Somatoform disorder

 The term somatoform derives from the Greek word

soma for body

The somatoform disorders are a broad group of illnesses

that have bodily signs and symptoms as a major

component.

 These disorders encompass “mind-body’’ interactions

 the brain, in ways still not well understood, sends

various signals that impinge/ interrupt/ on the patient's

awareness, indicating a serious problem in the body

 Subtypes of somatoform disorder
(1) Somatization disorder: characterized by many physical

complaints affecting many organ systems

(2) Conversion disorder: characterized by one or two

neurological complaints

(3) Hypochondriasis: characterized less by a focus on symptoms

than by patients' beliefs that they have a specific disease

(4) Body dysmorphic disorder: characterized by a false belief or

exaggerated perception that a body part is defective

 Cont...
(5) Pain disorder: characterized by symptoms of pain that are

either exclusively related to, or significantly exacerbated by,

psychological factors

(6) Undifferentiated somatoform disorder: which includes

somatoform disorders not otherwise described that have

been present for 6 months or longer

(7) Somatoform disorder not otherwise specified: symptoms

do not meet any of the somatoform disorder diagnoses

mentioned above
 1.Somatization disorder
Somatization:

is the tendency to experience,

communicate, and amplify psychological
and interpersonal distress in the form of
somatic distress and medically

unexplained symptoms.
 Somatization disorder:
o is an illness of multiple somatic complaints
o involves multiple organ systems
o occurs over a period of several years

• The disorder is chronic and is associated with

o significant psychological distress
o impaired social and occupational functioning
o and excessive medical-help-seeking
behaviour.
 Epidemiology

• The lifetime prevalence in the general population is estimated

to be 0.2 %- 2% in women and 0.2 % in men

• Female-to-male ratio 5:1

• occurs most often among patients who have little education

and low incomes.

• begins before age 30

• it usually begins during a person's teenage years.

• About two thirds of all patients have identifiable psychiatric

symptoms
 Etiology

 The cause of somatization disorder is unknown

 Psychosocial Factors
o the cause involve interpretations of the symptoms
as social communication whose result is
o to avoid obligations (e.g., going to a job a
person does not like),
o to express emotions (e.g., anger at a spouse),

o or to symbolize a feeling or a belief (e.g., a pain

in the gut).
 Cont…
 Genetics

Twin studies: Concordance rate of 29 % in

monozygotic twins and 10 % in dizygotic twins
• run in families and occurs in 10 to 20 percent of the
first-degree female relatives of probands of patients
with somatization disorder
• The male relatives of women with somatization
disorder show an increased risk of antisocial
personality disorder and substance-related disorder
 DSM-V-TR Diagnostic Criteria
A. A history of many physical complaints beginning
before age 30 years occur over a period of several
years and result in treatment being sought(required
or wanted)or significant impairment in social,
occupational, or other important areas of functioning

B. Each of the following criteria must have been met,

with individual symptoms occurring at any time
during the course of the disturbance:
1. four pain symptoms:
a history of pain related to at least four different sites
or functions (e.g., head, abdomen, back, joints,
extremities, chest, rectum, during menstruation,
during sexual intercourse, or during urination)
2. two gastrointestinal symptoms:
a history of at least two gastrointestinal symptoms
other than pain (e.g., nausea, bloating, vomiting other
than during pregnancy, diarrhoea, or intolerance of
several different foods)
3. one sexual symptom:
a history of at least one sexual or reproductive
symptom other than pain (e.g., sexual indifference(lack
of interest), erectile or ejaculatory dysfunction,
irregular menses, excessive menstrual bleeding,
 4.one pseudoneurological symptom:
a history of at least one symptom or deficit suggesting a
neurological condition not limited to pain (conversion
symptoms such as impaired coordination or balance,
paralysis or localized weakness, difficulty swallowing or
lump(swelling) in throat, aphonia( Loss of voice), ....)
C. Despite appropriate investigation, each of the
symptoms in Criterion B cannot be fully
explained by a known general medical
condition or the direct effects of a substance
(e.g., a drug of abuse, a medication)
D. The symptoms are not intentionally produced
or feigned(pretend) (as in factitious disorder or
malingering)
 Clinical Features
Most common symptoms
o Nausea and vomiting (other than during
pregnancy)
o difficulty swallowing

