situation.

• BIOLOGICAL FACTORS- Brain imaging studies- hypometabolism of

dominant hemisphere and hypermetabolism of nondominant
hemisphere.

• Impaired hemispheric communication implicated in cause of

conversion disorder.
• Symptoms are caused by excessive cortical arousal that sets off
negative feedback loops between cerebral cortex and brainstem
reticular formation.

• Elevated levels of corticofugal output inhibit patient’s awareness

of bodily sensation which results in sensory deficits.

• Neuropsychological tests reveal subtle cerebral impairments in

verbal communication, memory, vigilance, affective incongruity
and attention.
CONDITION TEST CONVERSION FINDINGS

Anesthesia Map dermatomes Sensory loss doesn’t confirm to

recognized pattern of distribution
 
Hemianesthesia  Check midline  Strict half body split
 
   
Astasia abasia Walking, dancing With suggestion those who can’t walk
may still be able to dance. Alteration
  of sensory and motor findings with
suggestion.
Paralysis, paresis
Drop paralyzed hand Hand falls next to face and not on it
onto face Pressure noted in examiner’s hand
Hoover test under paralyzed leg when attempting
straight leg raising
 
 Give away weakness
 Check motor strength
CONDITION TEST CONVERSION FINDINGS

Coma Examiner attempts to Resists opening, Gaze preference is away

open eyes from doctor
 
  Ocular cephalic Eyes stare straight ahead, don’t move
maneuver from side to side
 
 Request a cough Essentially normal coughing sound
Aphonia indicates cords are closing.
Intractable Observe Short nasal grunts with little or no
sneezing sneezing on inspiratory phase, Little or
 
  no aerosolization of secretions. minimal
  facial expression, eyes open, stops when
  asleep and abates when alone
 
   
 
 Syncope Magnitude of changes in vital signs and
 Head up tilt test
venous pooling don’t explain continuing
symptoms
CONDITION TEST CONVERSION FINDINGS

Tunnel vision Visual fields Changing pattern on multiple

examinations
Profound Blindness Swinging
monocular flashlight sign (Marcus Absence of relative afferent pupillary
blindness Gunn) defect
  Binocular visual fields Sufficient vision in bad eye precludes
    plotting normal physiologic blind spot in
good eye
Severe bilateral Wiggle your fingers I
blindness am just testing Patient may begin to mimic new
coordination movements before realizing the slip

Sudden flash of bright  Patient flinches

light Patient does not look there
Look at your hand
Touch your index Even blind patients can do this by
fingers proprioception
MOTOR SYMPTOMS

• Motor symptoms - paralyses, functional weakness, gait

disturbances, fits resembling epilepsy and abnormal
movements.

• Worsen when attention called to them.

• Onset, temporal sequence and character of presenting

complaint not typical of neurological disorder.

• Previous unexplained symptoms are present. Psychiatric

comorbidity is present.
• Presence of positive sign of functional weakness doesn’t
exclude possibility of organic disease.

• Common form of psychogenic movement disorder is

psychogenic tremor.

• Psychogenic non epileptic seizures distinguished from epileptic

seizures by occurrence of seizure in presence of audience,
precipitated by stress, fall to ground is not abrupt, and tonic
clonic seizure is not found.

• Corneal reflexes are preserved and plantar are flexor. Firm

handling and pressure on supra orbital nerves to point of pain
arouse patient.
SENSORY SYMPTOMS
• Sensory disturbance- Sensory loss involve half of entire body from
top to toe or from right to left. Characteristically has glove or
stocking distribution on arms or legs.

• Sensory loss generally fails to fit in with known anatomical

boundaries.

• In conversion disorder blindness patients walk around without

collisions or self injury, pupils react to light and cortical evoked
potentials are normal
• Primary Gain - Achieve by keeping internal conflicts outside their awareness.
Symptoms have symbolic value and represent unconscious psychological
conflict.

• Secondary Gain - Advantages and benefits as a result of being sick. Excused

from obligations and difficult life situations, receiving support and assistance
that might not otherwise be forthcoming.

• La Belle Indifference - Patient’s inappropriately cavalier attitude toward

serious symptoms. Also seen in seriously ill medical patients who develop
stoic attitude.

• Identification- Unconsciously model symptoms on someone important.

