Somatizing Disorders

Background

the mind and body ideally should operate as one unit Þ breakdown in mind/body interactions can lead to disorders

10% of medical services are provided to patients without objective evidence of disease resulting in $20 million per year

treatment is often ignored

Somatizing (or Somatiform) Disorders: clinical entities that present with three characteristics

(1) physical symptoms of disease
(2) no physical explanation is demonstrable
(3) there is positive evidence of a psychiatric explanation

Sick Role as accepted by society: a person with an illness has the right to relief from obligations with honor (without blame), but also has the obligation to want to get well and is expected to cooperate with efforts towards that end

Alexithymia: an inability to articulate or even appreciate one’s own feelings; psychological pain is often communicated in the form of physical pain because that may be all that is known; this can be looked at as a throwback to infancy when physical and psychological pain were inseparable

Components of Somatiform Disorders

communication: patient expresses a complaint of mental or physical pain and requests care for that complaint

primary gain: resolution of a psychological conflict is the primary gain of the somatiform disorders

secondary gain: nuturance and power (sympathy from friends and family, relief of obligations) is a secondary gain

attention to physiological components of arousal

The Somatiform Disorders

Conversion Disorder: involves a single symptom in a single body system without physical explanation

Diagnosis: never by exclusion - need to find a positive psychiatric explanation

diagnostic clues include:

onset at time of stress

identification (mimicking disease state of others)

symbolism (symptom is a solution for a psychological conflict - the primary gain)

la belle indifference: patient indifference to a crippling syndrome

history of previous vague illness at times of emotional stress

histrionic personality type is also common

example: a patient with aggressive thoughts towards a supervisor has paralysis of his punching arm Þ the psychological conflict has been superficially solved because he is no longer capable of hitting his boss

Somatiform Pain Disorder: basically conversion disorder when the primary complaint is pain; there is an absence of physical findings and a psychological cause can be found

Somatization Disorder: polysymptomatic; primarily diagnosed in women

onset of complaints must be before age 30

multiple system impairment must involve at least eight complaints: 4 pain; 2 GI; 1 sexual; 1 pseudoneurologic
anxiety and depression are common co-morbid factors
this disorder has a chronic course and is very often related to a history of childhood abuse

Hypochondriasis: unrealistic interpretation of physical sensations as abnormal - symptom amplification

leads to preocupation with fear or belief of having serious disease even through the sensations may be normal
chronic and crippling, or may be transient (i.e. following a major illness)

what determines whether a transient course becomes chronic?

vulnerability: previous Axis I and II diagnosis (evidence that coping skills are somewhat lacking)
disability payments (may still be unconcious)
family: leads to secondary gains

doctor behaviors: the more tests, consults, etc we get, the more serious they think their complaint is

Body Dysmorphic Disorder

preoccupation with an imagined defect in physical appearance out of proportion to any actual physical abnormality
not significant to be labeled a delusion, but still must cause the patient considerable distress

Undifferentiated Somatoform Disorder

more than six months of physically unexplained illness that does not meet criteria for another somatiform disorder

Other Psychiatric Disorders that Present with Physical Complaints

psychosis; major depression; anxiety-panic disorder (tend to latch onto most dire possibilities of panic attacks - i.e. MI)

Management: requires biopsychosocial apporoach - patients are very difficult to deal with because there’s really not a lot to do for their complaints, and they usually refuse to talk to a psychiatrist; regularly scheduled appointments (not prn) can provide reassurance for the patient; gently try to educate them on the relationship between stress and symptoms; don’t overreact because that will reinforce their pain; however, don’t negate their suffering

Diagnosis	Motivation	Production of Symptoms
Conversion Disorder	Unconscious	Unconscious
Factitious Disorder	Unconscious	Conscious
Malingering Disorder	Conscious	Conscious

Motivation: is the patient aware of their reason for producing the symptoms that they do?

Production of symptoms: is the patiently conciously/actively doing something to produce the symptoms?