o pain in the arms and legs

o Shortness of breath unrelated to exertion,

o Amnesia/ loss of memory/, and complications

of pregnancy and menstruation
 Cont…
 Patients frequently believe that they have been sickly
most of their lives.
 commonly associated with
o major depressive disorder,

o personality disorders,

o substance-related disorders,

o generalized anxiety disorder and phobias

 Suicide threats are common, but actual suicide is rare

 symptoms results in an increased incidence of marital,
occupational and social problems.
 Differential Diagnosis
 General medical condition

 Major depressive disorder

 schizophrenia or delusional disorder

 Panic disorder
 Course and Prognosis
o chronic, undulating(rising and falling)
o relapsing disorder
o rarely remits completely

It is unusual for the individual with somatization

disorder to be free of symptoms
– for greater than 1 year, during which time they
may see a doctor several times.
 Psychiatric evaluation of a patient referred for
somatization

• Allowing the patient to report a detailed history of his or her

physical symptoms provides reassurance that the symptoms
are being taken seriously,

 Complete a physical examination:

o Perform an objective physical and laboratory examination of

the patient
o Conduct relevant portions of a physical and neurological

examination, which is likely to improve the alliance with the

patient.
 Treatment
• Somatization disorder is best treated when the patient has a single

identified physician as primary caretaker

• See patients during regularly scheduled visits

• Respond to each new somatic complaint with conducting partial

physical examination

• Additional laboratory and diagnostic procedures should generally

be avoided

• Physicians must always use their judgment about what symptoms

to work up and to what extent to rule out physical illness

 Cont…
 Psychotherapy:
o Individual and group psychotherapy decreases
these patients' personal health care expenditures
by 50 percent

patients are helped to cope with their symptoms,

to express underlying emotions, and to develop
alternative strategies for expressing their feelings
2. Conversion
Disorder
 symptoms or deficits affect voluntary
motor or sensory functions, which suggest
another medical condition
 caused by psychological factors because
the illness is preceded/ come first/ by
conflicts or other stressors.
 symptoms are not intentionally produced
 are not caused by substance use
 are not limited to pain or sexual
symptoms
 the gain is primarily psychological and
not social, monetary(financial), or legal.
 Epidemiology
general hospital psychiatric consultations in 5 to 15
%
Women to male adults 2:1 as much as 10:1

among children, an even higher predominance is

seen in girls.
Women are more likely subsequently to develop
somatization disorder

onset from late adolescence to early adulthood

 Cont…
rare before 10 years of age or after 35 years

Conversion symptoms in middle or old age highly



suggests the probability of occult neurological or other

medical condition.

Men with conversion disorder have often been



involved in occupational or military accidents

An association exists between conversion disorder and



antisocial personality disorder

 DSM-V-TR Diagnostic Criteria
A. One or more symptoms or deficits affecting voluntary motor
or sensory function that suggest a neurological or other
general medical condition.

B. Psychological factors are judged to be associated with the

symptom or deficit

C. the symptom or deficit is not intentionally produced or feigned (as

in factitious disorder or malingering).

D. the symptom or deficit cannot, after appropriate investigation, be fully

explained by a general medical condition, or by the direct effects of a
substance, or as a culturally sanctioned behaviour or experience
 Cont…
E. The symptom or deficit causes clinically

significant distress or impairment or

warrant(permit) medical evaluation

F. The symptom or deficit is not limited to pain

or sexual dysfunction, does not occur

exclusively during the course of

somatization disorder, and is not better

accounted for by another mental disorder.

 Clinical Features
The most common conversion disorder symptoms:

 gait disturbance, weakness, and paralysis, tics, and jerks

o Patients with the symptoms rarely fall; if they do, they

are generally not injured.

