Hotchocolate M.D.

Somatoform Disorders CLINICAL FEATURES:

o Many somatic complaints
HYACINTH C. MANOOD, M.D., F.P.P.A (Feb.2012)
o Long, complicated medical histories: circumstantial,
vague, inconsistent; disorganized
Group of illnesses that have bodily signs and
o Patients frequently believe that they have been
symptoms as a major component;
sickly most of their lives.
Symptoms are not imaginary;
o Psychological distress and interpersonal problems
Somatization disorder
are prominent;
Conversion disorder
o anxiety and depression are the most prevalent
Hypochondriasis
psychiatric conditions
Body Dysmorphic disorder
o Suicide threats are common
Pain disorder
o Patients may be perceived as dependent, self-
Undifferentiated Somatoform disorder
centered, hungry for admiration or praise, and
Somatoform disorder not otherwise specified
manipulative
o major depressive disorder, personality disorders,
Somatization Disorder substance-related disorders, generalized anxiety
Characterized by multiple somatic complaints in disorder, and phobias
multiple organ systems that cannot be explained o Nausea/vomiting, difficulty swallowing, pain in the
adequately on the basis of physical and laboratory arms and legs, shortness of breath unrelated to
examinations. exertion, amnesia, complications of pregnancy and
Chronic; excessive medical-help-seeking behaviors; menstruation
Briquets syndrome o chronic, undulating, and relapsing disorder that
Lifetime prevalence in the general population : rarely remits completely;
o 0.2 % to 2% in women o There should be a single identified physician as
o 0.2 percent in men primary caretaker;
Women outnumber men 5 to 20 times ; o Individual and Group Psychotherapy
Associated With little education and low income o Listen to somatic complaints as emotional
Begins before the age of 30 expressions rather than medical complaints
4 pain symptoms
2 gastrointestinal symptoms Conversion Disorder
1 sexual symptom symptoms or deficits that affect voluntary motor or
1 pseudoneurological symptom sensory functions, which suggest another medical
Cause is unknown condition, but that is judged to be caused by
ETIOLOGY psychological factors because the illness is preceded
A. PSYCHOSOCIAL by conflicts or other stressors.
Interpretation of symptoms: The disturbance does not conform to current
a. to avoid obligation concepts of anatomy and physiology of the CNS and
b. to express emotions PNS.
c. to symbolize a feeling or belief not intentionally produced, are not caused by
o symptoms substitute for repressed instinctual substance use, are not limited to pain or sexual
impulses. symptoms, and the gain is primarily psychological and
B. BIOLOGICAL FACTORS not social, monetary, or legal;
- Genetic loading women to men : 2-10 to 1
o 10 20% of first degree female relatives Symptoms are more common on the left than on the
o 29% concordance rate in monozygotic twins; 10% in right side of the body in women
dizygotic twins Prevalence is variable:
o 1/3 of general pop mild symptoms
o 11 500/100.000 pop.
o 2:1 female male ratio
o In children, higher predominance in girls
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Affected males often involved in occupational or
military accidents;
Onset at any time; most common in adolescents and
young adults
Comorbidity
o Medical and, especially, neurological disorders
o Depressive disorders, anxiety disorders, and
somatization disorders
o Personality disorders: histrionic type & passive-
dependent type
ETIOLOGY
According to psychoanalytic theory, conversion
disorder is caused by repression of unconscious
intrapsychic conflict and conversion of anxiety into
a physical symptom.
o conflict is between an instinctual impulse (e.g.,
aggression or sexuality) and the prohibitions
against its expression
In terms of conditioned learning theory, a
conversion symptom can be seen as a piece of
classically conditioned learned behavior; symptoms
of illness, learned in childhood, are called forth as a
means of coping with an otherwise impossible
situation.
hypometabolism of the dominant hemisphere and
hypermetabolism of the nondominant hemisphere
excessive cortical arousal that sets off negative
feedback loops between the cerebral cortex and the
brainstem reticular formation
Paralysis, blindness, and mutism are the most
common conversion disorder symptoms
Anesthesia and paresthesia are common, especially
of the extremities.
Pseudoseizures
Patients achieve primary gain by keeping internal
conflicts outside their awareness.
tangible advantages and benefits as a result of
being sick
La belle indifference is a patient's inappropriately
cavalier attitude toward serious symptoms
The onset of conversion disorder is usually acute,
but a crescendo of symptomatology may also occur;
approximately 95 percent of acute cases remit
spontaneously, usually within 2 weeks in
hospitalized patients
Recurrence occurs in one fifth to one fourth of
people within 1 year of the first episode
A good prognosis is heralded by acute onset,
presence of clearly identifiable stressors at the time
Hotchocolate M.D.
of onset, a short interval between onset and the
institution of treatment, and above average
intelligence.
