Elmeida Effendy

Department of Psychiatry
Medical Faculty- USU

 Somatoform

soma (Greek) :

body
Somatoform disorders : a broad
group of illnesses that have bodily
signs and symptoms as a major
component

Categories of Somatoform
Disorders in ICD-10 & DSM-IV
ICD-10
Somatization disorder
Undifferentiated somatoform

disorder
Hypochondriacal disorder
Somatoform autonomic
dysfunction
Persistent pain disorder
Other somatoform disorders
No category
No category
Neurasthenia

DSM-IV TR
Somatization disorder
Conversion disorder
Hypochondriasis
Body dysmorphic disorder
Pain disorder
Undifferentiated somatoform
disorder
Somatoform disorderNo
category

DSM -5 :
Somatic Symptom
and Related
Disorders

 Somatic Symptom and Related

Disorders)
Somatic Symptom Disorder (311)
Specify if: With predominant pain
Specify if: Persistent
Specify current severity: Mild, Moderate,

Severe

Illness Anxiety Disorder (315)

Specify whether: Care seeking type. Care

avoidant type
Conversion Disorder (Functional
Neurological Symptom Disorder) (318)
Feeding and Eating Disorder
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 Specify symptom type:

(F44.4) With weakness or paralysis
(F44.4) With abnormal movement
(F44.4) With swallowing symptoms
(F44.4) With speech symptom
{F44.5) With attacks or seizures
(F44.6) With anesthesia or sensory

loss
(F44.6) With special sensory symptom
(F44.7) With mixed symptoms
Specify if: Acute episode, Persistent
Specify if: With psychological stressor
(specify stressor). Without psychological
stressor

 Psychological Factors Affecting Other

Medical Conditions (322)

Specify current severity: Mild, Moderate,
Severe, Extreme
Factitious Disorder (includes Factitious
Disorder Imposed on Self,
Factitious Disorder Imposed on Another)
(324)
Specify Single episode. Recurrent episodes
Other Specified Somatic Symptom and
Related Disorder (327)
Unspecified Somatic Symptom and Related
Disorder (327)
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Somatization Disorder
Essential feature
: multiple somatic complaints in of long

duration, beginning before the age 30

multiple organ systems that occurs over a
period of several years and results in
significant impairment or treatment
seeking, or both
Differs from other somatoform disorders
because of the multiplicity of the
complaints and the multiple organ
systems that are affected
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 Chronic, associated with significant

psychological distress,impaired social

and occupational functioning and
excessive medical-help seeking
behavior
Early name for somatization disorder :

hysteria (condition incorrectly thought to

affect only women)

10

 1859 Paul Briquet, French physician ,

observed the multiplicity of

symptoms and affected organ
systems and commented on the
usually chronic course of the
disorder: Briquets syndrome

11

DSM-IV-TR Criteria
A. A history of many physical

complaints beginning before age 30

years
B. Each of the following criteria must
have been met, with individual
symptoms occuring at anytime
during the course of disturbance :

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4 pain symptoms : head, abdomen,

back, joints,extremities, chest, during
menstruation
2 gastrointestinal symptoms : nausea,
bloating, vomiting, diarrhea
1 sexual symptom : erectile/ejaculatory
dysfunction,irregular menses,
excessive menstrual bleeding
1 pseudoneurological symtom : impaired
coordination,paralysis,weakness,
difficulty swallowing, urinary
retention,hallucination,blindness
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 Epidemiology
Prevalence : < 1 %
Women : men = 2:1

Treatment
Continuing care by 1 doctor using only the

essential investigations can reduce the use

of health services & may improve patients
functional state

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Hypochondriasis
The term hypochondriasis is one of

the oldest medical terms, originally

used to describe disorders believed
to be due to disease of the organs
situated in the hypochondrium. It is
now defined by DSM-IV & ICD-10 in
terms of conviction & or fear of
disease unsupported by the results
of appropriate medical investigation
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 DSM-IV described the condition as a

preoccupation with a fear or belief of

having a serious disease based on the
individuals interpretation of physical
signs of sensations as evidence of
physical illness. Appropriate physical
evaluation doesnt support the dx of
any physical disorder than can account
for the physical signs or sensations or
for the individuals unrealistic
interpretation of them
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 Aetioloy
The cause is unknown
Cognitive formulations suggest that there is

faulty appraisal of normal bodily sensations

which are interpreted as evidence of
disease. This misinterpretation is
maintained by behaviours such as
continually seeking reassurance &
examining or rubbing the supposedly
affected part

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 Treatment
Repeated reassurance is unhelpful & may

serve to prolong the patients concerns.