• Hemi anesthesia of the body beginning precisely

along the midline. symptoms may involve the
organs of special sense and can produce deafness,
blindness, and tunnel vision.
 Course and Prognosis
 Onset usually acute
 usually of short duration
 Spontaneous remission 95% usually within 2 weeks
 The prognosis is less than 50% if symptoms have been
present for 6 months or longer
 Recurrence occurs in one fifth to one fourth of people within
1 year of the first episode
 tremor and seizures are poor prognostic factors.
 good prognosis
 acute onset,
 presence of clearly identifiable stressors
 a short interval between onset and the institution of
treatment
 Paralysis, aphonia, and blindness
 Treatment
• most important is a relationship with a caring and

confident therapist


Psychotherapy

•Insight-oriented supportive or behavior therapy

•behavioral relaxation exercises

•Direct confrontation(disagreement) has no real benefit

•Focus on coping stress

3.
Hypochondriasis
 hypochondriasis is derived from the old medical term
hypochondrium (below the ribs) characterized by 6
months or more of a general and non delusional
preoccupation with
– fears of contracting
– or the idea that one has, a serious disease based on
the person's misinterpretation of bodily symptoms
Epidemiology
 6-month prevalence in a general medical clinic
population is 4 to 6 %, but it may be as high as 15 %.
 Men and women are equally affected
 most commonly appears in persons 20 to 30 years of
age
 social position, education level, and marital status
do not appear to affect the diagnosis.
 DSM-V-TR Diagnostic 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.
B. The preoccupation persists despite appropriate
medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity
& not restricted to a circumscribed concern about
appearance
D. The preoccupation causes clinically significant
distress or impairment
E. duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by
mental illness
 Clinical Features

 Believe that they have a serious disease that

has not yet been detected, and they cannot
be persuaded(convinced) to the
contrary(differen)
 Their convictions persist despite negative
laboratory results,
 the benign course of the alleged disease over
time, and appropriate reassurances from
physicians.
 Course and Prognosis
• one third to one half of all patients with
hypochondriasis eventually improve significantly
• Good prognosis:
o sudden onset of symptoms, brief episode
o the absence of a personality disorder
o the absence of a related non psychiatric medical
condition.
o treatment-responsive anxiety or depression
• Most children with hypochondriasis recover by
late adolescence or early adulthood.
 Treatment
 office visits
• Frequent, regularly scheduled physical examinations

• Physicians are not abandoning them

• That their complaints are being taken seriously

Pharmacotherapy: comorbidities with anxiety disorder or major depressive

disorder.

• Psychotherapy
o Group psychotherapy:

provides the social support and social interaction that seem to reduce their anxiety.

– Individual insight-oriented psychotherapy, behavioural therapy, cognitive

therapy, may be useful.

4. Body Dysmorphic
Disorder
Preoccupation with an imagined defect in
appearance
 causes clinically significant distress or
impairment in important areas of
functioning.
 Epidemiology
poorly studied condition
patients are more likely to go to
o dermatologists
o internists
o plastic surgeons
The most common age of onset is between
15 and 30 years
 women are affected somewhat more often
than men
likely to be unmarried.
Cont...
Body dysmorphic disorder commonly coexists
with other mental disorders
One study found that more than 90 percent of
patients with body dysmorphic disorder had
experienced a major depressive episode in their
lifetimes
about 70 percent had experienced an anxiety
disorder; and
about 30 percent had experienced a psychotic
disorder
 DSM-V-TR Diagnostic Criteria
• Preoccupation with an imagined defect in
appearance excessive concern in the presence of
slight physical abnormality
• clinically significant distress or impairment in social,
occupational, or other important areas of
functioning.
• The preoccupation is not better accounted for by
another mental disorder (e.g., dissatisfaction with
body shape and size in anorexia nervosa).
• The most common concerns
o involve facial flaws, particularly those involving
specific parts (e.g., the nose).
o Other body parts are hair, breasts, and genitalia

• Common comorbid diagnoses

– depressive disorders and anxiety disorders
– patients may also have traits of OCD, schizoid, and
narcissistic personality disorders
 Differential diagnosis

