Somatoform Disorders

Levent Tekin, MD
 Somatization is defined as a specific disorder
with multiple medical help-seeking behaviors,
accompanied by somatic complaints and
symptoms that cannot be explained by physical
findings.
Although physical complaints indicate a
medical problem, they have no organic basis.
Physical examination and laboratory findings
are usually normal. Even if there are
abnormalities, they do not explain the patient's
complaints.

Definition
 Genetic / Biological Predisposition (Pain
sensitivity)
Early Traumatic Experiences (Violence,
maltreatment, deprivation)
Learning (Seeing attention due to discomfort,
lack of reinforcement to express mental distress
in non-physical ways)
Culture / Social Norms (Attitudes that
stigmatize and devalue not physical suffering,
but spiritual pain)

etiology
 It is a frequently watched feature; expressing emotions
becomes difficult and affect regulation is impaired
In the languages ​of some societies, there are no words to
describe spiritual experiences, and emotions are
expressed through bodily signs.
They show features such as difficulty in identifying and
recognizing their emotions, and inability to distinguish
between emotions and bodily sensations.
Completely normal functions such as heartbeat and
bowel movements or minor problems such as tension
headache are interpreted as a sign of serious illness.

alexithymia
 Somatic (Somatic) Symptom Disorder
Illness Anxiety (Hypochondriasis) Disorder
Conversion Disorder
Psychological Factors Affecting Other Medical
Conditions
Factitious Disorder
Another Identified Somatic Symptom and
Associated Disorder
Other Unspecified Somatic Symptom and
Associated Disorder

Somatic Symptom Disorder and

Related Disorders DSM-5
A. One or more somatic symptoms that are distressing or
significantly disrupt daily life.
B. Excessive thoughts, feelings, or behaviors associated
with somatic symptoms or accompanying health
concerns, as manifested by at least one of the following:
Persistent thoughts that are disproportionate to the
severity of the person's symptoms.
A persistent high level of anxiety about health or
symptoms.
Excessive time and inner effort is wasted on these
symptoms or health concerns.
C. At least 6 months (Symptoms may not be continuous)

BODY SYMPTOM DISORDER DSM-5

Diagnostic Criteria
 Pain-predominant type (DSM-IV Pain
Disorder)
Persistent: Severe symptoms, significant
dysfunction, lasting >6 months

Mild: 1 B criterion
Medium: at least 2 B criterion
Severe: at least 2B criterion + Multiple
symptoms/ 1 very severe symptom

Somatic Symptom Disorder

 Environment and learning
A chaotic childhood for the most part
An anxious attachment to their caregivers
Anxiety sensitivities are high
Disease-related experiences in childhood
predispose to later medically unexplained
symptoms

etiology
 Amygdala volume is significantly smaller
than in healthy study groups
No significant difference is observed in
total brain volume, gray matter, white
matter and hippocampus volume.

neuropathology
 The degree of the disease and the anxiety level of the
patient do not show parallelism.
They are seen by many physicians.
Preoccupation with their symptoms and their bodies
The tendency to dependence is particularly evident in
the relationship with the physician.
Symptoms cannot be explained by a known physical
illness.
Dyspnea, palpitation, chest pain, headache, dizziness,
paralysis, anesthesia, blurred vision, burning in the
mouth, weight loss, abdominal pain, abdominal bloating,
food intolerance, diarrhea, dyspareunia, back pain etc.

Clinic
Past illnesses are often remembered as
life-threatening events, not as trivial
episodes.
eg; The appendix escaped just as it was
about to burst, came back from the dead
They are very adaptable when their needs
are met, but show outbursts of anger and
impulsive behavior when problems arise.
In these cases, physical examination and
laboratory findings are usually within normal
limits.
Even if there are abnormal findings, this does
not explain the patient's complaints.
Patients think that they have chronic diseases.
Health personnel initially approach these cases
very positively.
Attitudes of rejecting the patient, pretending to
be pretending may occur.
 Somatic symptom disorder can be
confused with physical illness.
Underlying physical illness may
complicate the clinical picture.
Therefore, a distinction should be made
with all physical diseases with multiple or
ambiguous somatic manifestations.
Collagen tissue diseases and endocrine
disorders are frequently confused (SLE,
hyperparathyroidism, porphyria etc.)

Differential diagnosis
 Multiple physical symptoms often persist for years.
It is chronic and spontaneous remissions are rare.
However, decreases and increases in symptoms are
common.
They often seek medical help.
It significantly affects the patient's life.
Due to frequent doctor changes, iatrogenic
complications and unnecessary surgical procedures
are common.
The effects and complications of these interventions
also complicate the disease.

