1. Somatoform Disorders
ARUN.MARUN.M
KVM COLLEGEKVM COLLEGE

2. Somatoform Disorders
A mental disorder characterized by a groupA mental disorder characterized by a group
of condition in which the physical pain andof condition in which the physical pain and
symptoms a person feels are related tosymptoms a person feels are related to
psychological factors.psychological factors.

3. Somatoform Disorders
A mental disorder characterized by physicalA mental disorder characterized by physical
symptoms that suggest physical illness orsymptoms that suggest physical illness or
injury symptoms that cannot be explainedinjury symptoms that cannot be explained
fully by a general medical condition or byfully by a general medical condition or by
the direct effect of a substance and are notthe direct effect of a substance and are not
attributable to another mental disorder.attributable to another mental disorder.

4. Somatoform Disorders
 Have you ever “played sick” in order to get outHave you ever “played sick” in order to get out
of something?of something? How did that work out (did youHow did that work out (did you
get what you wanted)?get what you wanted)?
 SickSick  attention (friends, family, medical) =attention (friends, family, medical) =
secondary gainssecondary gains
 Likely link between secondary gains andLikely link between secondary gains and
somatoform disorderssomatoform disorders
 Some medical condition may actually existSome medical condition may actually exist

5. Types of Somatoform Disorders
 Conversion DisorderConversion Disorder
 An expression of psychological conflict or need that involves anAn expression of psychological conflict or need that involves an
alteration or loss of physical functioning that suggests a bodilyalteration or loss of physical functioning that suggests a bodily
cause in the absence of a medical reasoncause in the absence of a medical reason
 HypochondriasisHypochondriasis
 Preoccupation with having or contracting a serious disease in thePreoccupation with having or contracting a serious disease in the
absence of a medical reasonabsence of a medical reason
 Somatization DisorderSomatization Disorder
 Repeated concern with a variety of bodily complaints in theRepeated concern with a variety of bodily complaints in the
absence of a medical reasonabsence of a medical reason
 Body Dysmorphic DisorderBody Dysmorphic Disorder
 Preoccupation with an imagined defect in appearance of a normal-Preoccupation with an imagined defect in appearance of a normal-
appearing personappearing person
 Pain DisorderPain Disorder
 Preoccupation with pain in the absence of an adequate physicalPreoccupation with pain in the absence of an adequate physical
basis for itbasis for it

6. Somatization Disorder
Somatization disorder is an illness ofSomatization disorder is an illness of
multiple somatic complaints in multiplemultiple somatic complaints in multiple
organ systems that occurs over a period oforgan systems that occurs over a period of
several years and results in significantseveral years and results in significant
impairment or treatment seeking, or bothimpairment or treatment seeking, or both

7. INCIDENCE
 Lifetime prevalence:Lifetime prevalence:
 0.2 – 2% in women0.2 – 2% in women
 less than 0.2% in menless than 0.2% in men

8. ETIOLOGY
Psychosocial FactorsPsychosocial Factors
 The cause is unknown.The cause is unknown.
 Interpretations of the symptoms as socialInterpretations of the symptoms as social
communication whose result is to avoidcommunication whose result is to avoid
obligations (e.g., going to a job a person doesobligations (e.g., going to a job a person does
not like), to express emotions (e.g., anger at anot like), to express emotions (e.g., anger at a
spouse), or to symbolize a feeling or a beliefspouse), or to symbolize a feeling or a belief
(e.g., a pain in the gut).(e.g., a pain in the gut).

9.  Biological FactorsBiological Factors
Patients have characteristic attention andPatients have characteristic attention and
cognitive impairments that result in thecognitive impairments that result in the
faulty perception and assessment offaulty perception and assessment of
somatosensory inputssomatosensory inputs

10. GeneticsGenetics
 Occurs in 10 to 20 percent of the first-Occurs in 10 to 20 percent of the first-
degree female, first-degree male relativesdegree female, first-degree male relatives
are susceptible to substance abuse andare susceptible to substance abuse and
antisocial personality disorder.antisocial personality disorder.
 29 percent in monozygotic twins and 1029 percent in monozygotic twins and 10
percent in dizygotic twinspercent in dizygotic twins

11. CytokinesCytokines
 Cytokines are messenger molecules that theCytokines are messenger molecules that the
immune system uses to communicate withinimmune system uses to communicate within
itself and with the nervous system,itself and with the nervous system,
including the brain.including the brain.
 The abnormal regulation of the cytokineThe abnormal regulation of the cytokine
system may result in some of the symptomssystem may result in some of the symptoms
seen in somatoform disorders.seen in somatoform disorders.

