Ii somatoform disorder

II Somatoform disorder:

1. 
   General:
   

I conversion disorder

II somatization disorder

III hypochondriasis

2. 
   Specific:
   

I dysmorphophobia

II Somaloform pain disorder

III chronic fatigue syndrome

1. 
   Dissociative (conversion) disorder:
   

Is also called "hysteria or hysterical disorder" and the predominant symptoms are physical. It has been called "conversion disorder" because the anxiety is converted into physical symptoms. It's also called "dissociative disorder" because the symptoms result from a lack of coordination of different psychological function.

Note: trails has been made to stop the use of hysteria "hys." But there are a large number of doctors who still use term especially in the emergency department and also clinics.

The dissociative symptoms ( or conversion symptoms) suggest physical illness but occur in the absence of relevant physical pathology, and is produced through unconscious psychological mechanisms. There are two obvious difficulties with this concept:

• 
  Exclusion of physical pathology is not easy here, especially when the pt consults for the first time.
  
• 
  It's not always easy to be certain that the symptoms are produced unconsciously rather than consciously and deliberately (malingering), so an unconscious element is necessary in hysteria.
  

The prevalence of hysteria varies according to certain considerations; it's more common in female an children (inferior social position) and is probably greater in less industrialized societies (i.e. more common in eastern countries) and more in low socioeconomics.

The common features (criteria) of dissociative disorder:

• 
  This disorder is characterized by predominantly physical symptoms (no insight)
  
• 
  It's produced through unconscious psychological mechanisms
  
• 
  It's must be differentiated from malingering (consciously and deliberately ) and underlying real physical illness must be excluded
  
• 
  The pt gets primary gain by relieving the conflict and secondary gain by obtaining sympathy and attention from others or by avoiding everyday responsibilities.
  
• 
  The disorder occurs mainly in less industrialized countries, low socioeconomic and in woman an children and less common in men.
  
• 
  The pt has apparent unconcern (belle indifference) even in the face of gross physical disability.
  
• 
  The conversion (dissociative) symptoms may be primary (conversion or dissociative) or called hysteria proper, and secondary to other psychiatric disorders like anxiety disorders and organic mental disorders. So it's important to search carefully for symptoms of these disorders before any final conclusion of the condition.
  

Note: secondary hysteria is more common (about 90%)

• 
  Although the disorder symptoms are not produced deliberately , they'er shaped by the patient concepts of illness. Sometimes they resemble those of relative or friend who has been ill or in relationship with previous experience (ex. Amnesia after years of head injury accident)
  
• 
  The symptoms may closely resemble symptoms of physical illness in some people and less in children and mentally retarded.
  
• 
  There is usually discrepancies b/t the signs and symptoms of the disorder and those of organic disease (ex. A pattern of sensory loss that does not correspond to the anatomical innervations of the part)
  
• 
  Conflicts which had occurred during childhood (according to are Freud) are repressed in the unconsciousness but the tongue slips, dreams and creative work refer to the presence of such conflict. These can appear to the outside when stressful life events occur.
  

Note: the symptoms types of dissociative disorder are important especially the convulsions ( hysterical fits and its difference from epilepsy)

Types and symptoms of dissociative (conversion) disorder:

1. 
   Motor symptoms:
   

1. 
   Voluntary muscle paralysis
   
2. 
   Tremor and tics
   
3. 
   Disordered gait
   
4. 
   Aphonia and mutism
   
5. 
   Convulsion
   

Note: The paralysis is the inability to move a part of body due to simultaneous action of extensor and flexor muscled in the hysterical pts.

Dissociative convulsions differ from epilepsy by:

• 
  The pt does not become unconscious.
  
• 
  The pattern of movement is not regular and stereotyped
  
• 
  No incontinence, no cyanosis, no injury, no tongue bite, no fractures, no dislocations
  
• 
  EEG is normal
  
• 
  It occurs in front of people and does not occur when the pt is alone
  
• 
  It's usually preceded by emotional upset and underlying depression
  

is not uncommon

• 
  Others (e. g. no aura, presence of gain, …etc)
  

2. Sensory symptoms:

1. Hyperesthesia and paraesthesia

2. Anesthesia

3. Pain

4. Blindness and tunnel vision

5. Deafness

3. Mental symptoms it includes

• 
  Dissociative amnesia : it usually develops acutely and the memory loss is patchy and inconsistent (e. g. amnesia of personal identity; so that the pt is unable to recall his name, address, or other family and personal details)
  
• 
  Dissociative fugue: here, the pt loses memory and wanders aimlessly away from usual surroundings
  
• 
  Dissociative stupor: here, the pt is motionless and mute and does not respond to stimulation (see; hysterical stupor) and other types of stupor should be excluded.
  