Natural Course and Prognosis

Abuse and addiction to prescribed drugs are
common.
Suicide attempts and threats are common due
to accompanying depressive symptoms.
25% of those who meet the diagnostic criteria
still meet these criteria one year later.
61% of initially reported symptoms disappear in
the future.
Symptoms improve in 50-70%
In 10-30%, it is observed that it gradually
worsens.
 SSRI
Physical side effects should be taken into
account.
Psychotherapy
Somatic interventions should be avoided.
Physical exercise is helpful.

Treatment
 Indicates a person's excessive preoccupation
with illness and health issues that takes up
most of the time.
Although there is no physical disorder in these
cases, there is a concern that they are seriously
ill.
They evaluate health-related information and
bodily sensations as threatening.
They constantly seek professional help.
They may claim that the diagnosis cannot be
made.

ILNESS ANXIETY DISORDER

 12-month prevalence in Turkey Mental
Health Profile Study;
0.8% in women
0.3% in men
0.6% of the entire population

epidemiology
 This rate is up to 3% in first-line patients.
Major depressive B, Panic B, Generalized
anxiety B may be co-diagnosed.
N=M
30-40 years in men
40-50 years common in women

epidemiology
 Having a serious illness in childhood
Serious illness of parents
physical or sexual abuse
Lack of parental care
Overprotective attitude

Risk factors
 These people fear both the disease and its
consequences.
The disease represents the problems that
the patient may experience, such as
sexual, social or professional success.
It is generally thought that hypochondriac
symptoms reflect maladaptive efforts
towards psychological conflicts.

etiology
genetic factors
environmental factors
Culture is an important determinant in
people's feelings and behaviors.
Somatization tendency is high in cultures
that do not care about psychological
explanations in the face of stress.
Most have a hypochondriac in their family
to imitate; can be a learned behavior
 A. Do not think that you have or will have
a serious illness.
B. No physical symptoms or, if any, not
severe. If there is another disease
condition, or if one is likely to occur, the
thinking about it is clearly excessive or
disproportionate.
C. There is a high level of health anxiety

DSM-5 Diagnostic Criteria

D. The person's health-related behaviors
are excessive (eg, scanning the body) or
are in an inappropriate avoidance, eg.
avoids going to the doctor and hospitals
E. The duration of dealing with the disease
is at least six months, but the specific
disease feared may change during this
time.
F. Thinking about the illness is not better
explained by another mental illness.
 The main symptom is the belief and fear
of having a serious physical illness.
This fear may be based on mild symptoms
that actually exist.
But there is insufficient evidence for a
serious physical illness.
His belief that he has a serious illness
persists despite medical assurances.
It disrupts the professional and social
harmony of the person.

Clinic
Subjects constantly probe their bodies
Such a patient can know and describe bowel
movements, the color and smell of stool day by
day.
Examination and laboratory findings are often
within normal limits.
On the other hand, patients want additional
examinations.
Concurrent presence of a physical illness does
not exclude a diagnosis of illness anxiety.
 It is a chronic disease and shows a fluctuating course.
Social and occupational functioning changes accordingly.
They seek ongoing medical care.
Unnecessary medical and surgical interventions are
common.
In hypochondriac cases, symptoms decrease within 4-5
years.
During this period, 63.5% of the cases meet the
diagnostic criteria.
In general, the prognosis is poor.
It does not improve in 50-70% of the cases.

Natural Course and Prognosis

 SSRI in cases accompanied by depression
and PD
psychotherapy is effective
Psychoeducation is important
Many cases resist psychiatric treatment
They can benefit from CBT
Unnecessary attempts should be blocked

Treatment
 It is a disorder called "hysteria" in the past
(the belief that the uterus is circulating in
the body)
Pierre Janet suggested that the
mechanism of conversion formation is
dissociation.
Linked to childhood traumas
Emotional responses to trauma change
the state of consciousness.

