SOMATOFORM DISORDER

D R . N Y O M A N R AT E P S P. K J ( K )

BAG/SMF Psikiatri fk unud/rsup

Sanglah denpasar
Hypochondriasis
 Introduction
 In DSM-IV, hypochondriasis is defined as a person's
preoccupation with the fear of contracting, or the belief of
having, a serious disease.
 This fear or belief arises when a person misinterprets bodily
symptoms or functions.
 The term hypochondriasis is derived from the old medical term
hypochondrium, ("below the ribs") and reflects the common
abdominal complaints of many patients with the disorder.
 Hypochondriasis results from patients' unrealistic or inaccurate
interpretations of physical symptoms or sensations, even
though no known medical causes can be found.
 Patients' preoccupations result in significant distress to them
and impair their ability to function in their personal, social,
and occupational roles.
 Epidemiology and etiology
 One recent study reported a 6-month prevalence of
hypochondriasis of 4 to 6 percent in a general medical clinic
population.
 Men and women are equally affected by hypochondriasis.
 Although the onset of symptoms can occur at any age, the
disorder most commonly appears in people 20 to 30 years of
age.
 Some evidence indicates that the diagnosis is more common
among blacks than among whites, but social position,
education level, and marital status do not appear to affect the
diagnosis.
 Clinical features-1
 Patients with hypochondriasis believe that they have a serious
disease that has not yet been detected, and they cannot be
persuaded to the contrary.
 They may maintain a belief that they have a particular disease;
as time progresses, they may transfer their belief to another
disease.
 Their convictions persist despite negative laboratory results,
the benign course of the alleged disease over time, and
appropriate reassurances from physicians.
 Yet their beliefs are not so fixed as to be delusions.
 Hypochondriasis is often accompanied by symptoms of
depression and anxiety and commonly coexists with a
depressive or anxiety disorder.
 Clinical features-2
 Although DSM-IV specifies that the symptoms must be
present for at least 6 months, transient hypochondriacal states
can occur after major stresses, most commonly the death or
serious illness of someone important to the patient, or a serious
(perhaps life-threatening) illness that has been resolved but
that leaves the patient temporarily hypochondriacal in its wake.
 Such states that last fewer than 6 months should be diagnosed
as somatoform disorder not otherwise specified.
 Transient hypochondriacal responses to external stress
generally remit when the stress is resolved, but they can
become chronic if reinforced by people in the patient's social
system or by health professionals.
 Diagnostic criteria-1
 The DSM-IV diagnostic criteria for hypochondriasis require that patients
be preoccupied with the false belief that they have a serious disease and
that the false belief be based on a misinterpretation of physical signs or
sensations .
 The belief must last at least 6 months, despite the absence of pathological
findings on medical and neurological examinations.
 The diagnostic criteria also stipulate that the belief not have the intensity of
a delusion (more appropriately diagnosed as delusional disorder) and that it
not be restricted to distress about appearance (more appropriately
diagnosed as body dysmorphic disorder).
 The symptoms of hypochondriasis must be of an intensity that causes
emotional distress or impairs the patient's ability to function in important
areas of life.
 Clinicians may specify the presence of poor insight; patients do not
consistently recognize that the concerns about disease are excessive.
 DSM-IV diagnosis criteria for
Hypochondriasis
A. Preoccupation with fears of having, or the idea that one has, a serious
disease based on the person-misinterpretation of bodily symptoms
B. The preoccupation persists despite appropriate medical evaluation and
reassurance.
C. The belief in criterion A is not of delusional intensity (as in delusional
disorder, somatic type) and is not restricted to a circumscribed concern
about appearance (as in body dysmorphic disorder).
D. The preoccupation causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by generalized anxiety
disorder, obsessive-compulsive disorder, panic disorder, a major
depressive episode, separation anxiety, or another somatoform disorder.
 Differential diagnosis-1
 Hypochondriasis must be differentiated from
nonpsychiatric medical conditions, especially
disorders that show symptoms that are not necessarily
easily diagnosed.
 Such diseases include AIDS, endocrinopathies,
myasthenia gravis, multiple sclerosis, degenerative
diseases of the nervous system, systemic lupus
erythematosus, and occult neoplastic disorders.
 Differential diagnosis-2
 Hypochondriasis is differentiated from somatization disorder
by the emphasis in hypochondriasis on fear of having a disease
and emphasis in somatization disorder on concern about many
symptoms.
 A subtle distinction is that patients with hypochondriasis
usually complain about fewer symptoms than do patients with
somatization disorder.
 Somatization disorder usually has an onset before age 30,
whereas hypochondriasis has a less specific age of onset.
 Patients with somatization disorder are more likely to be
women than are those with hypochondriasis, which is equally
distributed among men and women.
 Differential diagnosis-3
 Hypochondriasis must also be differentiated from the other
somatoform disorders.
 Conversion disorder is acute and generally transient and
usually involves a symptom rather than a particular disease.
The presence or absence of la belle indifference indifference is