Paralysis, aphonia, and blindness are associated
with a good prognosis, whereas tremor and seizures
are poor prognostic factors.
Resolution of the conversion disorder symptom is
usually spontaneous;
Insight-oriented supportive or behavior therapy
Hypochondriasis
characterized by a general and nondelusional
preoccupation with fears of having, or the idea that
one has, a serious disease based on the person's
misinterpretation of bodily symptoms
6-month prevalence of 4 to 6% up to 15% in a general
medical clinic population
Men and women are equally affected
most commonly appears in persons 20 to 30 years of
age
low thresholds for, and low tolerance of, physical
discomfort.
viewed as a request for admission to the sick role
made by a person facing seemingly insurmountable
and insolvable problems.
a variant form of other mental disorders, among
which depressive disorders and anxiety disorders
Psychodynamic School of Thought:
aggressive and hostile wishes toward others are
transferred (through repression and displacement) into
physical complaints.
also viewed as a defense against guilt, a sense of
innate badness, an expression of low self-esteem, and a
sign of excessive self-concern.
CLINICAL FEATURES
o Patients believe that they have a serious disease that
has not yet been detected, and they cannot be
persuaded to the contrary.
o often accompanied by symptoms of depression and
anxiety and commonly coexists with a depressive or
anxiety disorder.
o course is usually episodic;
o good prognosis is associated with high
socioeconomic status, treatment-responsive anxiety
or depression, sudden onset of symptoms, the
absence of a personality disorder, and the absence
of a related non-psychiatric medical condition;
o usually resist psychiatric treatment
o Group psychotherapy often benefits such patients,
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Body Dysmorphic Disorder
characterized by a preoccupation with an imagined
defect in appearance that causes clinically significant
distress or impairment in important areas of
functioning. ; concern is excessive and bothersome.
a poorly studied condition
most common age of onset is between 15 and 30
years
women are affected somewhat more often than men
commonly coexists with other mental disorders
may involve serotonin
reflecting the displacement of a sexual or emotional
conflict onto a nonrelated body part
defense mechanisms of repression, dissociation,
distortion, symbolization, and projection.
facial flaws, particularly those involving specific parts
(e.g., the nose).
ideas or frank delusions of reference (usually about
persons' noticing the alleged body flaw
either excessive mirror checking or avoidance of
reflective surfaces
attempts to hide the presumed deformity (with
makeup or clothing).
usually begins during adolescence
usually has a long and undulating course with few
symptom-free intervals
clomipramine (Anafranil) and fluoxetine (Prozac)
reduce symptoms in at least 50 percent of patients
Augmentation with clomipramine (Anafranil),
buspirone (BuSpar), lithium (Eskalith),
methylphenidate (Ritalin), or antipsychotics may
improve the response rate.
Pain Disorder
characterized by the presence of, and focus on, pain
in one or more body sites and is sufficiently severe to
come to clinical attention.
somatoform pain disorder, psychogenic pain disorder,
idiopathic pain disorder, and atypical pain disorder
Lifetime prevalence is approximately 12%
Associated with other psychiatric disorders,
especially affective and anxiety disorders
Chronic pain appears to be most frequently
associated with depressive disorders, and acute pain
appears to be more commonly associated with
anxiety disorders.
may be symbolically expressing an intrapsychic
conflict through the body.
Hotchocolate M.D.
symbolic meaning of body disturbances may also
relate to atonement for perceived sin, to expiation of
guilt, or to suppressed aggression.
displacement, substitution, and repression.
Pain behaviors are reinforced when rewarded and are
inhibited when ignored or punished.
Intractable pain has been conceptualized as a means
for manipulation and gaining advantage in
interpersonal relationships, for example, to ensure
the devotion of a family member or to stabilize a
fragile marriage.
often have long histories of medical and surgical care.
completely preoccupied with their pain and cite it as
the source of all their misery
Major depressive disorder is present in about 25 to 50
percent of patients with pain disorder
generally begins abruptly and increases in severity for
a few weeks or months.
treatment approach must address rehabilitation.