CONVERSION DISORDER
 Most common somatic symptom disorder
It is thought that up to 1/3 of new
applicants to neurology units are caused
by neurologically unexplained symptoms.
The incidence of conversion symptoms in
cases admitted to general medical units is
about 20-25%.
1-14% of hospital psychiatric
consultations are due to conversion
symptoms.

epidemiology
F>M
More common in adolescence and early
adulthood
25-30% of applications in military hospitals
Antisocial PD diagnosis is common in male
patients.
Risk groups: Living in rural areas, low education
level, low IQ level, low socioeconomic
conditions, military personnel in combat
More common in patients with a family history
of Conversion Disorder
These symptoms occur outside of the
person's control.
Fainting, convulsions, paralysis, inability to
stand, loss of feeling in hands and feet,
mutism can be seen in conversion
disorder.
Neurological diseases should be excluded
because the symptoms are similar to
those of neurological diseases.
With the formation of symptoms in this way,
the person gets rid of anxiety, this is called
primary gain.
The person's getting rid of some of his
responsibilities for this reason is called
secondary gain.
The probability of childhood sexual abuse in
psychogenic seizures is 24-69%.
There is a disorder in the relationship with the
mother
Recognizing the importance of learning
Neuropsychological test findings show
that there is a disorder in both
hemispheres.
There is a neurological cause in 11.8% of
the cases.
Suspicion of a neurological disease, late
onset, length of symptom duration, and
taking medication are predictors of
organicity.
It can be thought that the symptoms are the
symbolic expression of feelings and thoughts
that are a source of anxiety that cannot be
expressed otherwise.
The symptom can be interpreted as a
compromise between a strong instinctive
impulse (such as anger, aggression) and a
superego prohibition.
eg; the right hand may represent the patient's
tendency to aggression, and the paralysis in
this hand may represent its inhibition.
In most patients, an acute psychosocial
stressor is present just before symptom
onset.
Another important environmental factor is
secondary earnings.
In this way, the patient escapes from his
responsibilities.
This is a cause that feeds the disease.
 A. With one or more changes in voluntary
motor or sensory function
B. Clinical findings provide evidence of
incompatibility or incompatibility between
the symptom in question and known
neurologic or general medical conditions

Conversion D. DSM-5 Diagnostic

Criteria
C. This symptom or deficiency is not
better explained by another health or
mental condition.
D. This symptom or deficiency causes
clinically significant distress or impairment
or requires health evaluation.
 Going with engine loss (paralysis)
Unusual movement (eg tremor, gait
disturbance)
with swallowing symptoms
Out with a speech sign (eg: slurred speech)
with attacks or convulsions
With anesthesia or sensory loss
Special sensory symptoms (eg, sight, smell,
hearing)

Types
 In this disorder, there are changes in
physical function that are clearly related
to a psychological need, suggesting a
physical illness.
Symptoms are not under voluntary
control.
It cannot be explained by a known
physiopathological mechanism.
It occurs after stress factors and traumatic
experiences.

Signs and Symptoms

The mood of patients is highly variable.
In these cases, a special affective disorder
called La belle indifference is observed.
This term describes the patient's symptom
showing an inappropriate mood, rather
than worrying about it.
However, this condition is not unique to
conversion disorder.
Hysterical Ataxia
hysterical paralysis or paresis
hysterical aphonia
Loss of skin sensations
hysterical blindness
pseudo seizures
Autonomic and other manifestations; nausea,
vomiting, pseudopregnancy, unconsciousness,
dystonia, gait disturbance, dizziness, weakness,
deafness, headache, abdominal pain, globus
hystericus
 Superficially resembling epileptic seizures.
Seizures that do not show epilepsy-specific EEG
abnormalities.
It can mimic every symptom of epilepsy.
Pseudo seizures occur in 5-20% of outpatients with
epilepsy.
Epilepsy cases that do not respond to treatment
should be considered from this perspective.
More common in children (after 10 years) and
adolescents.
It decreases with age, very little after the age of 40.

Pseudoseizures
female/male =4/1
If there is a history of physical and sexual
abuse, it should be investigated
especially...
Frequent association with dissociative
symptoms, mood disorders, personality
disorders, PTSD and anxiety disorder
33% chance of epilepsy at the same time
 Detailed physical and neurological
examinations should be performed to
differentiate it from neurological diseases and
other physical diseases.
Conversion symptoms may accompany and be
confused with many psychiatric disorders.
Simulation, Factitious Distortion
schizophrenia, catatonia
somatic symptom disorder
Epilepsy, MS
drug-induced movement disorders

Differential diagnosis
 As it may be a single episode, the
symptoms may recur throughout life.
The onset is sudden with a stressor.
It rarely becomes chronic.
There may also be real physical signs of
disuse, such as atrophy and contractures.

Natural Course and Outcome

 Treatment success depends on underlying
personality traits and predisposition to
psychotherapy.
Short-term psychotherapy is
recommended
Family therapy increases the effectiveness
of treatment
CBT
SSRI
Anxiolytics in the acute stage, faradization

Treatment
 The person deliberately produces physical
or psychological symptoms.
They can produce symptoms such as
acute pain or intentionally injuring their
body, resulting in injury.
The person adopts the patient role.