• 
  Ganser syndrome: it's a rare condition in which dissociative memory disorder is accompanied by psychogenic physical symptoms, visual hallucination and apparent clouding of consciousness. It has been described among prisoners.
  

Note: organic brain disease should be excluded.

• 
  Multiple personality: it's an exceedingly rare condition in which there are sudden alternations between the pt's normal state and another complex pattern of behavior (a 2^nd personality). Each is forgotten by the pt when the other is present.
  

• 
  Epidemic hysteria:
  

Dissociative or conversion disorders occasionally spread as an epidemic within a group of people. The epidemic occurs most often in closed groups of young women (e. g. in a girls school, a nurse's home and occasionally it happens in a group of men)

It usually occurs at a time of heightened anxiety in the group, sometimes there's of involvement in an epidemic of physical disease already present in the outside community.

Usually epidemic hysteria begins with a person who's highly suggestible, histrionic and already the focus of attention for some reason. Another suggestible person responds in the same way and the other cases follow, first in the more suggestible people and then among those with less predisposition. The symptoms are variable, but fainting and dizziness are common.

Treatment of patients with hysterical disorder (conversion or dissociative disorder):

• 
  It's important to exclude underlying real physical illness especially organic disease of CNS.
  
• 
  The pt present in general practice or hospital causality departments respond well to "resolve any provoking stressful circumstances" combined with strong suggestion that the symptoms will recover
  
• 
  It should be explained to the pt that the disability is caused not by a physical disease but by an interference with conscious control over action disease perception, or memory.
  
• 
  The staff should concern for the pt, but also encourage self-help(e.g. a pt with a dissociative disorder of gait should be encouraged to walk unaided and should not be offered a wheelchair.
  

In addition to that, psychological treatment can be of benefit which includes the following:

Exploratory psychotherapy

Abreaction: expression of emotion

Behavior therapy: it has a minor role.

Note: medication has no part to play in the treatment of these conditions, except when the symptoms are secondary to depressive disorder or other psychiatric disorders that require treatment.

II Somalization disorder

The main feature of this disorder are multiple, recurrent and changing physical symptoms which are not accounted for by physical pathology or autonomic arousal.

The condition begins in adolescence or early adult life and runs a chronic and often fluctuating course. Pts usually consult many doctors, seeking repeated reassurance and demanding more investigations. The pt may have underlying depression or anxiety symptoms. The treatment is mainly reassurance and limit of additional harm through inappropriate drugs or procedures.

III Hypochondriacal disorder

The essential feature of this disorder is persistent pre-occupation with the possibility of having a serious physical illness, despite negative results of investigations and appropriate explanation and reassurance. Pts may be concerned about a single symptom, such as fatigue or headache, or about several symptoms. They have fewer symptoms than pts with somatization disorder. They may be underlying depressive or anxiety symptoms. The disorder takes usually a chronic course through less so than somatization disorder . Re-assurance and advice to avoid further investigation are necessary

2. 
   Specific somatoform disorder
   

I Dysmorphophobia: it refer to persistent and inappropriate concern

About the appearance of the body, for example about the shape and size of the nose or the breasts. Some of those consulting plastic surgery and dermatology clinics also demand surgical intervention (plastic surgery). Surgery can sometimes be beneficial but should be avoid in:

• 
  Patient who have been dissatisfied with previous cosmetic surgery.
  
• 
  Patients with a history of psychological problems
  
• 
  Patients with very unrealistic expectation of surgery
  

Note: most of those pts must be reassured to reduce distress and persuaded about the un-necessity of surgery.

II Somatoform pain disorder :

In this poorly defined condition chronic pain can not be explained by any

Physical or mental disorder. The cause is unknown.

Social or psychological factors could be the underlying cause.

III chronic fatigue syndrome: it's characterized by symptoms of chronic fatigue, malaise and depression which are common after viral infections (e.g. influenza, hepatitis, infectious mononucleosis). Numerous viruses including EBV have been incriminated but non has been proved to cause the condition. Different methods have been used to treat the condition:

Antidepressant drugs

Graduated increase in activity

Cognitive behavioral therapy

• 
  Other conditions including
  

Munchausen syndrome (hospital addiction):

It's an uncommon and extreme form of factitious disorder in which pts give plausible and often dramatic histories of an acute illness with feigned symptoms and signs. The pt may attend a series of hospitals and present under different names at each of them. They frequently demand under strong analgesics for pain. The etiology of this condition is unknown and the pts usually have abnormal personalities .