Antidepressants, such as tricyclics and SSRIs, are the
most effective pharmacological agents.
psychodynamic psychotherapy
Undifferentiated Somatoform Disorder
characterized by one or more unexplained physical
symptoms of at least 6 months' duration, which are
below the threshold for a diagnosis of somatization
disorder
autonomic nervous system and fatigue or weakness.
autonomic arousal disorder
Somatoform Disorder Not Otherwise
Specified
a residual category for patients who have symptoms
suggesting a somatoform disorder, but do not meet
the specific diagnostic criteria for other somatoform
disorders
e.g., pseudocyesis
Pseudocyesis - a false belief of being pregnant that is
associated with objective signs of pregnancy, which
may include abdominal enlargement (although the
umbilicus does not become everted), reduced
menstrual flow, amenorrhea, subjective sensation of
fetal movement, nausea, breast engorgement and
secretions, and labor pains at the expected date of
delivery.
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 Hotchocolate M.D.
SUBSTANCE ABUSE DISORDER Transient visual, auditory and tactile
Dr. Rene Yat (2012) hallucinations
Illusions
ALCOHOL
MARIJUANA Psychomotor agitation
METHAMPHETAMINE Grand mal seizures
OPIATES
COCAINE 12 oz = 1 oz = 5 oz
BENZODIAZEPINES
BARBITURATES MEDICAL FINDINGS OF ALCOHOLISM
KETAMINE DEPRESSION
FACTS ABOUT ALCOHOLISM
ANXIETY
Alcohol intoxication, dependence, and abuse are
among the most prevalent mental disorders in the PHOBIAS
general populations SUICIDAL THINKING
Alcoholism knows no racial barriers DELUSIONS AND HALLUCINATIONS
It is the #1 drug of abuse in the USA
At least 15 million have serious alcohol-related MEDICAL COMPLICATIONS OF ALCOHOLISM
problems
CARDIOVASCULAR
At least 4.6 million adolescents have serious alcohol
related problems GASTROINTESTINAL
Alcohol related cause is second to heart disease and NUTRITIONAL
cancer VITAMIN DEFICIENCY
ENDOCRINOLOGIC DEFECTS
Alcohol Intoxication NEUROLOGIC COMPLICATIONS
is defined by the presence of important maladaptive
ONCOLOGY
behavioral or psychological changes due to alcohol
INFECTIONS
ingestion; Inappropriate sexual or aggressive behavior,
mood lability, impaired judgment, impaired social,
CARDIOVASCULAR EFFECT OF ALCOHOLISM
educational or occupational functioning.
HYPERTENSION
INCREASED PULSE RATE
Signs of alcohol intoxication
ALCOHOLIC CARDIOMYOPATHY
Slurred speech
EKG FINDINGS OF ATRIAL AND VENTRICULAR
Lack of coordination
ARRYTHMIAS, INTRAVENTRICULA CONDUCTION
Unsteady gait
ANOMALIES
Nystagmus
Impairment in attention and memory
GASTROINTESTINAL EFFECT OF ALCOHOLISM
Stupor or coma
Reflux esophagitis
Gastric and esophageal ulcer
Alcohol Withdrawal Syndrome
Mallory Weiss syndrome
It developed after cessation of heavy and
Erosive gastritis, atrophic gastritis, gastric
prolonged alcohol use.
hemorrhage
Tremulousness
Chronic pancreatitis
Insomnia
Malabsorption and diarrhea
Nausea and vomiting
Fatty liver
Autonomic hyperarousal
Cirrhosis of the liver
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 Hotchocolate M.D.
Nutritional effect of alcoholism Oncological Effects of Alcoholism
Folic acid deficiency Cancer of the mouth
Pyridoxine deficiency Cancer of the tongue
Thiamine deficiency Cancer of the oropharynx
Iron deficiency CA of the hypopharynx
Zinc deficiency CA of the larynx
Vitamin A,D,K deficiency CA of the esophagus
CA of the liver
Endocrinologic Effect of Alcoholism
Adrenocortical function Infections and alcoholism
Adrenomedullary function Pneumonia
Thyroid function Tuberculosis
Gonadal function Meningitis
Pituitary function Peritonitis
Alcoholic hypoglycemia Ascending cholangitis
Alcohol ketosis Pharyngitis

Neurological Effect of Alcoholism Treatment for alcoholism

A. Wernickes - Korsakoff psychosis
B. Cerebral atrophy
C. Peripheral neuropathy
D. Alcohol myopathy
Wernicke-Korsakoff syndrome
is a two-stage brain disorder caused by an alcohol
induced thiamine deficiency. Thiamine is needed for
cells to generate energy from sugar. If thiamine levels
drop too low, this ability ceases. Wernicke
encephalopathy is the first phase and Korsakoff
psychosis is the second chronic stage of the disorder.
Symptoms of the Wernicke-Korsakoff syndrome
include confusion, permanent gaps in memory,
problems with learning new information, vision
impairment, stupor, coma, hypothermia,
hypotension, ataxia, and confabulation
Confabulation is a symptom where patients make up
stories to fill the missing gaps in their memories. They
may not be lying, but actually believe the newly
created memories.
