Somatoform disorders

prof. MUDr. Hana Papeov, CSc.

Department of Psychiatry, First Faculty of
Medicine, Charles University and General
University Hospital in Prague
 Characteristics

Somatic complains of major medical maladies without

demonstrable peripheral organ disorder
Psychological problems and conflicts are important in
initiating, exacerbating and maintaining the disturbance.
Physical and laboratory examinations do not explain
the vigorous and sincere patientscomplaints.
The morbid preoccupation interferes with and anxiety
are frequently present and may justify specific treatment
 Diagnostic guidelines
Somatization disorder F45.0
A definite diagnosis requires the presence of all of
the following:
At least 2 years of multiple and variable physical
symptoms with no adequate physical explanation has
been found,
Persistent refusal to accept the advice or reassurance of
several doctors that there is no physical explanation for
the symptoms,
Some degree of impairment of social and family
functioning attributable to the nature of symptoms and
resulting behavior.
 DSM- IV versus ICD
Somatization disorders appeared first in DSM-III.
Current diagnostic criteria (DSM-IV) are simplified and
symptoms from each of four symptoms group (pain, 2
GIT, 1 sexual symptoms, 1 pseudoneurological ) are
required.
Usually diagnosed in the primary care
Difficult when the patient forgets (represses) or refuses
(supresses) medically relevant information and critical
events.
In contrast with current DSM IV the conversion
disorder is assigned in ICD 10 to the cluster of
dissociative disorders.
 Differential diagnosis

Medical conditions - multiple sclerosis, brain tumour,

hyperparathyroidism, hyperthyroidism, lupus
erythematosus
Affective (depressive) and anxiety disorders
1 or 2 symptoms of acute onset and short duration
Hypochondriasis - patients focus is on fear of
disease not focus on symptoms
Panic disorder - somatic symptoms during panic
episode only
Differential diagnosis
Conversion disorder - only one or two
Pain disorder - one or two unexplained pain
complaints, not a lifetime history of multiple
complaints
Delusional disorders - schizophrenia with
somatic delusions or depressive disorder with
hypochondriac delusions, bizzare, psychotic sy.
Undifferentiated somatization disorder - short
duration (e.g. less than 2 years) and less striking
symptoms
 Course of the illness
Chronic relapsing condition, the cause remains unknown
Onset from in adolescence to the 3th decade of life.
Psychosocial and emotional distress
coincides with the onset of new symptoms and health
care-seeking behavior
Clinical practice showed that typical episodes last 6
to 9 months with a quiescent time of 9 to 12 months..
 Therapy and Prognosis

The somatization disorders considerably affects

social life and working ability of patient.

Focus on management than

treatment.
Management strategies undertaken
by primary care
 Therapy and Prognosis
The major importance for successful management
Trusting relationship between the patient and one
(if possible) primary care physician
Frequent changes of doctors are frustrating and
countertherapeutic.
Regularly scheduled visits every 4 or 6 weeks.
Brief outpatient visits - performance of at least partial
physical examination during each visit directed at the
organ system of complaint.
 Therapy and Prognosis

Understand symptoms as emotional message rather

than a sing of new disease
Avoid more diagnostic tests, laboratory evaluations
and operative procedures unless clearly indicated
Set a goal to get selected somatization patients
referral-ready for mental health care.
Group therapy (time limited, behavior oriented and
structured group: peer support, improvement of
coping strategies, perception and expression of
emotions and positive group experience
 Case history
52yrs, w.f.referred to general internist for back
pain and multiple other complaints
Disabled from her job of machine operator
History of 10 operations, in 5 hospitals and 7
different physicians in last 2 yrs.
Physical examination: Obese, wearing
transcutaneous el. nerve stimulation,
cooperative, shows the various scars with
certain enthusiasm.
 Case history
Mental status examination:
Cooperative and pleasant, somewhat seductive, no
pressure in her speech, euthymic, affect little shallow,no
problems with discussing of intimate details of her life.
The remainder of MSE within normal limits.
Disallowing all back-related symptoms (some
degeneration of vertebral bodies L2-5 revealed by spinal
radiographs) positive for 8 pain symptoms: 2 sexual, 4
GIT, 2 pseudoneurological onset at 26 yrs.
Diagnosis of somatization illness made in the presence of
comorbid medical condition.
Somatization disorder
undifferentiated F45.1
Includes unspecified psychophysiological
or psychosomatic disorder in patients
whose symptoms and associated
disability do not fit the full criteria for
other somatoform disorders.
The treatment and the outcome however do
not considerably differ.
 Hypochondriac disorder F45.2
Characterised by a persistent preoccupation and a
fear of developing or having one or more
serious and progressive physical disorders.
Patients persistently complain of physical problems
or are persistently preoccupied with their physical
appearance. The fear is based on the
misinterpretation of physical signs and sensations.
Physician physical examination does not reveal any
physical disorder, but the fear and convictions
persist despite the reassurance.
 Diagnostic guidelines
A definite diagnosis requires presence of both of the
following criteria:
Persistent belief in the presence of at least one serious
physical illness despite repeated negative investigations
and examinations or persistent preoccupation with
presumed deformity or disfigurement.
Persistent refusal to accept the advice and reassurance
of several different doctors that there is no physical
illness or abnormity underlying the symptoms.
Includes: Body dysmorphic disorder, Hypochondriasis,
Dysmorphophobia (non delusional), Hypochondriacal neurosis,
Nosophobia
DSM - IV and ICD - 10

