Behavioral Medicine II o 1 pseudoneurological symptom

SOMATOFORM DISORDERS o Cannot be fully explained by physical and

laboratory examination
Broad group of illnesses and have bodily signs Clinical features
and symptoms o Impaired coordination or balance
Encompass mind-body interactions o Paralysis or localized weakness
Symptoms are not under voluntary control and o Difficulty swallowing or lump in throat
complaints are not imaginary o Aphonia
o Urinary retention
5 Specific somatoform disorders: o Hallucination
o Loss of touch or pain sensation
Somatization disorder o Double vision
- Many physical complaints affecting many o Blindness
organ systems
o Deafness
- Recurrent, chronic
o Seizures
Conversion Disorder
o Loss of consciousness
- One or two neurological complaints
- Acute, motor or sensory o Anxiety and depression
Hypochondriasis Course and Prognosis
- Focus on symptoms than by patients belief o Chronic and often debilitating
that they have a specific disease Treatment
- Disease concern / preoccupation o Best treated with 1 physician = patient have
Body Dysmorphic Disorder increased opportunities to express somatic
- False belief or exaggerated perception that complaints.
a body part is defective o Group and individual psychotherapy
- Subjective feeling of ugliness or concern Help cope with symptoms
with body defect Develop alternative strategies for
Pain disorder expressing their feelings
- Symptoms of pain that are either solely
related to or significantly exacerbated by
psychological factors CONVERSION DISORDER
- Pain syndrome stimulated
Affect voluntary motor and sensory functions
(neurological / general medical condition)
SOMATIZATION Monosymptomatic
o Motor symptoms ( paralysis, gait
Polysymptomatic disturbance)
Chronic o Sensory deficits ( anesthesia & paresthesia)
Associated with significant psychological o Visceral symptoms (urinary retention,
distress, impaired social and occupational diarrhea and pseudocyesis)
functioning and excessive medical help seeking Acute
behavior Caused by psychological factors preceeded by
Epidemiology stress
o F > M 5-20:1 Epidemiology
o Before 30 / teenage years o F > M (2-10:1)
o 0.2-2% general population o Men = associated with military accidents or
o Little education and low incomes occupational accidents
o Associated with personality disorder: o Common in adolescents and young adult
avoidant, paranoid, self defeating, OC o Rural populations
Etiology o Little education,low IQ, low socioeconomic
o Psychosocial factors groups
o Biological factors Comorbididty
Attention and cognitive impairements = o Depressive disorders
faulty perception and assessment of o Anxiety disorders
somatosensory inputs o Somatization disorder
Excessive distractability o Personality disorder
Inability to habituate to repetitive o Schizophrenia (rare)
stimuli Etiology
Grouping of cognitive constructs on an o Psychoanalytic factors
impressionable basis Repression of unconscious intrapsychic
Partial and circumstantial association
conflict and conversion anxiety into a
Lack of selectivity physical symptom
Decreased metabolism in the frontal The symptoms allow partial expression
love and the nondominant hemisphere of the forbidden wish oror urge to
Diagnosis disguise it so the patient can avoid
o 4 pain symptoms consciously confronting their
o 2 GI symptoms unacceptable impulses (vaginismus =
o 1 sexual symptom (irregular menses, protects patient from sexual wishes)
erectile dysfunction, irregular bleeding
 Allow patient to communicate = they
need special attention
Coping with impossible or difficult
situation
Manipulate others
o Learning theory
o Biological factors
Hypometabolism of the dominant
hemisphere
Excessive cortical arousal leading to
negative feedback
Inc. corticofugal output = inhibit
patient awareness of bodily sensation
(observe sensory deficits)
Clinical features
o Paralysis, blindness and mutism most
common
o Commonly associated with
Passive-aggressive
Dependent
Anti-social
Historionic personality disorder
Depression and anxiety
o Sensory symptoms
anesthesia and paresthesia
stocking and glove anesthesia of the
hands and feet or hemianesthesis from
midline
Involve special senses (deafness,
blindness, tunnel vision) unilateral or
bilateral
o Motor symptoms
Abnormal movements
Gait disturbance
Weakness
Paralysis
Movements worsen when you call their
attention
Astasia-abasia wildly ataxic,
staggering gait, jerky
truncalmovements, thrashing and
waving arms movements
o Seizure symptoms
Pseudoseizure (tongue biting and
urinary incontinence)
o Other associated features
Primary gain symptoms have
symbolic meaning
Secondary gain accrue tangible
