Somatoform Disorders

• A Somatic Symptom Disorder,

• formerly known as a somatoform disorder, is any mental

disorder that manifests as physical symptoms that suggest illness or
injury, but cannot be explained fully by a general medical condition or
by the direct effect of a substance, and are not attributable to
another mental disorder.

1
SD
• Somatic symptom disorders are a group of disorders, all of which fit
the definition of physical symptoms similar to those observed in
physical disease or injury for which there is no identifiable physical
cause.
• As such, they are a diagnosis of exclusion.

2
SD
• Somatic symptoms may be generalized in four major medical
categories:
• neurological,
• cardiac,
• pain,
• gastrointestinal somatic symptoms.

3
SD
• In people who have been diagnosed with a somatic symptom
disorder, medical test results are either normal or do not explain the
person's symptoms

4
SD

history and physical examination do not indicate the presence of a

known medical condition that could cause them,

5
SD
• DSM-5
• The patient must be excessively worried about their symptoms, and
this worry must be judged to be out of proportion to the severity of
the physical complaints themselves.
• A diagnosis of somatic symptom disorder requires that the subject
have recurring somatic complaints for at least six months.

6
Presentation
• Symptoms are sometimes similar to those of other illnesses and may
last for years.
• Usually, the symptoms begin appearing during adolescence,
• and patients are diagnosed before the age of 30 years.

7
Presentation
• Symptoms may occur across cultures and gender.
• Other common symptoms include anxiety and depression.

8
Presentation
• However, since anxiety and depression are also very common in
persons with confirmed medical illnesses,
• it remains possible that such symptoms are a consequence of the
physical impairment, rather than a cause.

9
Presentation
• Somatic symptom disorders are not the result of conscious
malingering (fabricating or exaggerating symptoms for secondary
motives) or factitious disorders (deliberately producing, feigning, or
exaggerating symptoms).

10
Presentation
• Somatic symptom disorder is difficult to diagnose and treat.
• Some advocates of the diagnosis believe this is because proper
diagnosis and treatment requires psychiatrists to work with
neurologists on patients with this disorder.

11
Classification
• DSM IV old classification
• Somatic symptom disorders used to be recognized as Somatoform
disorders
• The following were conditions under the term Somatoform Disorders:

12
Classification
• Conversion disorder: A somatic symptom disorder involving the actual
loss of bodily function such as blindness, paralysis, and numbness due
to excessive anxiety

13
Classification
• Somatization disorder

14
Classification
• Hypochondriasis

15
Classification
• Body dysmorphic disorder: wherein the afflicted individual is
concerned with body image, and is manifested as excessive concern
about and preoccupation with a perceived defect of their physical
appearance.

16
Classification
• Pain disorder

17
Classification
• Undifferentiated somatic symptom disorder – only one unexplained
symptom is required for at least six months.

18
New Classification
• DSM-5 (2013) somatic symptom disorders are recognized under the
term Somatic Symptom and Related Disorders:

19
NC
• Somatic symptom disorder: Will take over many of what was formerly
known as somatization disorders and hypochondriasis

20
NC
• Factitious disorder: Can be either imposed on oneself, or to someone
else (formally known as factitious disorder by proxy).

21
NC
• Illness anxiety disorder: A somatic symptom disorder involving
persistent and excessive worry about developing a serious illness.

22
NC
• Somatoform disorder not otherwise specified (NOS)

23
NC
• Included among these disorders are false pregnancy, psychogenic
urinary retention, and mass psychogenic illness (so-called mass
hysteria).

24
Epidemiology
• Somatization disorder – 1%
• Abridged somatization disorder – 6%
• Multisomatoform disorder – 24%
• Undifferentiated somatoform disorder – 69%

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Diagnosis

• Each of the specific somatic symptom disorders has its own diagnostic
criteria.

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Management
• Psychotherapy, more specifically, cognitive behavioural therapy (CBT),
is the most widely used form of treatment for Somatic symptom
disorder

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CBT
• Learn to reduce stress
• Learn to cope with physical symptoms
• Learn to deal with depression and other psychological issues
• Improve quality of life
• Reduce preoccupation with symptom

28
mgt
psychodynamic interpersonal psychotherapy (PIT) for patients with
Multisomatoform disorder has shown its long-term efficacy for
improving the physical quality of life in patients with multiple,
difficult-to-treat, medically unexplained symptoms.