Parent or a person who has recently died serve as a model for conversion
disorder. During pathological grief reaction, bereaved persons commonly have
symptoms of deceased.
FEATURES SUGGESTING PSYCHOGENIC MOVEMENT DISORDER

• Abrupt onset
• Inconsistent movements
• Incongruous movements
• Demonstrating exhaustion and fatigue
• Spontaneous remissions
• Movements disappear with distraction
• Response to placebo, suggestion or psychotherapy
• Deliberate slowness in carrying out requested voluntary movement.
• Bursts of verbal gibberish
• Excessive startle
DIFFERENTIAL DIAGNOSIS
• 25 to 50 percent receive diagnoses of neurological or nonpsychiatric medical
disorders.

• Conversion symptoms occur in schizophrenia, depressive disorders and anxiety

disorders but are associated with their own distinct symptoms.

• If patient’s symptoms are limited to pain, pain disorder is diagnosed.

• Patients complaints are limited to sexual function are classified as having a sexual
dysfunction rather than conversion disorder.

• In both malingering and factitious disorder symptoms are under conscious and
voluntary control. A malingerer’s history is usually more inconsistent and
contradictory than of a patient with conversion disorder and malingerer’s
fraudulent behavior is goal directed.
TREATMENT
• APPROACH TO THE PATIENT- Special attention given to H/O
trauma, sexual and physical abuse and family H/O conversion
symptoms.

• Physical examination to rule out neurological diseases such as

multiple sclerosis and other peripheral and central nervous
system disorders.

• Routine laboratory studies, electroencephalograms (to

distinguish between epilepsy and pseudo seizures) and other
studies (MRI, x-rays, spinal tap) to rule out organic etiologies.
• REASSURANCE- Many conversion syndromes have acute, benign
course and remit spontaneously with understanding and
support.

• HYPNOTHERAPY- Oldest treatment for conversion disorder.

Inconclusive and not predictive of treatment outcome.

• SODIUM AMYTAL for diagnosing conversion disorder,

uncovering traumatic events and providing therapeutic relief
was used in conversion hysteria. Rarely used because number of
questions in its clinical value.
• PSYCHOTHERAPY- Behavioral interventions focus on improving
self esteem, capacity for emotional expression and
assertiveness and ability to communicate comfortably with
others.

• PHARMACOLOGICAL TREATMENT- Accompanying comorbid

depression, anxiety and behavior problems respond to
pharmacologic interventions.

• PHYSICAL THERAPY- With chronic conversion muscle

contractures occur. Process of slowly progressive exercises and
activity help restore functioning.
PSYCHOLOGICAL FACTORS AFFECTING OTHER MEDICAL CONDITIONS
• Patients have physical disorders caused by or adversely
affected by emotional or psychological factors.

• A medical condition must always be present to make

diagnosis.

• Denial and refusal of treatment, exacerbation of asthma

or irritable bowel attacks by anxiety and manipulation of
insulin or diuretics in efforts to lose weight.
• DSM 5 - Presence of medical symptom or condition and
presence of one or more clinically significant psychological or
behavioral factors.

• Adversely affects medical condition by increasing risk of

suffering, death or disability which is an essential feature.

• Diagnosis is made when effect of psychological issue on medical

condition is unambiguous and leads to documentable effects on
course and outcome of medical condition.
TREATMENT

• Frequent communication with patient’s primary medical team

and family.

• Psychoeducational intervention clarifies emotional and

behavioral factors that play role in aggravating underlying
medical condition.

• Medication is given incase of underlying psychiatric disorder.

FACTITIOUS DISORDER
• Factitious means “artificial, false” from Latin facticius “made by
art.”

• Feign, misrepresent, simulate, cause, induce or aggravate illness to

receive medical attention, regardless of whether or not they are ill.

• Patients inflict painful, deforming or life threatening injuries on

themselves, their children or other dependents.

• Primary motivation is not avoidance of duties, financial gain or

anything concrete. Motivation is to receive medical care and to
partake in medical system.
• Historically “Munchausen syndrome” introduced by asher in
reference to Baron Karl Von Munchausen legendary for his
outrageously exaggerated stories of his military career.

• Two distinguishing features of factitious disorder are

 Pathological lying (pseudologia fantastica) - telling of vague, self

aggrandizing, heroic tales often containing a kernel of truth. Differ
from normal liars by lying persistent, pervasive, disproportionate
and not motivated primarily by reward or external factors.

 Peregrination - tendency to travel widely.

ETIOLOGY
• Psychodynamic theories - Striving for mastery.

• Patients with factitious physical symptoms have childhood

traumatic illnesses, adult factitious illness behavior represent an
attempt to master and to feel in control of situations in ways in
which they never did as children.