an unreliable feature with which to differentiate the two
conditions.
 Pain disorder is chronic, as is hypochondriasis, but the
symptoms are limited to complaints of pain.
 Patients with body dysmorphic disorder wish to appear normal
but believe that others notice that they are not, whereas those
with hypochondriasis seek out attention for their presumed
diseases.
 Differential diagnosis-4
 Hypochondriacal symptoms can also occur in patients with depressive
disorders and anxiety disorders.
 If a patient meets the full diagnostic criteria for both hypochondriasis and
another major mental disorder, such as major depressive disorder or
generalized anxiety disorder, the patient should receive both diagnoses,
unless the hypochondriacal symptoms occur only during episodes of the
other mental disorder.
 Patients with panic disorder may initially complain that they are affected by
a disease (for example, heart trouble), but careful questioning during the
medical history usually uncovers the classic symptoms of a panic attack.
 Delusional hypochondriacal beliefs occur in schizophrenia and other
psychotic disorders but can be differentiated from hypochondriasis by their
delusional intensity and by the presence of other psychotic symptoms.
 In addition, schizophrenic patients' somatic delusions tend to be bizarre,
idiosyncratic, and out of keeping with their cultural milieus.
 Differential diagnosis-5
 Hypochondriasis is distinguished from factitious
disorder with physical symptoms and from
malingering in that patients with hypochondriasis
actually experience and do not simulate the symptoms
they report.
 Course and prognosis
 The course of hypochondriasis is usually episodic; the
episodes last from months to years and are separated by
equally long quiescent periods.
 There may be an obvious association between exacerbations of
hypochondriacal symptoms and psychosocial stressors.
 Although well-conducted large outcome studies have not yet
been reported, an estimated one third to one half of all patients
with hypochondriasis eventually improve significantly.
 A good prognosis is associated with a high socioeconomic
status, treatment-responsive anxiety or depression, the sudden
onset of symptoms, the absence of a personality disorder, and
the absence of a related nonpsychiatric medical condition.
 Most children with hypochondriasis recover by late
adolescence or early adulthood.
 Treatment-1
 Patients with hypochondriasis are usually resistant to
psychiatric treatment although some accept this
treatment if it takes place in a medical setting and
focuses on stress reduction and education in coping
with chronic illness.
 Among such patients, group psychotherapy is the
modality of choice, in part because it provides the
social support and social interaction that seem to
reduce their anxiety.
 Individual insight-oriented psychotherapy may be
useful, but is generally unsuccessful.
 Treatment-2
 Frequent, regularly scheduled physical examinations
are useful to reassure patients that their physicians are
not abandoning them and that their complaints are
being taken seriously.
 Invasive diagnostic and therapeutic procedures should
only be undertaken, however, when objective
evidence calls for them.
 When possible, the clinician should refrain from
treating equivocal or incidental physical examination
findings.
 Treatment-3
 Pharmacotherapy alleviates hypochondriacal
symptoms only when a patient has an underlying
drug-responsive condition, such as an anxiety
disorder or major depressive disorder.
 When hypochondriasis is secondary to another
primary mental disorder, that disorder must be treated
in its own right.
 When hypochondriasis is a transient situational
reaction, clinicians must help patients cope with the
stress without reinforcing their illness behavior and
their use of the sick role as a solution to their
problems.
Pain disorder
 Introduction
 In DSM-IV, pain disorder is defined as the presence of pain
that is "the predominant focus of clinical attention."
 Psychological factors play an important role in the disorder.
 The primary symptom is pain, in one or more sites, which is
not fully accounted for by a nonpsychiatric medical or
neurological condition.
 The symptoms of pain are associated with emotional distress
and functional impairment.
 The disorder has been called somatoform pain disorder,
psychogenic pain disorder, idiopathic pain disorder, and
atypical pain disorder.
 Epidemiology
 Low back pain has disabled an estimated 7 million
people;
 more than 8 million physician office visits annually;
 Female : male=2:1;
 The peak ages of onset are in the fourth and fifth
decades;
 most common in people with blue-collar occupations;
 genetic inheritance or behavioral mechanisms are
possibly involved;
 Clinical features-1
 Patients with pain disorder do not constitute a
uniform group but, instead, are a heterogeneous
collection of people with low back pain, headache,
atypical facial pain, chronic pelvic pain, and other
kinds of pain.
 A patient's pain may be posttraumatic, neuropathic,
neurological, iatrogenic, or musculoskeletal; to meet
a diagnosis of pain disorder, however, the disorder
must have a psychological factor that is judged to be
significantly involved in the pain symptoms and their
ramifications.
 Clinical features-2
 Patients with pain disorder often have long histories of medical
and surgical care.
 They visit many physicians, request many medications, and may be
especially insistent in their desire for surgery.
 Indeed, they can be completely preoccupied with their pain and cite it
as the source of all their misery.
 Such patients often deny any other sources of emotional
dysphoria and insist that their lives are blissful except for their
