Somatoform disorders

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Somatoform disorders

• prof. MUDr. Hana Papežová, CSc.
• Department of Psychiatry, First Faculty of
  Medicine, Charles University and General
  University Hospital in Prague

2
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

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Diagnostic guidelinesSomatization 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.

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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.

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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

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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

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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..

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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

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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.

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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

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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.

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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.

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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.

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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.

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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

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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

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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

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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.

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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.

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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.

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Somatoform autonomicdisorder 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.

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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.

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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.

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F50 Eating Disorders
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SPECTRUM OF EATING DISOREDRS
OBESITY
BULIMIA
RESTRICTING ANOREXIA
BINGE EATING
BING-PURG. ANOREXIA
IMPULSE INHIBITION FOOD RESTRICTION PERFECTIONISM

BODY WEIGHT DRIVE TO EAT IMPULSIVITY
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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

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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.

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Anorexia nervosa F50.0

• Endocrine disorder of hypothalamic-pituitary-gona
  dal 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).

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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).

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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).

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Eating disorders and the brain
EATING BEHAVIOUR
BRAIN
BODY
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Anorexia nervosa, Starvation the Brain
AN
PHYSICAL STATE STARVATION
PSYCHICAL DISEASE BRAIN ALTERATION
?
STARVATION
BRAIN ALTERATION
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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.
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Anatomy of CNS Brain atrophy I
Computed Tomography
VENTRICULAR BRAIN RATION
AN (50) BN (50) COPP (50)
Laessle et al 1989
Krieg et al 1989
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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
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SENSORY IMPUT
INTEGRATION
vision
DORSOLATERAL PREFRONTAL CX IMPULSE INHIBITION
AMYGDALA ASSOCIATIVE LEARNING
VISUAL CORTEX
smell
OLFACTORY CORTEX
HYPOTHALAMUS SENSING ENERGY BALANCE
ORBITOFRONTAL CORTEX DECISION MAKING REWARD VALUE
TASTE CORTEX INSULA FRONTAL OPERCULUM
taste

• INSULIN
• LEPTIN
• GHRELIN
• BLOOD GLUCOSE

OUTPUT BEHAVIOUR
METABOLIC SIGNALS
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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.

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Precontemplation
Recovery
MET
Contemplation
Relapse
Preparation
Maintenance
CAT
Stages of Change Model
Action
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CBT for the eating disorders

• Making links between behaviour, cognitions and
  affect
• modifying these in parallel

Cognition (e.g. gaining weight)
Emotions (e.g.anxiety, disgust)
Behaviour (e.g.food avoidance)
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Prevention

• Increase knowledge
• Promote acceptance
• Diversity puberty
• Nature of eating d/o
• Discourage dieting
• Reduce teasing
• Media literacy

• Self acceptance
• Increase self esteem
• Coping strategies
• Reduce body dissatisfaction
• Healthy eating
• Limit internalization