Somatoform Disorders

Somatoform (DSM-4) physical symptoms suggesting

DISORDERS

a medical condition, yet the symptoms are

Ramon S. Javier, MD
Department of Neurology & Psychiatry
UST Faculty of Medicine & Surgery
not fully explained by the medical disorder,
by substance use, or by another mental
disorder.

Physical symptoms are not intentionally
produced.

Somatoform Disorders Somatoform Disorders

Pain symptoms:
 headache

(ICD-10) repeated presentation of physical  abdominal pain
symptoms, together with persistent request  back pain
for medical investigation, although patients  joint pain
have been reassured by their physicians that  chest pain
the symptoms have no physical basis.  pains involving the extremities
 pain during menstruation
 pain during sexual intercourse
 pain during urination

Somatoform Disorders Somatoform Disorders

Gastrointestinal symptoms:
Sexual symptoms:

 nausea  sexual indifference
 dizziness  erectile or ejaculatory dysfunction
 bloating  irregular menses
 vomiting other than during pregnancy,  excessive menstrual bleeding
diarrhea, or intolerance of several different  vomiting throughout pregnancy
foods.

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Somatoform Disorders

Pseudoneurological symptoms:
 Impaired coordination or balance
 Paralysis or localized weakness
 Dysphagia or lump in throat
 aphonia
 Urinary retention
 Diplopia
 Hypoanesthesia
 Dissociative symptoms
Somatization Disorders
(DSM-IV)

many somatic symptoms that cannot be
explained adequately on the basis of
physical and laboratory examinations.

begins before the age of 30

chronic and associated with significant
psychological distress, impairment of social
and occupational functioning and seek
excessive medical help.
Somatization Disorder
Epidemiology

lifetime prevalence:
 0.1% or 0.2%
 5-to-1 female to male ratio

beginning before the age 30

2/3 have identifiable psychiatric symptoms

1/2 have mental disorder

commonly assoc. w/ personality disorder.
Classification of Somatoform
Disorder (DSM-IV)

Specific somatoform disorder
 Somatization disorder
 Conversion disorder
 Hypochondriasis disorder
 Body dysmorphic disorder
 Pain disorder
 Undifferentiated SD
 Somatoform disorder not otherwise
described
Somatization Disorders
(DSM-IV)

combination of at least
4 pain symptoms
 2 gastointestinal symptoms
 1 sexual symptom
 1 pseudoneurological symptom.
Etiology:
Psychosocial factor

psychoanalytic interpretations of
symptoms rest on the hypothesis that
the symptoms substitute for repressed
instinctual impulses.

behavioral perspective emphasizes that
parental teaching, parental example, and
ethnic mores may teach some children to
somatize.

Social, cultural, and ethnic factors.
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 Etiology:
Biological factor

Neuropsychological basis:
 patients have characteristic attention and
cognitive impairments that result in faulty
perception and assessment of somatosensory
inputs.

Brain-imaging study:
 decrease metabolism in the frontal lobes in the
nondominant hemisphere

Genetic:
 occurring in 10 to 20% of the 1st degree female
relatives.
Conversion Disorder
(DSM-IV)

presence of one or more neurological
symptoms that cannot be explained by a known
neurological or medical disorder.

psychological factors be associated with the
initiation or exacerbation of the symptoms.

symptom of deficit is not intentionally produced.

symptom or deficit causes significant distress
or impairment to social, occupational and other
important areas.
Conversion Disorder
Epidemiology

lifetime prevalence:
 22 per 100,000 population

most common in adolescent

ratio of women to men - 5 to 1

in men usually occupational or military
accidents.

most common among rural pop.
Etiology:
Biological factor

Cytokines:
 help cause some of the nonspecific
symptoms of disease, especially
infection, hypersomnia, anorexia,
fatigue, and depression.
Conversion Disorder
(DSM-IV)

paralysis, blindness, and mutism are the
most common symptoms.

most commonly associated with passive-
aggressive, dependent, antisocial, and
histrionic personality disorders.

sensory sx. - anesthesia and paresthesia

motor sx. - abnormal movements, gait
disturbances, weakness and paralysis.

pseudoseizures
Etiology:
Psychological factors

Repression of unconscious intrapsychic
conflict and conversion of anxiety into
physical symptom.

Symptoms allow partial expression of
the forbidden wish or urge but disguise it
to avoid consciously confronting there
unacceptable impulse.
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 Etiology:
Biological factors

Brain-imaging
 hypometabolism of the dominant hemisphere
and hypermetabolism of the dominant
hemisphere.
 Impaired hemispheric communication.

Excessive cortical arousal - sets off negative
feedback loops between the cerebral cortex
and brainstem reticular formation.
Hypochondriasis Disorder
Epidemiology

prevalence:
 4 to 6% in a general medical clinic
population.

occurs at any age > 20 - 30 yrs.

men and women equally affected

social position, education level, and
marital status do not appear to affect the
diagnosis.
Body Dysmorphic Disorder
(DSM-IV)

Preoccupation with an imagined defect or
exaggerated distortion of a minimal or
minor defect in physical appearance.

Preoccupation causes clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning.

Preoccupation is not better accounted for
by another mental disorder.
Hypochondriasis Disorders
(DSM-IV)

Preoccupation with the fear of contracting,
or the belief of having a serious disease.

Usually abdominal complaints.

Unrealistic or inaccurate interpretations of
physical symptoms or sensations.

No known medical cause.

Preoccupation result in significant distress
and impair their ability to function.
Etiology:
Hypochondriasis

symptoms reflect a misinterpretation of bodily
symptoms.

request for admission to the sick role made by
a person facing seemingly insurmountable
and insolvable problems.

coexisting with depression and anxiety
disorder,

aggression and hostile wishes are transferred
into physical complaints
Body Dysmorphic Disorder
Epidemiology

most common age of onset - 15 - 20 yrs.

women are often affected than men

affected patient likely unmarried.

commonly coexist with mental disorders.

90% experience major depression.

70% - anxiety disorder.

30% - psychotic disorder.
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 Etiology: Body Dysmorphic Disorder:
Body Dysmorphic Disorder Common location of imaging defects.

unknown
hair - 63%

due to high comorbidity with depressive
nose - 50%
disorder serotonin neurotransmitter maybe
involved.
skin - 50%

psychodynamic models - displacement of
eyes - 27%
sexual or emotional conflict into a
head, face - 20%
nonrelated body part.

overall body build - 17%

lips - 17%

Pain Disorder Pain Disorder

(DSM-IV) Epidemiology

Pain in one or more anatomical sites is the
more common in women.

predominant focus of the clinical presentation
and is of sufficient severity to warrant clinical
attention.

Causes significant distress or impairment in
social, occupational or other important areas of
functioning.

Psychological factor plays an important role in
the onset, severity, exacerbation, or
maintenance of the pain.

peak ages of onset - 4th and 5th decades

most common in blue collared occupation

genetic inheritance or behavioral mechanisms
are possibly involved in the transmission.

assoc. with depressive, anxiety and substance
abuse disorders.

Pain Disorder Pain Disorder

Etiology:Psychosocial factor

Symbolic expression of intrapsychic conflict
through the body.

Unconscious regard of emotional pain as
weak and somewhat lacking in legitimacy.

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

Means to obtain love.

Means of manipulation and gaining advantage
in interpersonal relationship.
Etiology: Biological factor

Neurotransmitter serotonin maybe
involved in the descending inhibitory
pathway for pain.

Role of endorphins in the modulation of
pain.