29
mgt
• Antidepressant medication has also been used to treat some of the
symptoms of depression and anxiety that are common among people
who have somatic symptom disorder.
• Medications will not cure somatic symptom disorder, but can help the
treatment process when combined with CBT.

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History

• Somatisation disorder was first described by Paul Briquet in 1859 and

was subsequently known as Briquette's syndrome.
• He described patients who had been sickly most of their lives and
complained of multiple symptoms from different organ systems.
• Symptoms persist despite multiple consultations, hospitalisations and
investigations.

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Hypochondriasis
• Hypochondriasis or hypochondria is a condition in which a person is
excessively and unduly worried about having a serious illness.

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HYP
• Hypochondria is often characterized by fears that minor bodily or
mental symptoms may indicate a serious illness, constant
self-examination and self-diagnosis, and a preoccupation with one's
body.

33
HYP
• Many individuals with hypochondriasis express doubt and disbelief in
the doctors' diagnosis, and report that doctors’ reassurance about an
absence of a serious medical condition is unconvincing, or
short-lasting.

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HYP
• Additionally, many hypochondriacs experience elevated blood
pressure, stress, and anxiety in the presence of doctors or while
occupying a medical facility, a condition known as "white coat
syndrome".

35
HYP
• Many hypochondriacs require constant reassurance, either from
doctors, family, or friends, and the disorder can become a debilitating
challenge for the individual with hypochondriasis, as well as their
family and friends.

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HYP
• Some hypochondriacal individuals completely avoid any reminder of
illness, whereas others frequently visit medical facilities, sometimes
obsessively. Some sufferers may never speak about it.

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HYP
• It has been claimed that this debilitating condition results from an
inaccurate perception of the condition of body or mind despite the
absence of an actual medical diagnosis.
• An individual with hypochondriasis is known as a hypochondriac.

38
HYP
• Hypochondriacs become unduly alarmed about any physical or
psychological symptoms they detect, no matter how minor the
symptom may be, and are convinced that they or others have, or are
about to be diagnosed with, a serious illness.

39
HYP
• Often, hypochondria persists even after a physician has evaluated a
person and reassured them that their concerns about symptoms do
not have an underlying medical basis

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HYP
• or, if there is a medical illness, their concerns are far in excess of what
is appropriate for the level of disease.
• It is also referred to hypochondriaism which is the act of being in an
hypochondriatic state;

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HYP
• acute hypochondriaism. Many hypochondriacs focus on a particular
symptom as the catalyst of their worrying, such as gastro-intestinal
problems, palpitations, or muscle fatigue.
• To qualify for the diagnosis of hypochondria the symptoms must have
been experienced for at least 6 months.

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HYP
• The DSM-IV-TR defines this disorder, "Hypochondriasis", as a
somatoform disorder and one study has shown it to affect about 3%
of the visitors to primary care settings.
• The 2013 DSM-5 replaced the diagnosis of hypochondriasis with the
diagnoses of somatic symptom disorder and illness anxiety disorder.

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Signs and symptoms

• Hypochondriasis is categorized as a somatic amplification disorder

• a disorder of "perception and cognition“
• that involves a hyper-vigilance of situation of the body or mind and a
tendency to react to the initial perceptions in a negative manner that
is further debilitating.

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Signs and symptoms
• Hypochondriasis manifests in many ways.
• Some people have numerous intrusive thoughts and physical
sensations that push them to check with family, friends, and
physicians.
• For example, a person who has a minor cough may think that they
have tuberculosis.
• Or sounds produced by organs in the body, such as those made by
the intestines, might be seen as a sign of a very serious illness to
patients dealing with hypochondriasis.

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Signs and symptoms
• Other people are so afraid of any reminder of illness that they will
avoid medical professionals for a seemingly minor problem,
• sometimes to the point of becoming neglectful of their health when a
serious condition may exist and go undiagnosed.
• Yet others live in despair and depression, certain that they have a
life-threatening disease and no physician can help them.
• Some consider the disease as a punishment for past misdeeds.

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Signs and symptoms
• Hypochondriasis is often accompanied by other psychological
disorders.
• Bipolar disorder
• clinical depression
• obsessive-compulsive disorder (OCD),
• phobias, and somatization disorder are the most common accompanying
conditions in people with hypochondriasis
• as well as a generalized anxiety disorder diagnosis at some point in their life.

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Signs and symptoms
• Many people with hypochondriasis experience a cycle of intrusive
thoughts followed by compulsive checking, which is very similar to
the symptoms of obsessive-compulsive disorder.
• However, while people with hypochondriasis are afraid of having an
illness, patients with OCD worry about getting an illness or of
transmitting an illness to others.
• Although some people might have both, these are distinct
conditions.