Acamprosate ( aotal )
Naltrexone
Disulfiram ( antabuse ) not used anymore because of
adverse side effect.
Metronidazole surreptitiously given by some doctor to
hasten up intoxication. ( dangerous practice )
JELLINEKS TYPE OF ALCOHOLISM
Alpha alcoholism: the earliest stage of the disease,
manifesting the purely psychological continual
dependence on the effects of alcohol to relieve bodily or
emotional pain. This is the "problem drinker", whose
drinking creates social and personal problems. Whilst
there are significant social and personal problems, these
people can stop if they really want to; thus, argued
Jellinek, they have not lost control, and as a
consequence, do not have a "disease".
Beta alcoholism: polyneuropathy, or cirrhosis of the
liver from alcohol without physical or psychological
dependence. These are the heavy drinkers that drink a
lot, almost every day. They do not have
physical addiction and do not
suffer withdrawal symptoms. This group do not have a
"disease".

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Gamma alcoholism: involving acquired tissue
tolerance, physical dependence, and loss of control. This
is the AA alcoholic, who is very much out of control, and
does, by Jellinek's classification, have a "disease".[13]
Delta alcoholism: as in Gamma alcoholism, but with
inability to abstain, instead of loss of control.
Epsilon alcoholism: the most advanced stage of the
disease, manifesting as dipsomania, or periodic
alcoholism.
Serum blood alcohol level and its effect
0.02-0.03 BAC: No loss of coordination, slight
euphoria and loss of shyness. Depressant effects are
not apparent. Mildly relaxed and maybe a little
lightheaded.
0.04-0.06 BAC: Feeling of well-being, relaxation,
lower inhibitions, sensation of warmth. Euphoria.
Some minor impairment of reasoning and memory,
lowering of caution. Your behavior may become
exaggerated and emotions intensified (Good
emotions are better, bad emotions are worse)
0.07-0.09 BAC: Slight impairment of balance, speech,
vision, reaction time, and hearing. Euphoria.
Judgment and self-control are reduced, and caution,
reason and memory are impaired, .08 is legally
impaired and it is illegal to drive at this level. You will
probably believe that you are functioning better than
you really are.
0.10-0.125 BAC: Significant impairment of motor
coordination and loss of good judgment. Speech may
be slurred; balance, vision, reaction time and hearing
will be impaired. Euphoria.
0.13-0.15 BAC: Gross motor impairment and lack of
physical control. Blurred vision and major loss of
balance. Euphoria is reduced and dysphoria (anxiety,
restlessness) is beginning to appear. Judgment and
perception are severely impaired.
0.16-0.19 BAC: Dysphoria predominates, nausea may
appear. The drinker has the appearance of a "sloppy
drunk."
Hotchocolate M.D.
0.20 BAC: Felling dazed, confused or otherwise
disoriented. May need help to stand or walk. If you
injure yourself you may not feel the pain. Some
people experience nausea and vomiting at this level.
The gag reflex is impaired and you can choke if you
do vomit. Blackouts are likely at this level so you may
not remember what has happened.
0.25 BAC: All mental, physical and sensory functions
are severely impaired. Increased risk of asphyxiation
from choking on vomit and of seriously injuring
yourself by falls or other accidents.
0.30 BAC: STUPOR. You have little comprehension of
where you are. You may pass out suddenly and be
difficult to awaken.
0.35 BAC: Coma is possible. This is the level of
surgical anesthesia.
0.40 BAC and up: Onset of coma, and possible death
due to respiratory arrest.
DRUG FREE WORKPLACE
Dr. Rene Yat
FACTS
ABOUT 74% OF THE WORKFORCE ARE INTO DRUGS
Most common substance of abuse is alcohol,
methamphetamine, marijuana
It costs employers around $100 billion a year
through lost productivity, increased absenteeism,
and drug-related injuries.
60% of the worlds illegal drug market is in the US
>20 Million Americans use Marijuana
6 Million use cocaine
Half a million use heroin
13 Million Americans are alcoholics
2/3 of drug abusers are employed! are full time
There are more high income drug abusers than low
income abusers
The overall rate of drug abuse in America is 5%.
Current estimates of drug users in these country is
about 5.6 Million
This translate to 600 billion pesos industry
About 8.4 Million people are underemployed
About 6.4 Million out of school are unemployed
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 Hotchocolate M.D.
D. Post-accident Testing
It is an employer-mandated testing of an individual
who is directly involved in a motor vehicle crash or
other accident or near miss accidents.
