Somatoform Disorders Flashcards
Definition of medically unexplained symptoms
-Symptoms where no structural cause has been identified despite comprehensive investigation
=Do not correspond to or are clearly not typical of any known physical condition
=Are associated with an absence of any physical signs or structural abnormalities
=Are associated with an absence of any abnormalities in comprehensive laboratory, imaging and invasive investigations
-Psychiatric causes of medically unexplained symptoms are:
=Somatoform disorders: symptoms associated with undue distress
=Functional (or dissociative) disorders: common syndrome with associated structural abnormalities with unclear aetiology
Examples of functional disorders
-Cardio: atypical chest pain
-Resp: hyperventilation
-GI: IBS
-Neuro: dissociative seizures, weakness and sensory symptoms
-Rheumatology: fibromyalgia
-ID: chronic fatigue syndrome
Presenting features of somatoform disorders
-Undue concern with symptoms or preoccupation they have a severe illness (>6 months)
=Persists even after reassurance with normal results
-Preoccupation with minor or imagined defect in their appearance
-Anxiety and impaired functioning due to symptoms
-Frequent attendance at care providers and requests for investigations
Subtypes of somatoform disorder
-Somatisation disorder
=Preoccupation with multiple, recurrent and frequently changing physical SYMPTOMS
=No identifiable physiological explanation
=Patients are often seeking relief from their symptoms
-Hypochondriacal disorder
=Misinterpretation of normal bodily sensations to mean they have a serious and progressive physical disease e.g Cancer
=Patients often seek investigations to diagnose the underlying disease and refuse to accept reassurance
-Body Dysmorphic Disorder (BDD)
=Patient is preoccupied with imagined or minor defect in their physical appearance (e.g. ugly hands)
=Causes significant distress and/or functional impairment
-Somatoform autonomic dysfunction and persistent somatoform pain disorder
Epidemiology of somatoform disorders
-Medically unexplained symptoms represent around one third of medical outpatient appointments and a large proportion of primary care
=In these patients, functional or dissociative disorders are more common than somatoform disorders
-Somatoform disorders usually present in adolescence or early adulthood
-Somatisation disorder is about ten times more common in females
-~50% of patients with somatisation disorder have coexisting mental illness
Aetiology of somatoform disorders
-In somatoform disorders, symptoms are not under voluntary control –they cause genuine distress and functional impairment
=This different from factitious disorder and malingering in which the patient is feigning symptoms for their own gain
-Hypochondriacal disorder and BDD are both based on an overvalued idea at their core
=Childhood sexual abuse increases risk, growing up in environments where physical distress more readily acknowledged than psychological
- Abnormally intense self-directed attention interferes with normal ‘automatic’ cognitive processing, causing errors (much like thinking too long about how to spell a word)
- Abnormal sense of agency or disrupted sensory prediction prevents patients from differentiating self-generated versus involuntary movements, or normal from abnormal sensory input
Risk factors for somatoform disorders
-Childhood sexual abuse
-Growing up in environment that acknowledges physical more than emotional distress
-Life stressor (often the trigger for onset or worsening of perceived symptoms)
-Pre-existing anxiety disorder
Differential diagnosis of somatoform disorders: abnormal response to physical symptoms
-Undiagnosed unknown or known medical condition
-Functional disorders (dissociative/conversion disorders)
-Somatoform disorder
-Factitious disorder
-Malingering
-Anxiety disorders
-Mood disorders
-Psychotic disorder
=Schizophrenia
=Delusional disorder
Diagnostic criteria for somatisation disorder
-Numerous unexplained symptoms in multiple systems
-At least 2 years of unexplained symptoms
=Nausea, vomiting, diarrhoea, constipation food intolerance, abdominal pain
=Loss of libido, ED, irregular menses, menorrhagia, dysmenorrhoea
=Dysuria, frequency, urinary retention, incontinence
=Paralysis, paraesthesia, sensory loss, seizures, difficulty swallowing, impaired coordination or balance
-Persistent refusal to accept reassurance from multiple doctors that there is no physical cause
-Resulting functional impairment due to the symptoms and consequential behaviour
-Mild: one cognitive symptom
-Moderate: 2+ cognitive (anxiety)
-Severe: 2+ with multiple physical symptoms/ 1 severe
Differential diagnosis process
-Symptoms secondary to another psychiatric disorder; other psychiatric disorder
-Positive evidence of functional disorder (Hoover sign in neurological symptoms, pain relieved by defecation in IBS, tenderness at specific points in fibromyalgia): functional/ dissociative disorder
-Abnormal response to symptoms
=Undue concern over symptoms: Somatization disorder
=Undue concern over presence of underlying disorder: hypochondriacal disorder
=Undue concern over appearance: body dysmorphic disorder
-Symptoms fabricated
=Gain is sick role: factitious disorder
=Gain is external (benefits): malingering
ICD-10 diagnosis of somatization disorder
-At least 2 years of symptoms with no physical explanation found
-Persistent refusal by the patient to accept reassurance from several doctors that there is no physical cause for the symptoms
-Some degree of functional impairment due to the symptoms and resulting behaviour
=Most patients with somatization disorder will have a long history of contact with medical services, during which numerous investigations may have been conducted.