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Signs and symptoms
• Patients with hypochondriasis often are not aware that depression
and anxiety produce their own physical symptoms, and mistake these
symptoms for manifestations of another mental or physical disorder
or disease.
• For example, people with depression often experience changes in
appetite and weight fluctuation, fatigue, decreased interest in sex and
motivation in life overall
• Intense anxiety is associated with rapid heartbeat, palpitations,
sweating, muscle tension, stomach discomfort, dizziness, shortness of
breath, and numbness or tingling in certain parts of the body (hands,
forehead, etc.).

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Signs and symptoms
• If a person is ill with a medical disease such as diabetes or arthritis, there
will often be psychological consequences, such as depression.
• Some even report being suicidal.
• In the same way, someone with psychological issues such as depression or
anxiety will sometimes experience physical manifestations of these
affective fluctuations, often in the form of medically unexplained
symptoms.
• Common symptoms include headaches; abdominal, back, joint, rectal, or
urinary pain; nausea; fever and/or night sweats; itching; diarrhoea;
dizziness; or balance problems.
•

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Signs and symptoms
• Many people with hypochondriasis accompanied by medically
unexplained symptoms feel they are not understood by their
physicians, and are frustrated by their doctors’ repeated failure to
provide symptom relief.

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Causes

• The genetic contribution to hypochondriasis is probably moderate,

with heritability estimates around 10-37%.

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Causes
• exposure to illness-related information are widely believed to lead to
short-term increases in health anxiety and to have contributed to
hypochondriasis in individual cases.
• Overly protective caregivers and an excessive focus on minor health
concerns have also been implicated as potential causes of
hypochondriasis.

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Causes
• In the media and on the Internet, articles, TV shows and
advertisements regarding serious illnesses such as cancer and
multiple sclerosis often portray these diseases as being random,
obscure and somewhat inevitable.
• In the short term, inaccurate portrayal of risk and the identification of
non-specific symptoms as signs of serious illness may contribute to
exacerbating a fear of illness.
• Major disease outbreaks or predicted pandemics can have similar
effects.

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Causes
• There is anecdotal evidence that it is common for serious illnesses or
deaths of family members or friends to trigger hypochondria in
certain individuals.
• Similarly, when approaching the age of a parent's premature death
from disease, many otherwise healthy, happy individuals fall prey to
hypochondria.
• These individuals believe they are suffering from the same disease
that caused their parent's death, sometimes causing panic attacks
with corresponding symptoms.

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Diagnosis

• The ICD-10 defines hypochondriasis as follows:

• A. Either one of the following:
• A persistent belief, of at least six months' duration, of the presence of
a minimum of two serious physical diseases (of which at least one
must be specifically named by the patient).
• A persistent preoccupation with a presumed deformity or
disfigurement (body dysmorphic disorder).

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Diagnosis
• B. Preoccupation with the belief and the symptoms causes persistent
distress or interference with personal functioning in daily living, and
leads the patient to seek medical treatment or investigations (or
equivalent help from local healers).

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Diagnosis
• C. Persistent refusal to accept medical advice that there is no
adequate physical cause for the symptoms or physical abnormality,
except for short periods of up to a few weeks at a time immediately
after or during medical investigations.

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Diagnosis
• D. Most commonly used exclusion criteria: not occurring only during
any of the schizophrenia and related disorders (F20–F29, particularly
F22) or any of the mood disorders (F30–F39).

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Diagnosis
• The DSM-IV defines hypochondriasis according to the following
criteria:

• A. Preoccupation with fears of having, or the idea that one has, a

serious disease based on the person's misinterpretation of bodily
symptoms.

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Diagnosis
• B. The preoccupation persists despite appropriate medical evaluation
and reassurance.

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Diagnosis
• C. The belief in Criterion A is not of delusional intensity (as in
Delusional Disorder, Somatic Type) and is not restricted to a
circumscribed concern about appearance (as in Body Dysmorphic
Disorder).

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Diagnosis
• D. The preoccupation causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.

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Diagnosis
• E. The duration of the disturbance is at least 6 months.

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Diagnosis
• F. The preoccupation is not better accounted for by Generalized
Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a
Major Depressive Episode, Separation Anxiety, or another
Somatoform Disorder.