In DSM IV criteria for hypochondriacal

disorder are essentially the same as those of
ICD-10
Since DSM-I
In DSM-IV addition of poor insight during
the current episode
 Differential diagnosis
Ruling out organic disease, usually completed by
the primary care physician.
Somatization disorder - in somatization disorder
concern about symptoms indifference about diseas
x
the preoccupation with 1 or 2 physical illness
persistent, no sex differences, no special familial
context
 Differential diagnosis
Signs of malingering- actually experienced
symptoms reported rather simulate them.
Somatic delusions in psychotic disorders,
depressive disorder schizophrenia and delusional
disorders-the more serious disorders.
Anxiety and panic disorders-somatic symptoms
of anxiety sometimes interpreted as signs of serious
physical illness but the conviction of presence of
physical illness do not develop.
Therapy and prognosis
To date no evidence-based treatment has been
described.
The comorbid psychiatric symptom may
facilitate the referral to psychiatrist and improve
frequently the hypochondriasis
Otherwise patients strongly refuse the mental
health care professionals and remain in primary
health care.
Similar management and group therapy
strategy as in somatization disorder may be useful.
 Course of the illness
The illness is usually long-standing, with episodes
lasting moths or years.
Frequently recurrences occurs after psychosocial
distress and induce impairment in psychosocial
functioning and work abilities.
that approximately 50 % of patients show
improvement, in other cases a chronic fluctuating
course remain.
Higher socio-economic status, presence of other
treatable condition, anxiety and depression, an acute
onset, absence of personality disorder or comorbid
organic disease predict better outcome.
Somatoform autonomic
disorder F45.3
The somatoform autonomic disorder has been
similar chronic relapsing condition as the
somatisation disorder.
Patients report worse health than do those with
chronic medical condition and their report of
specific symptoms
If they meet the severity criteria is sufficient and
need not to be considered legitimate by the
clinician.
 Somatoform pain disorders F45.4
Persistent severe and distressing pain that cannot
be explained fully by a physiological process of
physical illness.
It occurs in association with emotional conflicts or
psychosocial problems.
Chronic pain - a way of seeking human
relationship, attention and support
Sometimes dissipate when an accompanying
psychiatric disorder is treated.
 Somatoform pain disorders (2)
It has been always difficult to specify to
which extend the chronic pain is associated
with a given lesion.
The expression of chronic pain may vary
with different personalities and cultures.
It has been clinically accepted that the patient
is not malingering and the complaints about
the extend of the pain are to be believed.
F50 Eating Disorders
 SPECTRUM OF EATING
DISOREDRS

OBESITY BULIMIA RESTRICTING ANOREXIA

BINGE EATING BING-PURG. ANOREXIA

IMPULSE INHIBITION
FOOD RESTRICTION
BODY WEIGHT
PERFECTIONISM
DRIVE TO EAT
IMPULSIVITY
Risk Factors in Eating Disorders
Environmental
media images
teasing from peers

Family
maternal obesity and weight preoccupation
psychiatric disorders; substance abuse

