Somatoform Disorders: Classification Somatization Disorder (Briquet?s syndrome) Conversion disorder (conversion hysteria) Hypochondriacal disorder Somatoform pain disorder (psychogenic pain) Body dysmorphic disorder (dysmorphophobia) Somatization Disorder (Briquet?s Syndrome) Criterion A: Onset < age 30 Many physical complaints Lasting over several years Resulting in treatment sought, or significant impairment in social, occupational, or other important areas of functioning Somatization Disorders: Criterion B Symptoms Four pain symptoms (i.e., pain in four sites or involving four functions). Examples: head abdomen back during menstruation during sex during urination Somatization Disorders: Symptoms, cont?d Two gastrointestinal symptoms (other than pain): nausea bloating vomiting (other than during pregnancy) diarrhea intolerance of several different foods Somatization Disorders: Symptoms, cont?d One sexual symptom (other than pain), e.g.: sexual indifference erectile or ejaculatory dysfunction irregular menses excessive menstrual bleeding vomiting throughout pregnancy Somatization Disorders: Symptoms, cont?d One pseudoneurological symptom (other than pain), e.g.: impaired coordination or balance paralysis or localized weakness difficulty swallowing or lump in throat aphonia urinary retention hallucinations Somatization Disorders: Symptoms, cont?d loss of touch or pain sensation double vision blindness deafness seizures dissociative symptoms (e.g., amnesia) loss of consciousness (other than fainting) Somatization Disorders: Criterion C Either: After appropriate investigation, each B symptom cannot be fully explained by medical condition or drug effect, or Complaints or resulting impairment in excess of what would be expected from history, physical exam, or lab findings Somatization: Associated Features Needless operations and medical care Suicide attempts Somatization: Rates, Risk Factors 0.4% overall (ECA study) (male + female) 1% in urban women 1-2% in hospitalized women Elevated rate of psychopathy (Antisocial Personality Disorder) in male relatives Female relatives with Briquet?s syndrome Treatment of Somatization Essentially no demonstrated effective treatments, drug or psychotherapeutic Treat accompanying depression (which is frequently present) in usual fashion, via antidepressant medications Centralize & coordinate medical treatment Avoid excessive or invasive testing, unnecessary surgery Conversion Disorder 1+ pseudoneurological symptoms Psychological factors judged to be associated with symptom, because: initiation or exacerbation preceded by: conflicts or stressors Clinically significant distress or impairment Conversion Disorder, cont?d Not malingered Not medically explained Not limited to: pain or sexual dysfunction Does not occur exclusively in course of Somatization disorder Not better accounted for by another mental disorder Treatment of Conversion Insight-oriented psychotherapy was, at one time, the treatment of choice However, these patients are not very psychologically minded Today, supportive psychotherapy is more often employed Pain Disorder Pain in 1+ anatomical sites predominant focus of clinical presentation and Sufficiently severe to warrant attention Causes significant distress or impairment Psychological factors judged to have important role in onset, severity, exacerbation or maintenance of pain Pain Disorder, cont?d Not malingered Not better accounted for by Mood disorder or Anxiety disorder or Psychotic disorder or Dyspareunia Treatment of Pain Disorders Analgesics (carefully used, due to addiction potential) Certain tricyclic antidepressants Newer anticonvulsants (e.g., Neurontin, Lyrica) Relaxation training Cognitive behavioral therapy Body Dysmorphic Disorder Preoccupation with imagined defect in appearance. If slight anomaly present, person?s concern is markedly excessive. Causes clinically significant distress or impairment Not better accounted for by another mental disorder Treatment of Dysmorphophobia Psychotherapy doesn?t work well as these patients have little insight Low doses of neuroleptics may help, to the extent that beliefs verge on delusions Hypochondriasis Preoccupation with fears of having, or idea that one has, serious disease: based on misinterpretation of bodily symptoms Preoccupation persists despite appropriate medical evaluation and reassurance Not of delusional intensity Causes clinically significant distress or impairment Treatment of Hypochondriasis Notoriously refractory to psychotherapy Low-dose neuroleptics sometimes used (rationale: it?s like low-grade delusional problem) Treat accompanying depression in usual fashion (antidepressant therapies) Hypochondriasis, cont?d Lasts ? 6 months Not better accounted for by: Generalized anxiety disorder, Obsessive-compulsive disorder, Panic disorder, Major depressive episode, Separation anxiety, or another somatoform disorder Other Somatoform Disorders Undifferentiated somatoform disorder For things that look like somatization disorder, but don?t quite meet the criteria Not Otherwise Specified Pseudocyesis (false pregnancy) Chronic fatigue syndrome? (some cases), but many of these are now diagnosed as ?fibromyalgia? (treatment: LyricaTM FDA-approved)
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