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Mgt

cognitive behavioural therapy (CBT) is an effective treatment for

hypochondriasis.
selective serotonin reuptake inhibitors can also reduce symptoms,
hypochondriasis responds well to antipsychotics, particularly the
newer atypical antipsychotic medications.

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Etymology

• Among the regions of the abdomen, the hypochondrium is the

uppermost part. The word derives from the Greek term
hypokhondrios, meaning "of the soft parts between the ribs and
navel" from ὑπό hypo ("under") and khondros, or cartilage (of the
sternum). Hypochondria in Late Latin meant "the abdomen".

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Etymology
• The term hypochondriasis for a state of disease without real cause
reflected the ancient belief that the viscera of the hypochondria were
the seat of melancholy and sources of the vapour that caused morbid
feelings.
• Until the early 18th century, the term referred to a "physical disease
caused by imbalances in the region that was below your rib cage"
(i.e., of the stomach or digestive system). For example, Robert
Burton's The Anatomy of Melancholy (1621) blamed it "for everything
from 'too much spittle' to 'rumbling in the guts'".

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Hysteria
• Hysteria colloquially means ungovernable emotional excess and can
refer to a temporary state of mind or emotion;
• however, beginning in 1900 B.C., hysteria was considered a
diagnosable physical illness in females and then in the 1500s shifted
to a mental illness

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Hysteria
• Many influential psychiatrists such as Sigmund Freud and Jean-Martin
Charcot dedicated research to hysteria patients.
• currently, most doctors practicing Western medicine do not accept
hysteria as a medical diagnosis

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Hysteria
• The blanket diagnosis of hysteria has been fragmented into myriad
medical categories such as epilepsy, histrionic personality disorder,
conversion disorders, dissociative disorders, or other medical
conditions
• Furthermore, social deviances, such as deciding not to wed, are no
longer considered psychological disorders

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History

• The word hysteria originates from the Greek word “uterus,” hystera.
• The oldest record of hysteria dates back to 1900 B.C. when Egyptians
recorded behavioural abnormalities in adult women on medical
papyrus

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History
• The Egyptians attributed the behavioural disturbance to a wondering
uterus- Thus later dubbing the condition hysteria

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History
• To treat hysteria Egyptian doctors prescribed various medications For
example, doctors put strong smelling substances on the patients’
vulvas to encourage the uterus to return to its proper position

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History
• Another tactic was to smell or swallow unsavoury herbs to encourage
the uterus to flee back to the lower part of the female’s stomach

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History
• The ancient Greeks accepted the ancient Egyptians’ explanation for
hysteria; however, they included in their definition of hysteria the
inability to bear children or the failure to marry
• Ancient Romans also attributed hysteria to an abnormality in the
womb; however, discarded the traditional explanation of a wandering
uterus

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History
• Instead, the ancient Romans credited hysteria to a disease of the
womb or a disruption in reproduction (i.e. a miscarriage, menopause,
etc.)
• Hysteria theories from the ancient Egyptians, ancient Greeks, and
ancient Romans were the basis of the Western understanding of
hysteria

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History
• Between the fifth and thirteenth centuries, however, the increasing
influence of Christianity in the Latin West altered medical and public
understanding of hysteria
• St. Augustine's writings suggested that human suffering resulted
from sin, and thus, hysteria became perceived as satanic possession
• With the shift in perception of hysteria came a shift in treatment
options

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History
• Instead of admitting patients to a hospital, the church began treating
patients through prayers, amulets, and exorcisms
• Furthermore, during the medieval and Renaissance periods many
patients of hysteria were prosecuted as witches and underwent
interrogations, torture, and execution

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History
• However, during the sixteenth and seventeenth centuries activists
and scholars worked to change the perception of hysteria back to a
medical condition
• Particularly, French physician Charles Lepois insisted that hysteria
was a malady of the brain
• In addition, in 1697, English physician Thomas Sydenham theorized
that hysteria was an emotional condition, instead of a physical
condition

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History
• Many physicians followed Lepois and Sydenham's lead and hysteria
became disassociated with the soul and the womb
• During this time period science started to focalize hysteria in the
central nervous system
• As doctors developed a greater understanding of the human nervous
system, the neurological model of hysteria was created, which further
propelled the conception of hysteria as a mental disorder

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History
• In 1859 Paul Briquet defined hysteria as a chronic syndrome
manifesting in many unexplained symptoms throughout the body's
organ systems

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History
• French psychologist, who studied five of hysteria's symptoms
(anaesthesia, amnesia, abulia, motor control diseases, and character
change) in depth and proposed that hysteria symptoms occurred due
to a lapse in consciousness

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History
• Both Charcot and Janet inspired Sigmund Freud's work .
• Freud theorized hysteria stemmed from childhood sexual abuse or
repression, and was also one of the first to apply hysteria to men.