=This often results in iatrogenic disease with physically explainable symptoms (e.g. abdominal adhesions from frequent exploratory surgery).
=Due to frequent courses of medication, these patients are often dependent on analgesics and sedatives.
Describe hypochondriacal disorder
-Patients misinterpret normal bodily sensations, which lead them to believe that they have a serious and progressive physical disease.
-These patients tend to ask for investigations to definitively diagnose or confirm their underlying disease.
-However, despite repeated normal examination and investigations, hypochondriacal patients refuse to accept the reassurance of numerous doctors that they do not suffer from a serious physical illness.
-This is in contrast to somatization disorder, where patients tend to seek relief from their symptoms
Describe body dysmorphic disorder
-Body dysmorphic disorder (dysmorphophobia) is a variant of hypochondriacal disorder, in which patients are preoccupied with an imagined or minor defect in their physical appearance.
-The symptoms should not be better accounted for by another disorder (e.g. concerns regarding weight and body shape are usually more accurately attributed to an eating disorder).
-This imagined defect or deformity can concern any part of the body (e.g. a ‘crooked nose’ or ‘ugly hands’). The preoccupation causes significant distress or impairment in functioning.
-The psychopathology of both hypochondriacal disorder and body dysmorphic disorder takes the form of an overvalued idea
=The belief is not delusional because patients are open to some explanation and their fears can be allayed, at least for a short while.
=A persistent delusional disorder (somatic delusional disorder) is diagnosed if the belief is held with delusional intensity
Assessment of somatoform disorder
-History
=Do you often worry about your health/that you have a serious illness?
=Do you struggle to believe when a doctor tells you there is nothing wrong?
=Are you bothered by lots of different symptoms?
=Are you concerned about your appearance
-Examination
=Thorough physical exam with a focus on the system presenting on that occasion
-Investigations
=Take complaints seriously and investigate them as appropriate
=Avoid doing excessive and unnecessary investigations to reassure the patient
==This can actually worsen the problem/symptoms
==Also unnecessary invasive investigations can cause iatrogenic harm
Management of somatoform disorders
-Bio
=Rule out underlying physical condition
=SSRIs can be useful for moderate to severe BDD
==Pharmacotherapy is also useful in managing comorbid psychiatric illness
=Limit use of unnecessary medications to avoid dependence and iatrogenic harm
-Psycho
=A supportive and empathic relationship with the patient and aiding their understanding of their condition is likely the most important intervention
==Being dismissive can make the problem worse and reinforce the idea that they aren’t being listened to
=CBT (+/-ERP: exposure with response prevention) is recommended for patients with functionally impairing BDD
=In somatisation/hypochondriacal disorder, individual or group psychotherapy can reduce symptoms and help develop alternative strategies for managing emotions
-Social
=Consistent GP, regular fixed interval appointments, increased support during times of stress, involve family members and/or carers in the management