12. CytokinesCytokines
 Cytokines are messenger molecules that theCytokines are messenger molecules that the
immune system uses to communicate withinimmune system uses to communicate within
itself and with the nervous system,itself and with the nervous system,
including the brain.including the brain.
 The abnormal regulation of the cytokineThe abnormal regulation of the cytokine
system may result in some of the symptomssystem may result in some of the symptoms
seen in somatoform disorders.seen in somatoform disorders.

13. Diagnosis
 A history of many physical complaintsA history of many physical complaints
beginning before age 30 years that occurbeginning before age 30 years that occur
over a period of several years and result inover a period of several years and result in
treatment being sought or significanttreatment being sought or significant
impairment in social, occupational, or otherimpairment in social, occupational, or other
important areas of functioningimportant areas of functioning

14.  Each of the following criteria must haveEach of the following criteria must have
been met, with individual symptomsbeen met, with individual symptoms
occurring at any time during the course ofoccurring at any time during the course of
the disturbance:the disturbance:
 four pain symptoms: a history of painfour pain symptoms: a history of pain
related to at least four different sites orrelated to at least four different sites or
functionsfunctions
 two gastrointestinal symptoms: a historytwo gastrointestinal symptoms: a history
of at least two gastrointestinal symptomsof at least two gastrointestinal symptoms
other than painother than pain

15.  one sexual symptom: a history of at least oneone sexual symptom: a history of at least one
sexual or reproductive symptom other thansexual or reproductive symptom other than
painpain
 one pseudoneurological symptom: a history ofone pseudoneurological symptom: a history of
at least one symptom or deficit suggesting aat least one symptom or deficit suggesting a
neurological condition not limited to painneurological condition not limited to pain
(conversion symptoms such as impaired(conversion symptoms such as impaired
coordination or balance, paralysis or localizedcoordination or balance, paralysis or localized
weakness, difficulty swallowing or lump inweakness, difficulty swallowing or lump in
throat, aphonia, urinary retention,throat, aphonia, urinary retention,
hallucinations, loss of touch or pain sensation,hallucinations, loss of touch or pain sensation,
double vision, blindness, deafness, seizures;double vision, blindness, deafness, seizures;
dissociative symptoms)dissociative symptoms)

16. C. Either:C. Either:
1) symptoms in Criterion B cannot be1) symptoms in Criterion B cannot be
fully explained by a known GMCfully explained by a known GMC
or 2) when a GMC does exist, theor 2) when a GMC does exist, the
symptoms in Criterion B are in excesssymptoms in Criterion B are in excess
of what would be expected based onof what would be expected based on
medical factsmedical facts
D. Symptoms not intentionallyD. Symptoms not intentionally producedproduced

17. Clinical FeaturesClinical Features
 Patients with somatization disorder have manyPatients with somatization disorder have many
somatic complaints and long, complicated medicalsomatic complaints and long, complicated medical
histories.histories.
Nausea and vomiting (other than duringNausea and vomiting (other than during
pregnancy), difficulty swallowing, pain in thepregnancy), difficulty swallowing, pain in the
arms and legs, shortness of breath unrelated toarms and legs, shortness of breath unrelated to
exertion, amnesia, and complications of pregnancyexertion, amnesia, and complications of pregnancy
and menstruation are among the most commonand menstruation are among the most common
symptoms.symptoms.

18.  Patients frequently believe that they havePatients frequently believe that they have
been sickly most of their lives.been sickly most of their lives.
 Psychological distress and interpersonalPsychological distress and interpersonal
problems are prominent; anxiety andproblems are prominent; anxiety and
depression are the most prevalentdepression are the most prevalent
psychiatric conditions.psychiatric conditions.
 Suicide threats are common, but actualSuicide threats are common, but actual
suicide is raresuicide is rare

19.  Somatization disorder is commonlySomatization disorder is commonly
associated with other mental disorders,associated with other mental disorders,
including major depressive disorder,including major depressive disorder,
personality disorders, substance-relatedpersonality disorders, substance-related
disorders, generalized anxiety disorder, anddisorders, generalized anxiety disorder, and
phobias. The combination of these disordersphobias. The combination of these disorders
and the chronic symptoms results in anand the chronic symptoms results in an
increased incidence of marital,increased incidence of marital,
occupational, and social problemsoccupational, and social problems