Behavioral
personality and psychological factors
developmental model
 Anorexia nervosa F50.0
a) Weight is maintained at least 15% below that expected
(either lost or never achieved) , or Quetelets body-mass
index is 17,5 or less. Prepubertal patients fail to make the
expected weigh gain during the period of growth.
b) The weight loss is self induced by diets, avoidance of
fatting foods and one or more following: self-induced
vomiting, self induced purging, excessive exercise, use of
appetite suppressant and/or diuretics.
c) There is body image distorsion in the form of a
specific psychopathology with increasing emaciation the
patients feeling to be too large persists and she imposes
herself a low weight threshold.
Anorexia nervosa F50.0
Endocrine disorder of hypothalamic-pituitary-
gonadal axis, amenorhea in women men by lost of
sexual interest and potency.
masked by hormonal replacement therapy
Elevated levels of growth hormone, cortisol,
decrease thyroidal hormone and abnormalities in
insulin secretion.
Prepubertal onset-delayed or stopped development
on juvenile level (growth, breasts and the genitals).
 Bulimia Nervosa F50.2
a) Persistent preoccupation with eating and an
irresistible craving for food, the patients have the
episodes of binge eating during which a large amounts
of food are consumed in a short period of time.
b) The patient attempts to compensate the
fattening effect of consumed food by one or more
following behaviour: self-induced vomiting, abuse of
laxatives or diuretics, alternating periods of starvation,
use of appetite suppressants, thyroid hormones or
manipulation insulin( mainly in diabetic patients).
 Bulimia Nervosa F50.2
c) The psychopathology consists of
1.morbid dread of fatness (the patient set herself or
himself a sharply defined weight threshold below the
premorbid weight that constitutes the optimum or
healthy weight).
2.frequent history of anorexia nervosa, the earlier
episode may have been fully or mildly expressed (mild
form with moderate loss of weight and/or a transient
phase of amenorhea).
 Eating disorders and the brain

EATING
BRAIN BEHAVIOUR

BODY
 Anorexia nervosa, Starvation
& the Brain

AN
PHYSICAL STATE PSYCHICAL DISEASE
=
STARVATION ? =
BRAIN ALTERATION

BRAIN ALTERATION STARVATION

 Why? nurture does environment
matter?
perinatal factors
family relationships
life events

Studies with experimental starvation show

that even healthy not-predisposed people
can experience similar aspects of starvation.
 Anatomy of CNS Brain atrophy I

VENTRICULAR BRAIN RATION %

Computed Tomography

AN (50) BN (50) COPP (50)

Laessle et al 1989 Krieg et al 1989
Brain atrophy III

WHITE MATTER
(myelinated axons, lipids)
decreased in acute AN
normal after recovery

GREY MATTER
(neural cell bodies)
decreased in acute AN
decreased after recovery!!

Katzman 1996, 1997, 2001; Lambe 1997

 SENSORY IMPUT INTEGRATION

vision DORSOLATERAL
PREFRONTAL CX
VISUAL CORTEX AMYGDALA
ASSOCIATIVE IMPULSE
LEARNING INHIBITION

smell
OLFACTORY
CORTEX
HYPOTHALAMUS
SENSING ENERGY
ORBITOFRONTAL BALANCE
TASTE CORTEX
taste
INSULA CORTEX
FRONTAL DECISION MAKING
OPERCULUM REWARD VALUE INSULIN
LEPTIN
GHRELIN
BLOOD GLUCOSE
OUTPUT
BEHAVIOUR METABOLIC SIGNALS
 The role of leptin in malnutrition

Circulating leptin levels are in most of the malnutrition

states decreased in paralelle with drop of body fat
Hypoleptinemia is rather the consequence than the cause
of anorexia nervosa and most of the malnutrition states
Hypoleptinemia triggers complex adaptive response to
limited energy sources (body fat). This adaptation
includes decreased energy expenditure, amenorrhea,
immunodeficiency etc.
 Recovery Precontemplation

MET
Relapse Contemplation

Maintenance Preparation

CAT
Stages of Action
Change
Model
CBT for the eating disorders

Making links between

behaviour, cognitions Emotions
Cognition
and affect (e.g. gaining weight)
(e.g.anxiety,
disgust)
modifying these in
parallel
Behaviour
(e.g.food
avoidance)
 Prevention
Increase knowledge Self acceptance
Promote acceptance Increase self esteem
Diversity & puberty Coping strategies
Nature of eating d/o Reduce body
Discourage dieting dissatisfaction
Reduce teasing Healthy eating
Media literacy Limit internalization