• Anorexia nervosa

• Major depressive episode

• OCD

• Avoidant personality disorder or social

phobia
• Delusional disorder somatic type
 Course and Prognosis
 Begins during adolescence
 The onset can be gradual or abrupt.
 The disorder usually has a long and undulating
course with few symptom-free intervals.
 Treatment
 Treatment of patients with body dysmorphic
disorder with
• Surgical,
• Dermatological and
• Dental, to address the alleged defects is almost
invariably unsuccessful
Serotonin-specific drugs
Fluoxetine reduce symptoms in at least 50 percent
of patients
Treat coexisting disorder with the appropriate
pharmacotherapy and psychotherapy
 Pain Disorder
Formerly called
somatoform pain disorder
 psychogenic pain disorder
idiopathic pain disorder
 atypical pain disorder
 Epidemiology
• Prevalence
– lifetime prevalence 12 percent

– Pain disorder can begin at any age, peak onset is on 4th-

5th decade
– The gender ratio is unknown

• Chronic pain appears to be most frequently associated

with depressive disorders
• acute pain appears to be more commonly associated with
anxiety disorders
 Etiology
 Psychodynamic Factors
• Symbolically expressing an intrapsychic conflict through the body

• Pain can function as a method of obtaining love or a punishment

for wrong doing

 Behavioral Factors
• Pain behaviors are

– reinforced when rewarded

– inhibited when ignored or punished

• symptoms may become intense

 DSM V criterion
Pain in one or more anatomical sites

Pain cause significant distress/ suffering/

Pain cause impairment in social or occupational

functioning
• Inability to work

• Absence from work

• Frequent use of health care system

• Disruption of family normal life

 Clinical manifestation
 Common localization of pain

– Head, back, abdomen, pelvic, facial, chest

 Not better accounted by other psychiatric disorder

 Duration
– Chronic – 6 months or longer

– Acute – less than 6 months

 Treatment
May not be possible to cure the pain
 The treatment approach must address rehabilitation

 Discuss the issue of psychological factors

 Therapists must understand that the patient's experiences of

pain are real

Psychotherapy
 Individual psychotherapy

 Family therapy

 Behavioral – operant conditioning

6. Undifferentiated
Somatoform Disorder
• Undifferentiated somatoform disorder is
characterized by
– one or more unexplained physical symptoms of at least
6 months' duration
– which are below the threshold for a diagnosis of
somatization disorder

• Two types of symptom patterns:

1. those involving the autonomic nervous system
2.and those involving sensations of fatigue or weakness
 DSM-V-TR Diagnostic Criteria
One or more physical symptom

e.g. fatigue, loss appetite, gastrointestinal or

urinary complaints
Can not be explained by general medical illness or
direct effect of a substance
Significant distress or functional impairment
Symptoms are not intentionally produced or
feigned
Duration at least 6 months
7.Somatoform
Disorder NOS
 DSM-V-TR Diagnostic Criteria
• do not meet the criteria for any specific somatoform disorder.
E.g.,

• Pseudocyesis/Development of pregnancy symptoms in a nonpregnant

woman (e.g.,menstrual abnormalities, abdominal enlargement, and

breast changes/

o A disorder involving nonpsychotic hypochondriacal symptoms

of less than 6 months' duration.

o A disorder involving unexplained physical complaints (e.g.,

fatigue or body weakness) of less than 6 months' duration that

are not due to another mental disorder

 Case study one
• A middle-aged man is chronically preoccupied with
his health. For many years he feared that his
irregular bowel functions meant he had cancer. Now
he is very preoccupied about having a serious heart
disease, despite his physician’s assurance that the
occasional “extra beats” he detects when he checks
his pulse are completely benign. What is his most
likely diagnosis?
 Case study two

• A 20-year-old student is very distressed by a

small deviation of her nasal septum. She is
convinced that this minor imperfection is
disfiguring, although others can barely notice it.
 Case study three

• For the past three years, a 24- year-old college

student has suffered from chronic headaches,
fatigue, shortness of breath, dizziness, ringing
ears, and constipation. He is incensed when his
primary physician recommends a psychiatric
evaluation since no organic cause for his
symptoms could be found.
THANK
YOU!!!!