20. Course and PrognosisCourse and Prognosis
 Somatization disorder is a chronic and relapsingSomatization disorder is a chronic and relapsing
disorder that rarely remits completely.disorder that rarely remits completely.
 It is unusual for the individual with somatizationIt is unusual for the individual with somatization
disorder to be free of symptoms for greater thandisorder to be free of symptoms for greater than
1 year, during which time they may see a doctor1 year, during which time they may see a doctor
several times.several times.
 Research has indicated that a person diagnosedResearch has indicated that a person diagnosed
with somatization disorder has approximately anwith somatization disorder has approximately an
80 percent chance of being diagnosed with this80 percent chance of being diagnosed with this
disorder 5 years laterdisorder 5 years later

21. TreatmentTreatment
 Somatization disorder is best treated whenSomatization disorder is best treated when
the patient has a single identified physician asthe patient has a single identified physician as
primary caretaker. When more than oneprimary caretaker. When more than one
clinician is involved, patients have increasedclinician is involved, patients have increased
opportunities to express somatic complaints.opportunities to express somatic complaints.
 Psychotherapy, both individual and groupPsychotherapy, both individual and group
therapytherapy

22.  Conversion DisorderConversion Disorder
Conversion disorder is an illness ofConversion disorder is an illness of
symptoms or deficits that affect voluntarysymptoms or deficits that affect voluntary
motor or sensory functions, which suggestmotor or sensory functions, which suggest
another medical condition, but that isanother medical condition, but that is
judged to be caused by psychologicaljudged to be caused by psychological
factors because the illness is preceded byfactors because the illness is preceded by
conflicts or other stressors.conflicts or other stressors.

23. INCIDENCEINCIDENCE
 Highly prevalent FemaleHighly prevalent Female
 predominancepredominance
Young ageYoung age
Rural and low social classRural and low social class
Little-educated and psychologicallyLittle-educated and psychologically
unsophisticatedunsophisticated

24. ETIOLOGYETIOLOGY
 Psychoanalytic FactorsPsychoanalytic Factors
Caused by repression of unconscious intra-Caused by repression of unconscious intra-
psychic-conflict and conversion of anxietypsychic-conflict and conversion of anxiety
into a physical symptom.into a physical symptom.
 Learning TheoryLearning Theory
Conversion symptom can be seen as a pieceConversion symptom can be seen as a piece
of classically conditioned learned behavior;of classically conditioned learned behavior;
symptoms of illness, learned in childhood,symptoms of illness, learned in childhood,
are called forth as a means of coping withare called forth as a means of coping with
an otherwise impossible situation.an otherwise impossible situation.

25.  Biological FactorsBiological Factors
Increasing data implicate biological andIncreasing data implicate biological and
neuropsychological factors in theneuropsychological factors in the
development of conversion disorderdevelopment of conversion disorder
symptomssymptoms

26. Clinical FeaturesClinical Features
 Paralysis, blindness, and mutism are the mostParalysis, blindness, and mutism are the most
common conversion disorder symptoms.common conversion disorder symptoms.
 Conversion disorder may be most commonlyConversion disorder may be most commonly
associated with passive-aggressive, dependent,associated with passive-aggressive, dependent,
antisocial, and histrionic personality disorders.antisocial, and histrionic personality disorders.
 Depressive and anxiety disorder symptoms oftenDepressive and anxiety disorder symptoms often
accompany the symptoms of conversion disorder,accompany the symptoms of conversion disorder,
and affected patients are at risk for suicide.and affected patients are at risk for suicide.

27. SYMPTOMSSYMPTOMS
 Motor SymptomsMotor Symptoms
Involuntary movementsInvoluntary movements
TicsTics
TorticollisTorticollis
SeizuresSeizures
Abnormal gaitAbnormal gait
FallingFalling
ParalysisParalysis
WeaknessWeakness
AphoniaAphonia

28.  Sensory DeficitsSensory Deficits
Anesthesia, especially of extremitiesAnesthesia, especially of extremities
BlindnessBlindness
Tunnel visionTunnel vision
DeafnessDeafness
 Visceral SymptomsVisceral Symptoms
Psychogenic vomitingPsychogenic vomiting
Urinary retentionUrinary retention
DiarrheaDiarrhea

29. DIAGNOSISDIAGNOSIS
 One or more symptoms or deficits affectingOne or more symptoms or deficits affecting
voluntary motor or sensory function thatvoluntary motor or sensory function that
suggest a neurological or other generalsuggest a neurological or other general
medical condition.medical condition.
 Psychological factors are judged to bePsychological factors are judged to be
associated with the symptom or deficitassociated with the symptom or deficit
because the initiation or exacerbation of thebecause the initiation or exacerbation of the
symptom or deficit is preceded by conflictssymptom or deficit is preceded by conflicts
or other stressors.or other stressors.