Investigations should be limited to those
indicated by the medical priorities & not
extended to satisfy the patients other
concern
Misinterpretations of the significance of
bodily sensations should be corrected &
encouragement given to constructive ways
of coping with symptoms

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Body Dysmorphic Disorder

Dysmorphophobia
The preoccupation with the imagined

defect in appearance is usually an

overvalued idea, but individuals can
receive an additional diagnosis of
Delusional Disorder, Somatic type

19

 Patients with dysmorphophobia are

convinced that some part of their body

is too large, too small or misshapen. To
other people the appearance is normal
or there is a trivial abnormality
The common concerns are about the
nose, ears, mouth, breasts, buttocks or
penis, but any part of the body may be
involved

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 Assessment : questions about the

nature of the preoccupations with the

appearance & of the ways in which this
has interfered with personal & social
life
Embarrassment
misdiagnosis as
social phobia, panic disorder & OCD
Treatment :
secondary to a psychiatric disorder (MDD)
Primary BDD
difficult :

establish a working relationship in which

the patient feels that the psychiatrist is
sympathetic, understands the severity of
the problems & willing to help

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Pain Disorder
Chronic pain that is not caused by any

physical or spesific psychiatric disorder

DSM IV states that the essential feature :
predominant focus of the clinical
presentation & is of sufficient severity to
cause distress or impairment of
functioning, & no organic pathology or
pathophysiological mechanism
pain
or resulting social or occupational
impairment is grossly is excess of what
would be expected from the physical
findings
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 Epidemiology
>> people transient
<< people persistent or recurrent

disability
Pain
most common symptom among
people who consult doctors
Acute pain usually has an organic cause but
psychological factors can affect the subjective
response to pain whatever the main cause
Pain is particularly associated with depression,
anxiety, panic & somatoform disorders
Patients w/ multiple pains are especially likely
to have associated psychiatric disorder

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 Assessment
Investigation of possible physical cause

when (-) remember that pain may be the

first symptoms of a physical illness that
cannot be detected at an early stage
Full description of t/ pain & t/ circumstances
in which it occurs
Search for symptoms of a depressive or
other psychiatric disorder
Description of pain behaviours :
presentation of symptoms, request for
medication, responses to pain
Beliefs about t/ causes of pain & of its
implications
24

 Treatment
Individually planned, comprehensive &

involve t/ patients family

Skill is required to maintain a working
relationship w/ patients unwilling to accept
an approach that uses psychological
treatments as part of t/ treatment of pain

25

 Psychological care is directed to

assessing
any associated mental disorder
Whether psychological techniques are
indicated

26

 Some specific pain syndromes :

Headache
Facial pain
Back pain
Chronic pelvic pain

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Conversion Disorder
Used in DSM-IV to replace the older

term hysteria
Equivalent of dissociative (conversion)
disorder in ICD-10
Refers to a condition in which there are
isolated neurological symptoms that
cannot be explained in terms of
mechanism of pathology & there has
been a significant psychological
stressor
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 Clinical Features
w/ motor symptom or deficit : impaired

coordination or balance, paralysis or

localized weakness, difficulty swallowing or
lump in throat ,aphonia, urinary retention
w/ sensory symptom or deficit : loss of
touch or pain sensation, double vision,
blindness, deafness, hallucinations
w/seizures or convulsions : w/voluntay
motor or sensory component
w/ mixed presentation

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 Aetiology
unknown
Psychodynamic theories : emotional distress

into physical symptoms which have a

symbolic meaning
Social factors : determinants of onset &
development of t/ symptoms
Neurophysiological mechanism :
malfunctioning of t/ normal interactions
between regions of t/ brain concerned w/ t/
intention to move & those involved in t/
initiation of movement
Cognitive explanations
Cultural explanation
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 Treatment
Obtain medical & psychiatric history from

patient & informants

Appropriate medical & psychiatric
examination , arrange investigations for
physical causes
Reassure that t/ condition is temporary, well
recognized and for motor disorders due to a
problem of converting intention into action
Avoid reinforcing symptoms or disability
Offer continuing help w/ any related
psychiatric or social problems
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