somatoform disorders

Somatoform disordersد.وليد عزيز العميدي
Somatoform disorder : a generic term used in DSM for a group of disorders characterized by physical symptoms that are not explained by organic factors .
Categories of somatoform disorders in DSM-IV :
1- Somatization disorder.
2- Hypchondriasis.
3- Conversion disorder.
4- Body dysmorphic disorder.
5- Pain disorder associated with psychological factors ( and a general medical condition ).
6- Somatoform disorders not otherwise specified.
7- Undifferentiated somatoform disorder.
Conversion disorder : is the term used in DSM to replace the older term hysteria . the term refers to a condition in which there are isolated neurological symptoms that can not be explained in terms of known mechanisms of pathology and in which there has been a significant psychological stressor .
Clinical features : in DSM-IV , conversion disorder is divided into four types :
1- With motor symptoms or deficit : this subtype includes such symptoms as impaired coordination or balance , paralysis or localized weakness , difficulty swallowing or lump in throat , aphonia and urinary retention.
2- With sensory symptom or deficit : this subtype includes such symptoms as loss of touch or pain sensation , double vision , blindness , deafness and hallucinations.
3- With seizures or convulsions.
4- With mixed presentation .
Conversion symptoms are highly responsive to suggestion and may vary considerably in response to the comments of other people , especially doctors . symptoms may be reinforced by measures such as providing a wheelchair for the patient who has difficulty walking



Treatment : for acute conversion disorders seen in hospital emergency departments , reassurance and suggestion of improvement are usually appropriate , together with immediate efforts to resolve any stressful circumstances that provoked the reaction .the doctor should be sympathetic and positive and provide a socially acceptable opportunity for rapid return to normal physical functioning .
Where symptoms have persisted for more than few weeks more elaborate treatment is required . the general approach is to focus on removing any factors that are reinforcing the symptoms and disability and on encouraging normal behavioral .
Medication has no direct part to play in the treatment of these disorders . however, when a conversion disorder is secondary to a depressive or anxiety disorder, treatment of the primary condition usually leads to improvement in the secondary symptoms .
Somatization disorder : the essential feature of somatization disorder is multiple somatic complaints of long duration , beginning before the age of 30 . in DSM-IV , the criteria for diagnosis were made less restrictive : they require four pain symptoms , two gastrointestinal symptoms , one sexual symptom and one pseudoneurological symptom . the above symptoms are not intentionally produced or feigned and non of which is completely explained by physical or lab. examinations . the disorder is chronic and is associated with significant psychological distress , impaired social and occupational functioning and excessive medical –help-seeking behavior.
Problems caused by somatization :
- Excessive use of health resources.
- Moving from doctor to doctor or from hospital to hospital .
- Complaints are not assuaged by negative findings.
- Hostility develops between patients and doctors.
- Patients and doctors fail to appreciate the importance of psychological factors in developing symptomatology.
Aetiology : - heightened awareness of bodily sensations.
- Misinterpretation of bodily sensations.
- Family illness during childhood.
- Separation and loss during childhood.
- Genetic factors.
Treatment : treatment is difficult and patients often consume large amounts of resources . continuing care by one doctor using only the essential investigations , can reduce the use of health services and may improve patient`s functional state , avoid psychotropics except during period acute anxiety and depression . it also important to follow the patient to prevent substance abuse , doctor shopping , unnecessary procedures and diagnostic tests.
Hypochondriasis : DSM-IV describe the condition as a preoccupation with a fear or belief of having of having a serious disease based on the individual`s interpretation of physical signs of sensations as evidence of physical illness . appropriate physical evaluation does not support the diagnosis of any physical disorder than can account for the physical signs or sensations or for the individual`s unrealistic interpretation of them . the fear of having or belief that one has a disease , persist despite medical reassurance . the criteria go on to exclude patients with panic disorder or delusions , and require that symptoms have present for at least 6 months.
The aetiology unknown , cognitive formulations suggest that there is faulty appraisal of normal bodily sensations which are interpreted as evidence of disease. this misinterpretation is maintained by behaviors such as continually seeking reassurance and examining the supposedly affected part.
Treatment : repeated reassurance is unhelpful and may serve to prolong the patient`s concerns . investigations should be limited to those indicated by the medical priorities and not extended to satisfy the patient`s other concerns. Misinterpretation of the significance of the bodily sensations should be corrected .
Body dysmorphic disorder : in DSM , body dysmorphic disorder is the term for a subgroup of the syndrome dysmorphophobia which is a subjective description of ugliness and physical defect which the patient feels noticeable to others . it is not better accounted for by another psychiatric disorder . the preoccupation with the imagined defect in appearance is usually an overvalued idea . the syndrome overlaps with delusional disorder , hypochondriasis and obsessive compulsive disorder .
Patients with dysmorphophobia are convinced that some part of their body is too large , too small or misshapen. The common concerns are about the nose , ears , mouth , breasts or any part of the body .
Treatment : when body dysmorphic disorder is secondary to a psychiatric disorder such as major depression , the latter should be treated in the usual way . the treatment of primary body dysmorphic disorder is often difficult . counseling and practical help should be provided for any occupational , social or sexual difficulties that accompany the condition . surgery is usually contraindicated . there is beneficial effects from antidepressants especially with SSRI .
Pain disorder : this term denotes patients with chronic pain that is not caused by any physical or specific psychiatric disorder .DSM-IV states that the essential feature of this disorder is pain that is the predominant focus of the clinical presentation and is of sufficient severity to cause distress or impairment of functioning and that either no organic pathology or pathophysiological mechanism has been found to account for the pain or when there is related organic pathology , the pain or resulting social or occupational impairment is grossly in excess of what would be expected from the physical findings.
Aetiology :