30.  The symptom or deficit is not intentionallyThe symptom or deficit is not intentionally
produced.produced.
 The symptom or deficit cannot, afterThe symptom or deficit cannot, after
appropriate investigation, be fully explainedappropriate investigation, be fully explained
by a general medical condition, or by theby a general medical condition, or by the
direct effects of a substance, or as adirect effects of a substance, or as a
culturally sanctioned behavior orculturally sanctioned behavior or
experience.experience.

31.  The symptom or deficit causes clinicallyThe symptom or deficit causes clinically
significant distress or impairment in social,significant distress or impairment in social,
occupational, or other important areas ofoccupational, or other important areas of
functioning or warrants medical evaluation.functioning or warrants medical evaluation.
 The symptom or deficit is not limited toThe symptom or deficit is not limited to
pain or sexual dysfunction, does not occurpain or sexual dysfunction, does not occur
exclusively during the course ofexclusively during the course of
somatization disorder, and is not bettersomatization disorder, and is not better
accounted for by another mental disorder.accounted for by another mental disorder.

32.  Course and PrognosisCourse and Prognosis
Symptoms or deficits are usually ofSymptoms or deficits are usually of
short duration, and approximately 95short duration, and approximately 95
percent of acute cases remit spontaneously,percent of acute cases remit spontaneously,
usually within 2 weeks in hospitalizedusually within 2 weeks in hospitalized
patients.patients.

33. TreatmentTreatment
Insight-oriented supportive or behavior therapy.Insight-oriented supportive or behavior therapy.
Hypnosis, anxiolytics, and behavioural relaxationHypnosis, anxiolytics, and behavioural relaxation
exercises are effective in some cases.exercises are effective in some cases.

34.  HypochondriasisHypochondriasis
Hypochondriasis is characterized byHypochondriasis is characterized by
6 months or more of a general and6 months or more of a general and
nondelusional preoccupation with fearsnondelusional preoccupation with fears
of having, or the idea that one has, aof having, or the idea that one has, a
serious disease based on the person'sserious disease based on the person's
misinterpretation of bodily symptoms.misinterpretation of bodily symptoms.

35. EpidemiologyEpidemiology
 Men and women are equally affected byMen and women are equally affected by
hypochondriasis.hypochondriasis.
 Onset of symptoms can occur at any age,Onset of symptoms can occur at any age,
the disorder most commonly appears inthe disorder most commonly appears in
persons 20 to 30 years of age.persons 20 to 30 years of age.

36. EtiologyEtiology
Psychodynamic theoryPsychodynamic theory
 According to this theory, aggressive and hostileAccording to this theory, aggressive and hostile
wishes toward others are transferred (throughwishes toward others are transferred (through
repression and displacement) into physicalrepression and displacement) into physical
complaints.complaints.
 Hypochondriasis is also viewed as a defenceHypochondriasis is also viewed as a defence
against guilt, a sense of innate badness, anagainst guilt, a sense of innate badness, an
expression of low self-esteem, and a sign ofexpression of low self-esteem, and a sign of
excessive self-concern.excessive self-concern.

37. Learning theoryLearning theory
 Sick role made by a person facingSick role made by a person facing
seemingly insolvable problems.seemingly insolvable problems.
 The sick role offers an escape that allows aThe sick role offers an escape that allows a
patient to avoid obligations, to postponepatient to avoid obligations, to postpone
unwelcome challenges, and to be excusedunwelcome challenges, and to be excused
from usual duties.from usual duties.

38.  A third theory suggests thatA third theory suggests that
hypochondriasis is a variant form of otherhypochondriasis is a variant form of other
mental disorders, among which depressivemental disorders, among which depressive
disorders and anxiety disorders are mostdisorders and anxiety disorders are most
frequently included. An estimated 80frequently included. An estimated 80
percent of patients with hypochondriasispercent of patients with hypochondriasis
may have coexisting depressive or anxietymay have coexisting depressive or anxiety
disorders.disorders.