advantages and benefits as a resultof
being sick (excused from obligations)
La belle indifference unconcerned
about what appears to be major
Identification model their symptoms
on those of someone important to them
Course and prognosis
o Later may have neurological disorder
o 90-100% resolve in a few days or less than
a month
o Good prognosis:
Sudden onset
Easily identifiable stressor
Good premorbid judgement
No comorbidity
No ongoing litigation
Treatment
o Parenteral amobarbital or lorazepam
o Spontaneous
o Psychotherapy issues of stress and coping
o Hypnosis, anxiolytics and behavioral
relaxation
o Longer duration of patient sick role more
regressed more difficult to treat
HYPOCHONDRIASIS
Pre-occupation with fears of contracting or the
belief of having a serious disease significant
stress impair ability to function in their
personal, social and occupational roles
Misinterpret body symptoms or functions
Common abdominal complaints hypochondrium
below the ribs
Unrealistic or inaccurate interpretation of
physical symptoms or sensations
Epidemiology
o Atleast 6 months
o 4-6% in general population
o 3% medical students in their 1st 2 years
o M=F
o 20-30 yearsold
Etiology
o Misinterpretation of bodily symptoms
o Augment and amplify somatic sensation
o Low threshold for pain
o Sick roles offer an escape (excused to
usual duties, avoid noxious obligations)
o Aggressive and hostile wishes towards
others are transferred through
repression and displacements into
physical complaints
o Deserved punishment
Differential diagnosis
o AIDS, endocrinopathies, myasthenia gravis,
SLE, multiple schlerosis, degenerative
disease or nervous system, occult neoplastic
disorders
Course and prognosis
o Episodic months to years and are
separated with equally long quiescent
period
o Fewer symptom compared to somatization
disorder
o Good prognosis:
Upper socioeconomic status
Response to treatment
Sudden onset
Absence of personality disorder
Absence of related non psychiatric
medical condition
Most children recover by late
adolescence and early adulthood
Treatment
o Psychotherapy
o Frequent regular scheduled PE
Take complaints seriously
BODY DYSMORPHIC DISORDER
 Manipulation and gaining advantage in
Preoccupation with an imaged defect in interpersonal relationships
appearance o Biological factors
Causes significant distress or impairment in Cerebral cortex can inhibit firing of
important areas of functioning afferent pain fibers
Epidemiology Serotonin is the main neurotransmitter
o 15-30 yearsold in the descending inhibitory pathways
o F>M Endorphins play a role in CNS
o Unmarried individual modulation of pain = dec. Endorphin
o 90% MDD augment incoming sensory stimuli
o 70% anxiety disorder Most prominent symptoms
o 30% psychotic disorder o Anergia, anhedonia, dec. Libido, insomnia,
Etiology irritability, diurnal variation, weight loss
o Unknown Course and prognosis
o Serotonin o Begin abruptly
o Stereotype concept of beauty family and o Inc. saeverity for a few weeks or months
culture Treatment
o Displacement of sexual and emotional o Nerve block 6-8 months repeat
conflict nonrelated body part o Psychotherapy
Clinical feature Biofeedback esp. Migraine, myofacial
o Concerns involve facial flaws (nose) pain and tension headache
o Commonly assoc. symptoms Develop solid therapeutic alliance by
Frank delusions of reference empathizing with patients suffering
Excessive mirror checking / avoidance Acknowledge reality of pain
of reflective surface (make up and Alter negative thoughts and foster a
clothing) positive attitude
Attempts to hide presumed deformity o Pharmacotherapy
o Avoid social and occupational exposure SSRI and TCA
Comorbidity Amphetamine adjunct to SSRI
o MDD
o Anxiety disorder
o OCD
o Narcisstic personality disorder
Differential diagnosis
o Anorexia nervosa, gender identity disorder,
brain damage neglect syndrome
Treatment
o Psychotherapy
o Pharmacotherapy
SSRI (Clomipramine and Fluoxetine)

PAIN DISORDER

Pain in 1 or more body site

Associated with emotional distress and
functional impairement
Epidemiology
o F > M 2:1
o 4th and 5th decades
o Blue collar occupations job related injuries
o Genetic inheritance and behavioral
mechanism transmission
o Depressive disorder, anxiety disorder,
substance abuse common in families with
pain disordered patient
Etiology
o Psychodynamic factors
Symbolically expressing an intrapsychic
conflict (alexithymia unable to
articulate showed through their body)
Method of obtaining love, punishment
for wrong doing, expiating guilt,
attonement
o Behavioral factors
Reinforced when rewarded
Inhibited when ignored or punished
o Interpersonal factors