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Factitious
• cases of feigned illness not driven by a psychiatric disorder
• Malingering.
• Factitious disorder imposed on self
• Munchausen syndrome

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Factitious
• Factitious disorder imposed on self, also known as Munchausen
syndrome, is a factitious disorder wherein those affected feign
disease, illness, or psychological trauma to draw attention, sympathy,
or reassurance to themselves.
• Munchausen syndrome fits within the subclass of factitious disorder
with predominantly physical signs and symptoms, but patients also
have a history of recurrent hospitalization, travelling, and dramatic,
extremely improbable tales of their past experiences.
• The condition derives its name from fictional character Baron
Munchausen.

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Factitious
• Factitious disorder imposed on self is related to factitious disorder
imposed on another,
• which refers to the abuse of another person,
• typically a child, in order to seek attention or sympathy for the
abuser.
• This drive to create symptoms for the victim can result in
unnecessary and costly diagnostic or corrective procedures.

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Signs and symptoms

• In factitious disorder imposed on self, the affected person

exaggerates or creates symptoms of illnesses in themselves to gain
examination, treatment, attention, sympathy, and/or comfort from
medical personnel.
• In some extreme cases, people suffering from Munchausen syndrome
are highly knowledgeable about the practice of medicine and are able
to produce symptoms that result in lengthy and costly medical
analysis, prolonged hospital stays, and unnecessary operations.

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Signs and symptoms
• The role of "patient" is a familiar and comforting one, and it fills a
psychological need in people with this syndrome.
• This disorder is distinct from hypochondriasis and other somatoform
disorders in that those with the latter do not intentionally produce
their somatic symptoms.

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Signs and symptoms
• Factitious disorder is distinct from malingering in that people with
factitious disorder imposed on self don't fabricate symptoms for
material gain such as financial compensation, absence from work, or
access to drugs.

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Signs and symptoms
• The exact cause of factitious disorder is not known, but researchers
believe both biological and psychological factors play a role in the
development of this disorder.

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Signs and symptoms
• Risk factors for developing factitious disorder may include childhood
traumas, growing up with parents/caretakers who were emotionally
unavailable due to illness or emotional problems, a serious illness as a
child, failed aspirations to work in the medical field, personality
disorders, and low self-esteem.

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Signs and symptoms
• Arrhythmogenic Munchausen syndrome describes individuals who
simulate or stimulate cardiac arrhythmias to gain medical attention.

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Signs and symptoms
• A similar behaviour called factitious disorder imposed on another has
been documented in the parent or guardian of a child.

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Signs and symptoms
• The adult ensures that his or her child will experience some medical
affliction, therefore compelling the child to suffer through treatments
and spend a significant portion during youth in hospitals.
• Furthermore, a disease may actually be initiated in the child by the
parent or guardian.
• This condition is considered distinct from Munchausen syndrome.

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Signs and symptoms
• There is growing consensus in the paediatric community that this
disorder should be renamed "medical abuse" to highlight the harm
caused by the deception and to make it less likely that a perpetrator
can use a psychiatric defence when harm is done.

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Diagnosis

• Due to the deceptive behaviours involved, diagnosing factitious

disorder is very difficult. If the healthcare provider finds no physical
reason for the symptoms, he or she may refer the person to a
psychiatrist or psychologist (mental health professionals who are
specially trained to diagnose and treat mental illnesses).

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Diagnosis
• Psychiatrists and psychologists use thorough history, physical
examinations, laboratory tests, imagery, and psychological testing to
evaluate a person for physical and mental conditions.

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Diagnosis
• Once the person's history has been thoroughly evaluated, diagnosing
factitious disorder imposed on self requires a clinical assessment.

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Diagnosis

• Clinicians should be aware that those presenting with symptoms (or

persons reporting for that person) may malinger, and caution should
be taken to ensure there is evidence for a diagnosis.

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Diagnosis

• Lab tests may be required, including complete blood count (CBC),

urine toxicology, drug levels from blood, cultures, coagulation tests,
assays for thyroid function, or DNA typing.

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Diagnosis

• In some cases CT scan, magnetic resonance imaging, psychological

testing, electroencephalography, or electrocardiography may also be
employed.

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