39. Clinical FeaturesClinical Features
 Patients with hypochondriasis believe thatPatients with hypochondriasis believe that
they have a serious disease that has not yetthey have a serious disease that has not yet
been detected.been detected.
 They may maintain a belief that they have aThey may maintain a belief that they have a
particular disease or, as time progresses,particular disease or, as time progresses,
they may transfer their belief to anotherthey may transfer their belief to another
disease.disease.

40.  Their convictions persist despite negativeTheir convictions persist despite negative
laboratory results..laboratory results..
 Hypochondriasis is often accompanied byHypochondriasis is often accompanied by
symptoms of depression and anxiety andsymptoms of depression and anxiety and
commonly coexists with a depressive orcommonly coexists with a depressive or
anxiety disorder.anxiety disorder.

41. DiagnosisDiagnosis
 Preoccupation with fears of having, or the ideaPreoccupation with fears of having, or the idea
that one has, a serious disease based on thethat one has, a serious disease based on the
person's misinterpretation of bodily symptoms.person's misinterpretation of bodily symptoms.
 The preoccupation persists despite appropriateThe preoccupation persists despite appropriate
medical evaluation and reassurance.medical evaluation and reassurance.
 The belief in Criterion A is not of delusionalThe belief in Criterion A is not of delusional
intensity (as in delusional disorder, somatic type)intensity (as in delusional disorder, somatic type)
and is not restricted to a circumscribed concernand is not restricted to a circumscribed concern
about appearance (as in body dysmorphicabout appearance (as in body dysmorphic
disorder).disorder).

42.  The preoccupation causes clinically significantThe preoccupation causes clinically significant
distress or impairment in social, occupational,distress or impairment in social, occupational,
or other important areas of functioning.or other important areas of functioning.
 The duration of the disturbance is at least 6The duration of the disturbance is at least 6
months.months.
 The preoccupation is not better accounted forThe preoccupation is not better accounted for
by generalized anxiety disorder, obsessive-by generalized anxiety disorder, obsessive-
compulsive disorder, panic disorder, a majorcompulsive disorder, panic disorder, a major
depressive episode, separation anxiety, ordepressive episode, separation anxiety, or
another somatoform disorder.another somatoform disorder.

43. Course and PrognosisCourse and Prognosis
 The course of hypochondriasis is usuallyThe course of hypochondriasis is usually
episodic; the episodes last from months to yearsepisodic; the episodes last from months to years
and are separated by equally long quiescentand are separated by equally long quiescent
periods.periods.
 A good prognosis is associated with highA good prognosis is associated with high
socioeconomic status, treatment-responsivesocioeconomic status, treatment-responsive
anxiety or depression, sudden onset of symptoms,anxiety or depression, sudden onset of symptoms,
the absence of a personality disorder, and thethe absence of a personality disorder, and the
absence of a related nonpsychiatric medicalabsence of a related nonpsychiatric medical
condition.condition.
 Most children with hypochondriasis recover byMost children with hypochondriasis recover by
late adolescence or early adulthood.late adolescence or early adulthood.

44. TreatmentTreatment
 Patients with hypochondriasis usually resistPatients with hypochondriasis usually resist
psychiatric treatment.psychiatric treatment.
 Group psychotherapy often benefits suchGroup psychotherapy often benefits such
patients, in part because it provides the socialpatients, in part because it provides the social
support and social interaction that seem tosupport and social interaction that seem to
reduce their anxiety.reduce their anxiety.
 Other forms of psychotherapy, such asOther forms of psychotherapy, such as
individual insight-oriented psychotherapy,individual insight-oriented psychotherapy,
behavior therapy, cognitive therapy, andbehavior therapy, cognitive therapy, and
hypnosis may be useful.hypnosis may be useful.

45.  Pharmacotherapy alleviatesPharmacotherapy alleviates
Hypochondriacal symptoms only when aHypochondriacal symptoms only when a
patient has an underlying drug-responsivepatient has an underlying drug-responsive
condition, such as an anxiety disorder orcondition, such as an anxiety disorder or
major depressive disordermajor depressive disorder

46.  Body Dysmorphic DisorderBody Dysmorphic Disorder
Body dysmorphic disorder isBody dysmorphic disorder is
characterized by a preoccupation with ancharacterized by a preoccupation with an
imagined defect in appearance that causesimagined defect in appearance that causes
clinically significant distress or impairment inclinically significant distress or impairment in
important areas of functioning.important areas of functioning.