pain.
 Their clinical picture can be complicated by substance-related
disorders, because these patients attempt to reduce the pain
through the use of alcohol and other substances.
 Clinical features-3
 At least one study has correlated the number of pain symptoms
to the likelihood and severity of symptoms of somatization
disorder, depressive disorders, and anxiety disorders.
 Major depressive disorder is present in about 25 to 50 percent of all
patients with pain disorder,
 and dysthymic disorder or depressive disorder symptoms are reported
in 60 to 100 percent of the patients.
 Some investigators believe that chronic pain is almost always a
variant of a depressive disorder, a masked or somatized form
of depression.
 The most prominent depressive symptoms in patients with pain
disorder are anergia, anhedonia, decreased libido, insomnia, and
irritability; diurnal variation, weight loss, and psychomotor retardation
appear to be less common symptoms.
 Diagnostic criteria
 The DSM-IV diagnostic criteria for pain disorder require the
presence of clinically significant complaints of pain .
 The complaints of pain must be judged to be significantly
affected by psychological factors, and the symptoms must
result in a patient's significant emotional distress or functional
impairment (for example, social or occupational).
 DSM-IV requires that the pain disorder be associated primarily
with psychological factors or with both psychological factors
and a general medical condition.
 DSM-IV further specifies that pain disorder associated solely
with a general medical condition be diagnosed as an Axis III
condition and also allows clinicians to specify whether the
pain disorder is acute or chronic, depending on whether the
duration of symptoms has been 6 months or more.
 DSM-IV diagnosis criteria for pain
disorder
A. Pain in one or more anatomical
sites is the predominant focus of
the clinical presentation and is of
sufficient severity to warrant
clinical attention.
B. The pain causes clinically
significant distress or impairment
in social, occupational, or other
important areas of functioning.
C. Psychological factors are judged
to have an important role in the
onset, severity, exacerbation, or
maintenance of the pain.
 DSM-IV diagnosis criteria for pain
disorder
D. The symptom or deficit is
not intentionally produced
or feigned (as in factitious
disorder or malingering
E. The pain is not better
accounted for by a mood,
anxiety, or psychotic
disorder and does not meet
criteria for dyspareunia.
 Differential diagnosis-1
 Purely physical pain can be difficult to distinguish
from purely psychogenic pain, especially because the
two are not mutually exclusive.
 Physical pain fluctuates in intensity and is highly sensitive
to emotional, cognitive, attentional, and situational
influences.
 Pain that does not vary and is insensitive to any of these
factors is likely to be psychogenic.
 When pain does not wax and wane and is not even
temporarily relieved by distraction or analgesics, clinicians
can suspect an important psychogenic component.
 Differential diagnosis-2
 Pain disorder must be distinguished from other somatoform
disorders, although some somatoform disorders can coexist.
 Patients with hypochondriacal preoccupations may complain
of pain, and aspects of the clinical presentation of
hypochondriasis, such as bodily preoccupation and disease
conviction, can also be present in patients with pain disorder.
 Patients with hypochondriasis tend to have many more
symptoms than do patients with pain disorder, and their
symptoms tend to fluctuate more than do the symptoms of
patients with pain disorder.
 Conversion disorder is generally short lived, whereas pain
disorder is chronic. In addition, pain is, by definition, not a
symptom in conversion disorder.
 Malingering patients consciously provide false reports, and
their complaints are usually connected to clearly recognizable
goals.
 Course and prognosis
 The pain in pain disorder generally begins abruptly and
increases in severity for a few weeks or months.
 The prognosis varies, although pain disorder can often be
chronic, distressful, and completely disabling.
 When psychological factors predominate in pain disorder, the
pain may subside with treatment or after the elimination of
external reinforcement.
 The patients with the poorest prognoses, with or without
treatment, have preexisting characterological problems,
especially pronounced passivity; are involved in litigation or
receive financial compensation; use addictive substances; and
have long histories of pain.
 Treatment (1)
 General consideration
 discuss the issue of psychological factors early in treatment;
 explain how various brain circuits that are involved with
emotions;
 fully understand that the patient's experiences of pain are
real.
 Pharmacotherapy
 Analgesic medications are not generally helpful;
 Sedatives and antianxiety agents are not especially
beneficial;
 Antidepressants (TCA, SSRIs) are useful;
 Amphetamine used as an adjunct to SSRIs.
 Treatment (2)
 Behavioral therapy
 Biofeedback can be helpful;
 Hypnosis, transcutaneous nerve stimulation, and dorsal
column stimulation have been used;
 Nerve blocks and surgical ablative procedures are
ineffective
 Psychotherapy
 develop a solid therapeutic alliance;
 not confront somatizing patients;
 examine its interpersonal ramifications in the patient's life;
 Cognitive therapy
 Treatment (3)
 Pain control programs
 Multidisciplinary pain units use many modalities;
 physical therapy and exercise;
 offer vocational evaluation and rehabilitation;
 Concurrent mental disorders are diagnosed and treated;
 dependent on analgesics and hypnotics are detoxified.
 Conversion Disorder

