Somatoform Disorders

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What is somatization?

The expression physiological distress in physical symptoms.

What are somatoform disorders?

Disorders characterized by physical symptoms for which there is no apparent cause or etiology. In other words, they are disorders in which somatization plays a key role.

What is somatization disorder?

A type of somatoform disorder which involves multiple, chronic, recurrent, and medically unexplained symptoms. The disorder typically spans several organ systems.

What does psychosomatic mean?

It is an out-of-date term not typically used, but can be translated to "psychogenic physical problems"

What are some examples of somatoform disorders?

Somatoform disorders characteristically have no known physiological mechanisms and have no evidence of psychological etiology. Some examples are:
1) Somatization Disorder
2) Hypochondriasis
3) Pain Disorder
4) Undifferentiated Somatoform Disorder
5) Conversion Disorder
6) Body Dysmorphic Disorder

At what age does somatization disorder occur?

Younger than 30 years, followed by a chronic and fluctuating diagnosis.

What is somatization disorder comorbid with?

Personality disorders, particularly antisocial, histrionic, and borderline personality disorders.

What is hypochondriasis?

The belief that one has a serious disease. This is typically based off a patient misreading physical symptoms, and the fear persists despite medical reassurance otherwise. It is not diagnosed if it is secondary to depression, general anxiety disorder (GAD), OCD, etc.

What is pain disorder?

A preoccupation with pain in the absence of any physical findings.

What is undifferentiated somatoform disorder?

Kind of a waste-basket diagnosis. Any patient with medically unexplained physical symptoms that do not quite meet the criteria for somatoform disorder end up with this.

What is conversion disorder?

A loss or deficit in voluntary motor and sensory systems without any known medical cause. Some common forms include:
1) Paralysis
2) Gait and coordination disturbance
3) Anesthesias
4) Partial and/or complete blindness
5) Deafness
6) Aphonia (the inability to speak)
7) Convulsions

What is body dysmorphic disorder?

Also known as dysmorphophobia. It is defined by a preoccupation with either imagined or very small "defects" in personal appearance. Anorexia is not considered to be a part of the disorder. The disorder is closely associated with OCD.

What are some characteristics of body dysmorphic disorder?

1) Compulsive mirror-checking, or mirror-avoidance
2) Attempts to hide the "flaw"
3) Multiple medical visits or procedures, such as surgery, to hide or eliminate the "flaw"
4) Social withdrawal
(An example is the multiple surgeries undergone by Michael Jackson)

What is "psychological factors affecting medical condition" (PFAMC) ?

When physical symptoms can be traced with an organic pathology.

What is a factitious disorder?

When a patient feigns an illness, a behavior also seen in malingering. The patient is aware of the mechanisms and motives behind his "'illness" in both disorders. The motivations for the "illness" is only conscious in malingering.

Table: Somatization Disorder

Mechanism of illness production: unconscious
Motivation for illness production: unconscious

Table: Conversion Disorder

Mechanism of illness production: unconscious
Motivation for illness production: unconscious

Table: Hypochondriasis

Mechanism of illness production: unconscious
Motivation for illness production: unconscious

Table: Somatoform pain disorder

Mechanism of illness production: unconscious
Motivation for illness production: unconscious

Table: Factitious Disorder

Mechanism of illness production: conscious
Motivation for illness production: unconscious

Table: Malingering

Mechanism of illness production: conscious
Motivation for illness production: conscious

Will the definition of Somatiform disorders change in the DSM-V?

Yes, there are a few proposed changes for the next edition.
1) Somatic Symptom Disorders may be renamed and added with Factitious Disorder and PFAMC
2) Somatization Disorder, Hypochondriasis, Somatoform Pain Disorder, and Undifferentiated Somatoform Disorder may be combined to become Complex Somatic Symptom Disorder
3) Conversion Disorder may be renamed to be Functional Neurological Symptoms
4) Body Dysmorphic Disorder may be relocated and renamed to Anxiety and Obsessive Compulsive Spectrum Disorders

What do somatoform patients have in common?

1) They are comorbid with depression and anxiety
2) Social and role performance are impaired and illness becomes the primary focus.
3) Medical contact increases
4) They exploit medical resources and are broadly disliked by physicians
5) They are resistant to psychotherapies

What are some of the etiological theories behind somatoform disorders?

1) Sick-Role Enactment
2) Self-Handicapping
3) Perceptual Augmentation/Cognitive Misinterpretation

What is Sick-Role Enactment?