• Masochism - Patient relives childhood physical or emotional abuse

at hands of medical staff in a repetition compulsion.

• Physician and medical system become symbolic parents against

whom patient reenacts dependency, idealization and anger.
• Behavioral theories - Early in life patients received positive
reinforcement when sick and gained nurturing from medical
community they didn’t receive at home learned to see
medical system as a source of caring and emotional support.

• Biological factors - Impaired information processing

contributes to pseudologia fantastica and aberrant behavior
of patients with Munchausen disorder.

• Genetic patterns and electroencephalographic studies have

no abnormalities in patients with factitious disorders.
• Factitious Disorder Imposed on Another- (Schreier and
Libow) Perversion of mothering in which child is
dehumanized by mother and serves as fetishized object
through which mother’s dependency needs are met.

• Rosenberg - Disorder of empathy among perpetrating

mothers with pervasive themes of loneliness and isolation
under circumstances of uninvolved or absent husbands.

• Mother seeks relationship with physician who substitutes

for uninvolved husband of these traits.
 FACTITIOUS DISORDER INTENTIONAL PRODUCTION OR
(DSM-5) FEIGNING OF SYMPTOMS OR
DISABILITIES, EITHER PHYSICAL
OR PSYCHOLOGICAL (ICD-10)

Symptoms Factitious disorder imposed on self Feigns symptoms

Fabricates their symptoms and clinical  
findings
No apparent external reward
Claims to be ill
or motivation
Purposely misleads health professionals
 
No apparent external reward or
Aim is to take on sick role
motivation (out of illness role)
 

Factitious disorder imposed on another

Similar to factitious disorder on self
except object of feigned illness or injury is
another person.
CLUES FOR SUSPICION OF FACTITIOUS DISORDER
1.Sought treatment at various different hospitals or clinics.
2.Inconsistent, selective or misleading informant and
resists outside sources of information.
3.Course of illness is atypical.
4.Medical and surgical treatments have been done to little
or no avail.
5.Symptoms exceeds objective pathology.
6.Findings are self induced or worsened through self
manipulation.
7.Eagerly agrees to invasive medical procedures.
8.Physical evidence of a factitious cause.
9.Deteriorations or exacerbations before discharge.
10.Diagnosis of factitious disorder by atleast 1 healthcare
professional.
11.Patient noncompliant with diagnostic or treatment
recommendations.
12.Evidence from laboratory of disputes information.
13.History of work in healthcare field.
14.Gratuitous and self aggrandizing lying.
15.Prescribed opiate drugs when not indicated.
16.Opposes psychiatric assessment.
CLUES FOR SUSPICION FACTITIOUS DISORDER IMPOSED ON
ANOTHER
1. Diagnosis doesn’t match objective findings.
2. Signs or symptoms are bizarre.
3. Caregiver or suspected offender doesn’t express relief or
pleasure.
4. Inconsistent history of symptoms from different observers.
5. Caregiver insists on invasive or painful procedures.
6. Caregiver’s behavior doesn’t match expressed distress.
7. Signs and symptoms begin only in presence of one caregiver.
8. Sibling or another dependent had an unusual or unexplained
illness or death.
9. Sensitivity to multiple environmental substances or medicines.
10.Failure of dependent’s illness to respond to treatments.
11.Caregiver publicly solicits sympathy or donations or benefits
because of dependent’s rare illness.
12.Extensive unusual illness history in caregiver or caregiver’s family.
13.Caregiver seeks other medical opinions.
14. Caregiver perseverates about borderline abnormal results.
COURSE AND PROGNOSIS
• Onset of disorder or discrete episodes of seeking treatment
follow real illness, loss, rejection or abandonment.

• Long pattern of successive hospitalizations begins

insidiously and evolves.

• A course of repeated or long term hospitalization is

incompatible with meaningful vocational work and
sustained interpersonal relationships.

• Prognosis is poor.
DIFFERENTIAL DIAGNOSIS
• Conversion disorder no voluntary production of factitious
symptoms, no extreme course of multiple hospitalizations
and seeming willingness to undergo an extraordinary number
of mutilating procedures.

• Hypochondriacal patient doesn’t voluntarily initiate

production of symptoms.

• Antisocial personality don’t volunteer for invasive procedures

or resort to repeated or long term hospitalization.

• Malingering - obvious financial gain and to escape from legal

issues is present.
TREATMENT
• Once diagnosis is established doctor patient
relationship becomes irreparably damaged.