 Physical malfunctioning without any physical or organic pathology

 Malfunctioning often involves sensory-motor areas
 Persons show la belle indifference
 Retain most normal functions, but without awareness of this ability
 Statistics
 Rare condition, with a chronic intermittent course
 Seen primarily in females, with onset usually in adolescence
 Not uncommon in some cultural and/or religious groups
 Conversion disorder (cont.)

 Freudian psychodynamic view is still popular (anxiety converted into physical

symptoms)
 Emphasis on the role of trauma (stress), conversion, and primary/secondary
gain
 Detachment from the trauma and negative reinforcement seem critical
 Different from factitious disorder (intentional)
 Treatment
 Similar to somatization disorder
 Core strategy is attending to the trauma
 Remove sources of secondary gain
 Reduce supportive consequences of talk about physical symptoms
 Dissociative Disorders
 Derealization
 Loss of sense of the reality of the external world
 Depersonalization
 Loss of sense of your own reality
 5 types
 Depesonalization disorder
 Dissociative amnesia
 Dissociative fugue
 Dissociative trance disorder
 Dissociative identity disorder
 Dissociative Disorders
 Depersonalization disorder
 Severe feelings of depersonalization dominate the
individual’s life and prevent normal functioning
 It is chronic
 50% suffer from additional mood and anxiety disorders
 Cognitive profile (cognitive deficits in attention, STM,
spatial reasoning, perception (3D))
 Dissociative Disorders
 Dissociative Amnesia
 Inability to recall personal information, usually of a
stressful or traumatic nature
 Generalized vs. selective amnesia
 Dissociative Fugue
 Sudden, unexpected travel away from home, along with an
inability to recall one’s past (new identity)
 Occur in adulthood and usually end abruptly
 Dissociative Disorders
 Dissociative trance disorder
 Altered state of consciousness in which the person believes
firmly that he or she is possessed by spirits; considered a
disorder only where there is distress and dysfunction
 Trance and possession are a common part of some
traditional religious and cultural practices and are not
considered abnormal in that context
 Only undesirable trance considered pathological within that
culture is characterized as disorder
 Dissociative Disorders
 Dissociative Identity Disorder
 Formerly multiple personality disorder
 Many personalities (alters) or fragments of personalities
coexist within one body
 The personalities or fragments are dissociated
 Switch (transition form one personality to another, includes
physical changes)
 Can be simulated by malingers are usually eager to
demonstrate their symptoms whereas individuals with DID
attempt to hide symptoms
 Very high comorbidity
 Prevalence about 3%
 Dissociative Disorders
 Dissociative Identity Disorder
 Auditory hallucinations (coming from inside their heads)
 97% severe child abuse
 Extreme subtype of PTSD
 Onset – approximately 9 years
 Suggestible people may use dissociation as defense against
severe trauma
 Real and false memories
 Temporal lobe pathology (out of body experiences)
 Dissociative Disorders
 Treatment
 Dissociative amnesia and fugue
 Get better on their own
 Coping mechanisms to prevent future episodes
 DID
 Reintegration of identities
 Neutralization of cues
 Confrontation of early trauma
 hypnosis