Factitious Disorder
 Lack of visitors-Failure to develop close
relationships
Constantly changing complaints
High level of medical knowledge
Changing exaggerated fake stories
Inconsistency in medical results
Volunteering for any diagnostic procedure
The need to be a special patient
Showing anger or resentment when their
demands are not met
Tendency to change physicians

Factitious Disorder-common
features
 the unwanted-undesired child
History of rejecting and abusive parents
Dependency requirements not met
Hospital environment and doctors are
perceived as the strongest source of love
(mother) that fulfills their need for
dependency and approval.

Why?
 Unsaturated self-worth
Lack of sense of approval
History of hospitalization for a real illness
in childhood or adolescence
Neglect, abuse, abandonment by parent
Parents' incompetence and rejection of
close relationships

etiology
 Munchausen: Male… Traveler… Frequent
and prolonged hospitalizations… High
medical expenses… Borderline IQ
M by Proxy: Woman… Parents or
spouses… Illness by proxy
Factitious disorder of the caregiver
(Meadow syndrome, Polle syndrome)
created by the parent

clinical forms
 Attitude of the patient to produce misleading,
bodily or mental false symptoms in himself or
cause injury or illness
The person presents himself or herself to others
as sick, incapacitated, or injured
Misleading behavior is evident even in the
absence of obvious external rewards
This behavior is not better explained by another
mental illness, such as delusional disorder or
another psychotic disorder

Self Attributed Factitious Disorder

DSM-5 Diagnostic Criteria
 It can take a very long time to be diagnosed.
In most cases, it took years for the patient to
self-medicate.
Inconsistency in patient's narrative, medical
history
Having applied to many doctors and hospitals
Symptoms of unknown cause, undiagnosed, or
change after treatment is started

Clinic
Intensive knowledge of diseases and
medical terminology
Having scars or surgical scars
Appearance of new symptoms following
negative test results
A craving for medical testing or surgery
 Attitude to produce misleading, bodily or
mental false indications or cause injury or
illness in another.
The person presents another person to others
as sick, incapacitated, or injured.
Misleading behavior is evident even in the
absence of obvious external rewards.
This behavior is not better explained by another
mental illness, such as delusional disorder or
another psychotic disorder.

Factitious Disorder Imposed on

Another DSM-5 Diagnostic Criteria
 Reduction in the child's symptoms in the
absence of the caregiver
The mother seems overly attached to her child.
Inappropriate mood may be observed.
This disease was first described by Meadow in
1977, and it was observed that morphine-like
drugs were given to the child most frequently,
especially in this application made by the
mother.

Clinic
Combination of many factors
Abuse history
parents who refuse
attract attention, be the center of
attention
The role of borderline personality disorder
masochistic pleasure from medical
procedures
PURPOSE: I AM A GOOD MOTHER
 In factitious disorder, the symptoms are not aimed
at economic gain or avoidance of responsibility.
In simulation, the person voluntarily fakes illness or
symptoms for a specific purpose, such as a job,
higher insurance earnings, or evading military
service.
In the case of simulation, your symptoms may
cease abruptly
Simulation is distinguished from factitious disorder
by the presence of an external stimulus to produce
symptoms.

Simulation-Malingering
 1. If the confrontation with the person has a
forensic aspect (eg the person was sent for
examination by his/her own lawyer)
2. If there is a significant discrepancy between
the person's alleged stress or deficiency
(disability) and objective findings
3. Failure to cooperate during the diagnostic
evaluation and non-compliance with the
treatment applied
4. Having Antisocial Personality Disorder

“simulation” should come to mind

when:
 1) Presence of a general medical illness
2) Psychological factors negatively affect the
main disease
Psychological factors can affect the course of
the general medical condition, the
development, exacerbation and recovery of the
disease.
May impair treatment adherence and make
recovery more difficult.
A number of other medical health problems
may be added

Psychological Factors Affecting

Other Health Conditions
 1- Brief somatic symptom disorder: duration <
6 months
2- Brief illness anxiety disorder: duration < 6
months
3- Illness anxiety disorder without excessive
health-related behaviors: Criterion D is not met.
4. Pseudociesis: False belief that there are
objective signs of pregnancy and pregnancy
symptoms are reported, that she is pregnant.

Other Specified Somatic Symptom

and Related Disorders
Thank You!