• Negative emotions in doctor to be dealt with before

engaging patient in therapeutic endeavour.

• Main treatment is psychological using either

confrontational or Non confrontational strategies.

• Systemic interventions- Patients with factitious

disorders elicit negative and hostile emotions in general
hospital staff after deception exposed.
• Psychiatrist help staff members to vent and reduce anger
experienced when a factitious diagnosis is confirmed and help
staff to understand likely mechanisms underlying factitious
behaviour.
ETHICAL AND LEGAL ISSUES
 Confidentiality.
 Invasion of privacy.
 Involuntary hospitalization or treatment.

• No specific psychiatric therapy has been effective in treating

factitious disorders. Treatment focused on management rather
than on cure.
• Three major goals in treatment and management of factitious
disorders are
 To reduce risk of morbidity and mortality
 To address underlying emotional needs or psychiatric
diagnosis underlying factitious illness behavior.
 To be mindful of legal and ethical issues.

• Pharmacotherapy of factitious disorders is of limited use.

• Selective serotonin reuptake inhibitors useful in decreasing

impulsive behavior when is a major component in acting out
factitious behavior.
PAIN DISORDER
• Pain disorder is characterized by presence of and focus on pain in
one or more body sites and severe to clinical attention.

• Psychological factors necessary in genesis, severity or maintenance

of pain which causes significant distress, impairment or both.

• Pain disorder in DSM-5 is unspecified somatic symptom disorder.

• Patients with pain disorder aren’t uniform group but

heterogeneous collection of persons with low back pain,
headache, atypical facial pain, chronic pelvic pain and other kinds
of pain.
• Diagnosis of pain disorder must have psychological factor
significantly involved in pain symptoms and their ramifications.

• Patients with pain disorder have long histories of medical and

surgical care.
EPIDEMIOLOGY
• Prevalence of pain disorder is 12 percent.

• Chronic pain most frequently associated with depressive disorders

and acute pain commonly associated with anxiety disorders.

• Associated psychiatric disorders may precede pain disorder, cooccur

with it or result from it.
ETIOLOGY
PSYCHODYNAMIC FACTORS
• Patients experiencing bodily aches and pains without identifiable
physical causes symbolically expressing an intrapsychic conflict
through body.

• By displacing problem to body patient feel they have legitimate claim

to fulfillment of their dependency needs.

• Symbolic meaning of body disturbances relate to atonement for

perceived sin, to expiation of guilt or to suppressed aggression.

• 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.

• Moderate pain symptoms become intense when followed by

solicitous and attentive behavior of others, by monetary gain
or by successful avoidance of distasteful activities.
 
• INTERPERSONAL FACTORS - Intractable pain conceptualized as
means for manipulation and gaining advantage in
interpersonal relationships.

• Secondary gain is most important to patients with pain

disorder.
BIOLOGICAL FACTORS

 Cerebral cortex inhibits firing of afferent pain fibers. Serotonin is

main neurotransmitter in descending inhibitory pathways and
endorphins play role in central nervous system modulation of pain.

 Endorphin deficiency correlate with augmentation of incoming

sensory stimuli.

 Sensory and limbic structural or chemical abnormalities predispose

to pain experience.

• Pain disorder is chronic, distressful and completely disabling. Acute

pain disorders have favorable prognosis than chronic pain disorders.
TREATMENT
PHARMACOTHERAPY

• Analgesic medications don’t benefit patients with pain disorder.

• Sedatives and antianxiety agents aren’t beneficial and are

subject to abuse, misuse and adverse effects.

• Antidepressants such as tricyclics and selective serotonin

reuptake inhibitors are most effective pharmacological agents.
PSYCHOTHERAPY
• First step in psychotherapy is to develop a solid therapeutic
alliance by empathizing with the patient’s suffering.

• Cognitive behaviour therapy to alter negative thoughts and to

foster positive attitude.

• BIOFEEDBACK - Helpful in treatment of pain disorder particularly

with migraine pain, myofascial pain and muscle tension states
such as tension headaches.
• Hypnosis, transcutaneous nerve stimulation, dorsal column
stimulation and Pain Control Programs.
REFERENCES

CTP 10TH EDITION

ALLAN TASMAN 4TH EDITION
SYNOPSIS 11TH& 12TH EDITION
OXFORD TEXTBOOK OF PSYCHIATRY 2ND EDITION
THANK YOU