This testing is based on events that automatically
require testing. Theres no need for indicators of
employees impairment.
E. Periodic Testing
Is a catch all category that includes drug tests
conducted at designated intervals.
Types of Drug Testing Such tests are usually conducted as an adjunct to
Situational routine check-ups or recertification of occupational
Pre-employment drug testing licenses.
Reasonable cause drug testing The disadvantage of this test, users can simply abstain
Random Testing from use prior to the scheduled test. And there is a
high preponderance for loss of custody of urine
Post accident Testing
specimen.
Periodic testing
Rehabilitation Testing
F. Rehabilitation Testing
The frequency and manner of testing employees are
A. Pre-employment Drug Testing
determined by rehabilitation program professionals.
This is preventive because it denies employment to
Only the MRO should evaluate positive test results.
persons who are identified as drug users
The role could be expanded to include rehabilitation
It exposes the prospective employers to less liability
functions.
involving labor grievances and litigations
This is a sort of after care to maximize assurances that
Most frequently used type of testing
an employee would remain drug free.
B. Reasonable cause Testing
Drug testing is used when an employees unsafe or
Limitations of Drug Test
unacceptable job conduct clearly points to a
Unlike blood and alcohol levels, drug test cannot
problem, which may involve drug use.
measure impairment because drug concentrations in
This testing is conducted when an employer believes,
urine or blood do not correlate with the degree of
based on objective facts, that a particular employee
impairment.
is unable to perform his/her duties.
Drug test should be confirmed by GC/MS that is, Gas
E.g. accidents, deviations from safe working practices,
Chromatography and Mass Spectrophotometry which
and erratic workplace conduct.
is very expensive test.
C. Random Testing
One of the most controversial test because it pits the
5 elements of Drug Free Workplace
employers desires against the employees privacy
1. Formal written policy
interest.
2. 2 E.A.P.
Also known as unannounced testing
3. Training for supervisors
Also known as No cause testing
4. Employee Education
These two factors no notice and no cause are
5. 5 Drug Testing
responsible for the unpopularity of this testing
method.
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 Hotchocolate M.D.
Players in the Drug Testing Employers Right to Implement Testing
1. The employer Under an employment contract, an employer may
2. The donor always discharge an employee for a good cause. Good
3. Specimen collection site cause includes dishonesty, immoral conduct,
4. The laboratory negligence, incompetence, or disobedience of
5. MRO reasonable work rules. If a contract for a definite term
does not specifically state that an employer can
Substances to Test terminate an employee for failing to abide by the
Alcohol employers drug and alcohol policy, the employer may
Methamphetamine be faced with a breach of contract claim.
Marijuana Clearly, an employer can avoid cost of loss of
Cocaine productivity, and liability of breach of contract claim
Benzodiazepines arising from the discipline or discharge of an employee
Barbiturates who refuses to take a drug test, or who tests positive,
Others ( according to the employers SAP ) by specifically including a term addressing drug and
alcohol testing in any employment contract.
Direct Cost to your business
Drug abusing employees acquire 300% higher medical Indirect Cost
costs and benefits which consequently increases Credible studies show that a substance abuser will
health insurance rates. [U.S. Chamber of Commerce] function at about 67% of his/her capacity! Data
Illicit drug users are five times more likely to file a supports the "generalization" that they are NOT
workers' compensation claim. [U.S. Dept. of Justice, Drug productive workers! [National Institute on Drug Addiction]
Enforcement Administration] Employees using drugs are three times more likely to
Many illegal drugs are bought by money diverted from be late for work and 2.5 times more likely to have
legitimate businesses and could be as much as 100 absences of eight or more days. Collectively, substance
billion a year. (2.5% of GNP and 8% of discretionary abusers have an absentee rate of 30-35 days per year!
spending) [U.S. Chamber of Commerce] [U.S. Chamber of Commerce]
Drug use in the workplace breeds drug dealers in the
Benefits to the employer workplace. An Indiana Gallup survey revealed that 32%
Reduce operational cost of workers knew of drug use by employees on the job;
Preserve investor or shareholders interest and 10% had been offered drugs to use on the job while
Protect loyal employee at work.
Improve product and services Drug users have 3.6 times as many accidents. Up to
40% of industrial fatalities and 47% of industrial injuries
Increase profits
can be linked to alcohol abuse and alcoholism.
Help many people lead a healthier life
[Employee Assistance Society of North America]
Improve services to clients
Drug users tend to have bad work habits and tend to
reduce morale.
Now, its up to you to make the right choice!
A) DRUG FREE WORKER
B) DRUG CRAZED WORKER

END (,)

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