4. Somatization Disorder(ICD 10)
/Somatic Symptom Disorder
(DSM-5)
A. One or more somatic symptoms that are
distressing or result in significant disruption of
daily life.
B. Excessive thoughts, feeling, or behavior
related to the somatic symptoms or
associated health concerns as manifested by
at least one of the following.
5. 1. Disproportionate and persistent thoughts about the
seriousness of one’s symptoms.
2. Persistently high level of anxiety about health or
symptoms.
3. Excessive time and energy devoted to these symptoms or
health concerns.
C. Although any one somatic symptom may not be
continuously present, the state of being symptomatic is
persistent (typically more than 6 months).
6. Specify if :
With predominant pain (previously pain disorder) : This
specifier is for individuals whose somatic symptoms
predominantly involve pain.
Specify if :
Persistent : A persistent course is characterized by severe
symptoms, marked impairment, and long duration (more
than 6 months).
Specify current severity :
Mild : only one of the symptoms specified in criterion B is
fulfilled.
Moderate : two or more of the symptoms specified in
criterion B are fulfilled.
7. Lifetime prevalence in the general
population :
0.2 % to 2% in women
0.2 percent in men
Women outnumber men 5 to 20 times ;
Asso. With little education and low
income
8. Begins before the age of 30
4 pain symptoms
2 gastrointestinal symptoms
1 sexual symptom
1 pseudoneurological symptom
Cause is unknown
9. ETIOLOGY
A. PSYCHOSOCIAL
Interpretation of symptoms:
a. to avoid obligation
b. to express emotions
c. to symbolize a feeling or belief
- symptoms substitute for repressed instinctual impulses.
10. B. BIOLOGICAL FACTORS
- genetic loading10 – 20% of first degree
female relatives
29% concordance rate in monozygotic twins;
10% in dizygotic twins
11. CLINICAL FEATURES:
Many somatic complaints
Long, complicated medical histories: circumstantial, vague,
inconsistent; disorganized
Patients frequently believe that they have been sickly most of
their lives.
Psychological distress and interpersonal problems are
prominent;
anxiety and depression are the most prevalent psychiatric
conditions
Suicide threats are common
12. Patients may be perceived as dependent, self-
centered, hungry for admiration or praise, and
manipulative
major depressive disorder, personality
disorders, substance-related disorders,
generalized anxiety disorder, and phobias
Nausea/vomiting, difficulty swallowing, pain in
the arms and legs, shortness of breath
unrelated to exertion, amnesia, complications
of pregnancy and menstruation
13. chronic, undulating, and relapsing disorder that rarely remits
completely;
Treatment
There should be a single identified physician as primary caretaker;
Individual and Group Psychotherapy
Listen to somatic complaints as emotional expressions rather than
medical complaints
14. Frequent, regular scheduled physical examinations help to
reassure patients that their physicians are not abandoning
them and that their complaints are been taken seriously.
Other psychotherapy, such as individual insight-oriented
psychotherapy, behavior therapy, cognitive therapy, and
hypnosis, may be helpful.
16. Conversion Disorder
symptoms or deficits that affect voluntary motor or sensory
functions, which suggest another medical condition, but that
is judged to be caused by psychological factors because the
illness is preceded by conflicts or other stressors.
The disturbance does not conform to current concepts of
anatomy and physiology of the CNS and PNS.
17. not intentionally produced, are not caused by
substance use, are not limited to pain or sexual
symptoms, and the gain is primarily
psychological and not social, monetary, or
legal;
women to men : 2-10 to 1
Symptoms are more common on the left than
on the right side of the body in women
18. Prevalence is variable:
1/3 of general pop – mild symptoms
11 – 500/100.000 pop.
2:1 female – male ratio
In children, higher predominance in girls
19. Affected males often involved in occupational
or military accidents;
Onset at anytime; most common in
adolescents and young adults
20. Comorbidity
Medical and, especially, neurological
disorders
Depressive disorders, anxiety disorders, and
somatization disorders
Personality disorders: histrionic type &
passive-dependent type
21. ETIOLOGY
According to psychoanalytic theory,
conversion disorder is caused by repression
of unconscious intrapsychic conflict and
conversion of anxiety into a physical
symptom.
conflict is between an instinctual
impulse (e.g., aggression or sexuality)
and the prohibitions against its
expression
22. In terms of conditioned learning theory, a
conversion symptom can be seen as a piece of
classically conditioned learned behavior; symptoms
of illness, learned in childhood, are called forth as a
means of coping with an otherwise impossible
situation.
23. hypometabolism of the dominant
hemisphere and hypermetabolism
of the nondominant hemisphere
excessive cortical arousal that sets
off negative feedback loops
between the cerebral cortex and
the brainstem reticular formation
24. Paralysis, blindness, and mutism are
the most common conversion
disorder symptoms
anesthesia and paresthesia are
common, especially of the
extremities.
Pseudoseizures
25. Patients achieve primary gain by
keeping internal conflicts outside their
awareness.
tangible advantages and benefits as a
result of being sick
La belle indifference is a patient's
inappropriately cavalier attitude
toward serious symptoms
26. The onset of conversion disorder is usually
acute, but a crescendo of symptomatology
may also occur;
approximately 95 percent of acute cases
remit spontaneously, usually within 2 weeks
in hospitalized patients
Recurrence occurs in one fifth to one fourth
of people within 1 year of the first episode
27. A good prognosis is heralded by acute
onset, presence of clearly identifiable
stressors at the time of onset, a short
interval between onset and the institution
of treatment, and above average
intelligence.