47. EpidemiologyEpidemiology
 Most common age of onset is between 15Most common age of onset is between 15
and 30 yearsand 30 years
 Women are affected more often than men.Women are affected more often than men.
 Affected patients are also likely to beAffected patients are also likely to be
unmarried.unmarried.
 Body dysmorphic disorder commonlyBody dysmorphic disorder commonly
coexists with other mental disorderscoexists with other mental disorders

48. EtiologyEtiology
 The cause of body dysmorphic disorder isThe cause of body dysmorphic disorder is
unknown.unknown.
 Some patients, the pathophysiology of theSome patients, the pathophysiology of the
disorder may involve serotonin and may bedisorder may involve serotonin and may be
related to other mental disorders.related to other mental disorders.
 Stereotyped concepts of beauty emphasized inStereotyped concepts of beauty emphasized in
certain families and within the culture at largecertain families and within the culture at large
may significantly affect patients with bodymay significantly affect patients with body
dysmorphic disorder.dysmorphic disorder.

49.  In psychodynamic models, bodyIn psychodynamic models, body
dysmorphic disorder is seen as reflectingdysmorphic disorder is seen as reflecting
the displacement of a sexual or emotionalthe displacement of a sexual or emotional
conflict onto a nonrelated body part.conflict onto a nonrelated body part.

50. Clinical FeaturesClinical Features
 The most common concerns involve facialThe most common concerns involve facial
flaws, particularly those involving specificflaws, particularly those involving specific
partsparts
 Common associated symptoms includeCommon associated symptoms include
ideas of delusions of reference , eitherideas of delusions of reference , either
excessive mirror checking or avoidance ofexcessive mirror checking or avoidance of
reflective surfaces, and attempts to hide thereflective surfaces, and attempts to hide the
presumed deformity (with makeup orpresumed deformity (with makeup or
clothing). suicide.clothing). suicide.

51.  The effects on a person's life can beThe effects on a person's life can be
significant; almost all affected patientssignificant; almost all affected patients
avoid social and occupational exposure.avoid social and occupational exposure.
 As many as one third of the patients may beAs many as one third of the patients may be
housebound because of worry about beinghousebound because of worry about being
ridiculed for the alleged deformities, andridiculed for the alleged deformities, and
approximately one fifth attempt suicide.approximately one fifth attempt suicide.

52. DiagnosisDiagnosis
 Preoccupation with an imagined defect inPreoccupation with an imagined defect in
appearance. If a slight physical anomaly isappearance. If a slight physical anomaly is
present, the person's concern is markedlypresent, the person's concern is markedly
excessive.excessive.
 The preoccupation causes clinically significantThe preoccupation causes clinically significant
distress or impairment in social, occupational, ordistress or impairment in social, occupational, or
other important areas of functioning.other important areas of functioning.
 The preoccupation is not better accounted for byThe preoccupation is not better accounted for by
another mental disorder (e.g., dissatisfaction withanother mental disorder (e.g., dissatisfaction with
body shape and size in anorexia nervosa).body shape and size in anorexia nervosa).

53. TreatmentTreatment
 Treatment of patients with bodyTreatment of patients with body
dysmorphic disorder with surgical,dysmorphic disorder with surgical,
dermatological, dental, and other medicaldermatological, dental, and other medical
procedures to address the alleged defects isprocedures to address the alleged defects is
almost invariably unsuccessful.almost invariably unsuccessful.

54. AntidepressentsAntidepressents
 Tricyclic drugs, monoamine oxidaseTricyclic drugs, monoamine oxidase
inhibitors (MAOIs), SSRIhave reportedlyinhibitors (MAOIs), SSRIhave reportedly
been useful.been useful.

55.  Pain DisorderPain Disorder
A pain disorder is characterized by theA pain disorder is characterized by the
presence of, and focus on, pain in one orpresence of, and focus on, pain in one or
more body sites and is sufficiently severe tomore body sites and is sufficiently severe to
come to clinical attention.come to clinical attention.