An etiological theory in which a patient emulates the behavior of a sick individual in order to have less responsibility, receive a reward out of pity, or gain attention and sympathy.

What is Self-Handicapping?

An etiological theory in which an individual takes on certain physical symptoms in order to have something to blame when failing to meet or achieve a goal. A good example would be procrastinating when studying for an exam you don't expect to do well in. This way failure on the exam can be blamed on procrastination as opposed to inability.

What is Perceptual Augmentation or Cognitive Misinterpretation?

When a patient has a tendency to misinterpret all bodily sensations as serious and harmful.

What is the problem in diagnosing a conversion disorder?

Bodily dysfunctions as seen in conversion disorder can be caused by many things, such as an organic impairment, a true conversion disorder, or the dysfunction could be a fraud. It is difficult to differentiate.

What are the recommended DSM criteria for conversion disorder diagnosis?

1) One or more symptoms affecting voluntary motor or sensory systems or cause a loss of consciousness
2) The symptoms are not due to a medical condition
3) One or more diagnostic features show evidence of internal inconsistency with a neurological or medical disorder
4) The symptom causes distress, or impedes life socially and functionally
(Usually a psychological stressor is present, but does not need to be. Malingered and feigned symptoms aren't considered to be functional)

What is diagnosis by exclusion?

Diagnosing by exclusion is done by ruling out any other reasons behind a disorder. The effectiveness of diagnosis by exclusion depends on the report that the patient gives of symptoms, ability of the physician, and current medical knowledge.

What needs to be considered while diagnosing by exclusion?

1) Do the symptoms fit with the psychological reality? (i.e. can a patient respond to physical exams or not according to the physical symptoms?)
2) Can the symptoms be modified by drugs or hypnosis?

What is considered evidence of a correlation between conversion disorder and psychological causation?

This question must be asked in order to not have to rely on diagnosis by exclusion. Some of the qualifications are:
1) Do the symptoms follow a psychological stressor?
2) Do the symptoms allow for the patient to avoid unpleasant situations?
3) Does the patient receive sympathy or benefits because of the symptoms?

Does a "psych cause" guarantee that the disorder is non-organic?

No, it does not. There is a large false positive rate for conversion disorder diagnosis (between 25-60%) in earlier studies. Newer studies show a false positive only around 4%.

What were the findings of conversion disorder case study (1)?

A 24 year old male lost movement of his left arm and leg after hitting his girlfriend. Though hospitalized after the fight due to injury, no cause for left arm and leg dysfunction could be found. Later movement in limbs showed that the dysfunction was most likely caused by guilt and avoidance of going to jail. Once in jail movement again deteriorated and the patient was considered hysterical. No therapeutic aid helped. Eventually, a CAT scan revealed right frontoparietal hematoma without mass effect, causing paralysis. Patient filed suit.

How can you tell if the symptoms of conversion disorder are faked?

This is difficult to say, particularly because studies of the physiological integrity of patients show that affected symptoms are still perfectly functional, despite inability of the patient to move.

How do physicians feel about conversion disorder?

Many are angered and believe the disorder to be false, believing that paralysis is caused by desire to avoid or gain recognition. "The quickest way to treat conversion paralysis is to set fire to the patient's wheelchair."

What were the results of conversion blindness case studies?

In the experiment, four different shapes were shown individually and at random to a blind individual, and a patient suffering conversion blindness. The blind individual demonstrated a percentage of accuracy due to probability. The patient almost never answered correctly. Why? Because the patient could actually see!

What were the findings of de Gelder et al, in which a blind patient due to primary visual cortex damage was analyzed?

Patient suffered lesions in each visual cortex (bilateral). He could successfully maneuver down a narrow hallway with intended obstructions. Therefore extra-striate pathways can sustain visual-spatial skill even in the absence of perceptual awareness.

What did L. Weiskrantz find with his phenomenon of "blind sight"?

Patients with damage to their visual cortex still have visual function, without being able to consciously see.
Therefore, is conversion blindness similar to blind sight?
-Transcranial magnetic stimulation will also produce this effect.

Can "blind sight" occur in other senses?

Yes, the phenomenon of "deaf-hearing" and "numb-sense" also exist.

What did Omar Ghaffar's fMRI study of conversion anesthesia reveal?

fMRI took images of three patients with conversion anesthesia. Results:
1) Stimulation of functioning limb activates primary somatosensory region on the contralateral side of the brain.
2) Nothing occurred with the stimulation of the conversion limb.
3) Simultaneous stimulation of both limbs activated primary somatosensory regions on both sides of the brain!

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