Paralysis, aphonia, and blindness are
associated with a good prognosis,
whereas tremor and seizures are poor
prognostic factors.
28. Resolution of the conversion disorder
symptom is usually spontaneous;
Insight-oriented supportive or behavior
therapy
29. Hypochondriasis
characterized by a general and
nondelusional preoccupation with fears of
having, or the idea that one has, a serious
disease based on the person's
misinterpretation of bodily symptoms
30. 6-month prevalence of 4 to 6% up
to 15% in a general medical clinic
population
Men and women are equally
affected
most commonly appears in persons
20 to 30 years of age
31. low thresholds for, and low tolerance
of, physical discomfort.
viewed as a request for admission to
the sick role made by a person facing
seemingly insurmountable and
insolvable problems.
a variant form of other mental
disorders, among which depressive
disorders and anxiety disorders
32. Psychodynamic School of Thought:
“aggressive and hostile wishes toward others
are transferred (through repression and
displacement) into physical complaints.”
“also viewed as a defense against guilt, a
sense of innate badness, an expression of low
self-esteem, and a sign of excessive self-
concern.”
33. CLINICAL FEATURES
Patients believe that they have a
serious disease that has not yet
been detected, and they cannot
be persuaded to the contrary.
often accompanied by symptoms
of depression and anxiety and
commonly coexists with a
depressive or anxiety disorder.
34. course is usually episodic;
good prognosis is associated with
high socioeconomic status,
treatment-responsive anxiety or
depression, sudden onset of
symptoms, the absence of a
personality disorder, and the
absence of a related non-
psychiatric medical condition;
35. usually resist psychiatric
treatment
Group psychotherapy often
benefits such patients,
36. Body Dysmorphic Disorder
characterized by a preoccupation
with an imagined defect in
appearance that causes clinically
significant distress or impairment in
important areas of functioning. ;
concern is excessive and
bothersome.
a poorly studied condition
37. most common age of onset is
between 15 and 30 years
women are affected somewhat
more often than men
commonly coexists with other mental disorders
38. may involve serotonin
reflecting the displacement of a
sexual or emotional conflict onto a
nonrelated body part
defense mechanisms of repression,
dissociation, distortion,
symbolization, and projection.
39. facial flaws, particularly those involving
specific parts (e.g., the nose).
ideas or frank delusions of reference (usually
about persons' noticing the alleged body
flaw
either excessive mirror checking or
avoidance of reflective surfaces
attempts to hide the presumed deformity
(with makeup or clothing).
40. usually begins during adolescence
usually has a long and undulating course
with few symptom-free intervals
clomipramine (Anafranil) and fluoxetine
(Prozac) reduce symptoms in at least 50
percent of patients
Augmentation with clomipramine
(Anafranil), buspirone (BuSpar), lithium
(Eskalith), methylphenidate (Ritalin), or
antipsychotics may improve the response
rate.
41. Pain Disorder
characterized by the presence of,
and focus on, pain in one or more
body sites and is sufficiently severe
to come to clinical attention.
somatoform pain disorder,
psychogenic pain disorder,
idiopathic pain disorder, and
atypical pain disorder
42. Lifetime prevalence is approximately 12%
Associated with other psychiatric
disorders, especially affective and anxiety
disorders
Chronic pain appears to be most
frequently associated with depressive
disorders, and acute pain appears to be
more commonly associated with anxiety
disorders.
43. may be symbolically expressing an
intrapsychic conflict through the body.
symbolic meaning of body disturbances
may also relate to atonement for
perceived sin, to expiation of guilt, or to
suppressed aggression.
displacement, substitution, and repression.
44. Pain behaviors are reinforced when
rewarded and are inhibited when ignored
or punished.
Intractable pain has been conceptualized
as a means for manipulation and gaining
advantage in interpersonal relationships,
for example, to ensure the devotion of a
family member or to stabilize a fragile
marriage.
45. often have long histories of medical and
surgical care.
completely preoccupied with their pain and
cite it as the source of all their misery
Major depressive disorder is present in about 25
to 50 percent of patients with pain disorder
generally begins abruptly and increases in
severity for a few weeks or months.
46. treatment approach must address
rehabilitation.
Antidepressants, such as tricyclics
and SSRIs, are the most effective
pharmacological agents.
psychodynamic psychotherapy
47. Undifferentiated Somatoform Disorder
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
autonomic nervous system and
fatigue or weakness.
autonomic arousal disorder
48. Somatoform Disorder Not
Otherwise Specified
a residual category for patients who have
symptoms suggesting a somatoform
disorder, but do not meet the specific
diagnostic criteria for other somatoform
disorders
e.g., pseudocyesis
49. Pseudocyesis: a false belief of being pregnant that is associated with
objective signs of pregnancy, which may include abdominal
enlargement (although the umbilicus does not become everted),
reduced menstrual flow, amenorrhea, subjective sensation of fetal
movement, nausea, breast engorgement and secretions, and labor
pains at the expected date of delivery.