56. EpidemiologyEpidemiology
 The prevalence of pain disorder appears toThe prevalence of pain disorder appears to
be common.be common.
 Recent work indicates that the 6-month andRecent work indicates that the 6-month and
lifetime prevalence is approximately 5lifetime prevalence is approximately 5
percent and 12 percent, respectively.percent and 12 percent, respectively.

57. EtiologyEtiology
Psychodynamic FactorsPsychodynamic Factors
 Patients who experience bodily aches andPatients who experience bodily aches and
pains without identifiable and adequatepains without identifiable and adequate
physical causes may be symbolicallyphysical causes may be symbolically
expressing an intra-psychic conflict throughexpressing an intra-psychic conflict through
the body.the body.

58. Behavioral FactorsBehavioral Factors
 Pain behaviors are reinforced whenPain behaviors are reinforced when
rewarded and are inhibited when ignored orrewarded and are inhibited when ignored or
punished.punished.
Interpersonal FactorsInterpersonal Factors
 Means for manipulation and gainingMeans for manipulation and gaining
advantage in interpersonal relationships.advantage in interpersonal relationships.
 Such secondary gain is most important toSuch secondary gain is most important to
patients with pain disorder.patients with pain disorder.

59.  Biological FactorsBiological Factors
Serotonin and endorphins play a role in painSerotonin and endorphins play a role in pain
disorders.disorders.

60. DiagnosisDiagnosis
 Pain in one or more anatomical sites is thePain in one or more anatomical sites is the
predominant focus of the clinical presentationpredominant focus of the clinical presentation
and is of sufficient severity to warrant clinicaland is of sufficient severity to warrant clinical
attention.attention.
 The pain causes clinically significant distress orThe pain causes clinically significant distress or
impairment in social, occupational, or otherimpairment in social, occupational, or other
important areas of functioning.important areas of functioning.

61.  Psychological factors are judged to have anPsychological factors are judged to have an
important role in the onset, severity,important role in the onset, severity,
exacerbation, or maintenance of the pain.exacerbation, or maintenance of the pain.
 The symptom or deficit is not intentionallyThe symptom or deficit is not intentionally
produced or feigned (as in factitiousproduced or feigned (as in factitious
disorder or malingering).disorder or malingering).
 The pain is not better accounted for by aThe pain is not better accounted for by a
mood, anxiety, or psychotic disorder andmood, anxiety, or psychotic disorder and
does not meet criteria for dyspareunia.does not meet criteria for dyspareunia.

62. CLINICAL FEATURESCLINICAL FEATURES
 Low back pain, headache, atypical facialLow back pain, headache, atypical facial
pain, chronic pelvic pain, and other kinds ofpain, chronic pelvic pain, and other kinds of
pain.pain.
 Patients with pain disorder often have longPatients with pain disorder often have long
histories of medical and surgical care.histories of medical and surgical care.
 Patients often deny any other sources ofPatients often deny any other sources of
emotional dysphoria and insist that theiremotional dysphoria and insist that their
lives are blissful except for their pain.lives are blissful except for their pain.

63.  Their clinical picture can be complicated byTheir clinical picture can be complicated by
substance-related disorders, because thesesubstance-related disorders, because these
patients attempt to reduce the pain throughpatients attempt to reduce the pain through
the use of alcohol and other substances.the use of alcohol and other substances.

64. Course and PrognosisCourse and Prognosis
 The pain in pain disorder generally beginsThe pain in pain disorder generally begins
abruptly and increases in severity for a fewabruptly and increases in severity for a few
weeks or months.weeks or months.
 The prognosis varies, although painThe prognosis varies, although pain
disorder can often be chronic, distressful,disorder can often be chronic, distressful,
and completely disabling.and completely disabling.

65. TreatmentTreatment
PharmacotherapyPharmacotherapy
 Analgesic medications do not generally benefitAnalgesic medications do not generally benefit
most patients with pain disorder.most patients with pain disorder.
 Sedatives and antianxiety agents are notSedatives and antianxiety agents are not
especially beneficial and are also subject toespecially beneficial and are also subject to
abuse, misuse, and adverse effects.abuse, misuse, and adverse effects.
 Antidepressants, such as tricyclics and SSRIs,Antidepressants, such as tricyclics and SSRIs,
are the most effective pharmacological agentsare the most effective pharmacological agents

66.  PsychotherapyPsychotherapy
Some outcome data indicate thatSome outcome data indicate that
psychodynamic psychotherapy benefitspsychodynamic psychotherapy benefits
patients with pain disorder.patients with pain disorder.