"Munchausen syndrome of proxy": refers to a condition of unknown cause in which a parent gives a false account of symptoms in a child and may fake a physical fake a physical signs.

Malingering: it's the fraudulent imitation or exaggeration of symptoms with the intention of gaining financial or other rewards rewards and differs from factitious disorder (Munchausen disorder) in which no gain is present.

This condition is more commonly seen among prisoners, the military and people seeking compensation for accidents. When the diagnosis is certain, the pt should be informed tactfully of this conclusion and should be encourage to deal more appropriately with any problems that have contributed to the behavior.

Somatization disorder (Hysteria-Briquet's Syndrome):

These are somatic symptoms that can't be explained adequately on the basis of physical and laboratory examinations. These symptoms appear as expression for internal physical stress. Somatization is not purely a psychiatric disorder; they are seen in every branch of medicine. Its caused by chronic significant psychological stress. It causes impairment of social occupational functioning.

Criteria for diagnosis:

1. 
   History of many physical complains or belief that is sticky, beginning before the age of 30, and persisting for several years.
   
2. 
   At least 13 symptoms of the list below, first there must be:
   

1. 
   No organic pathology (physical disorder, effect of injury, medication, drug or alcohol abuse or withdrawal. To account for the symptoms or when there is related organic pathology, the complaint or resulting social or occupational impairment is grossly
   
2. 
   Not occurred during panic attack
   
3. 
   Has caused the person no take medicine.
   

The patient has excessive medical help seeking behavior, the changes doctors very frequently (doctors shopping). He has multiple symptoms that not stick to one organ, the disease is vague history (no onset, no aggravating or relieving factors) and not improved by medication.

Epidemiology :

Life time province in general population is 0.1-0.2 % and may reach up to 0.5% female are more than males in about 5-20 times. It occur usually in people with low education and low socio-economic status and occurs mostly in rural area, 2/3 of patient have psychological symptoms of many disorders (e.g. depression), either as cause or as result of disease. In a female somatization, there is 1-2% increase in the incidence of having other males of her family with other neurotic illnesses.

It is chronic relapsing disease, usually associated with symptoms of anxiety, and sometimes there is a suicide attempt.

Cause: definite causes are unknown, but some factors may play a role, and there are:

• 
  Job obligation
  
• 
  Parent teaching
  
• 
  Ethnic mores
  
• 
  Physical abuse
  
• 
  Biological factors
  

Symptoms: there is a long list contains many symptoms, and it is arranged according to systems, and these are:

• 
  Git: abdominal pain, vomiting, diarrhea, abdominal distention..
  
• 
  Pain: in the extremities, back ,joints, pain during urination.
  
• 
  Cardio- pulmonary: shortness of breath (not related to exertion), palpitation, chest pain, dizziness.
  
• 
  Urinary: burning sensation during micturation , urinary retention
  
• 
  Sexual: burning sensation in sexual oragans or rectum, sexual indifference( frigidity, dyspareunia (painful coitus), impotence, dysmenorrhea, irregular period, heavy bleeding and excessive vomiting during pregnancy.
  
• 
  CNS (pseudo neurotic symptoms); amnesia, difficulty in swallowing (dysphagia), loss of voice (aphonia), double vision, blurred vision, fainting (loss of consciousness), trouble walking, paralysis or muscle weakness, urinary retention.
  
• 
  Personality: the patient may have antisocial behavior, may be psychopathic or histrionic, may be associated with drug or alcohol abuse, and sometimes there is family history of antisocial behavior.
  

Differential diagnosis:

1. 
   Always exclude organic diseases.
   
2. 
   Other psychological illness: somatization may not be the only problem; from the history we can diagnose other disorders as anxiety, depression and schizophrenia.
   
3. 
   TCN disturbance: organ brain syndrome or drug abuse or withdrawal.
   

Treatment:

• 
  The doctors have skills in dealing with these patients, because somatism is difficult to be treated
  
• 
  We teach the doctors not to provoke the patient with the disease, but we tell the patient in empathic way.
  
• 
  We should listen to the patient, we ignore the previous complaint, and we encourage the psychological factors.
  
• 
  The patients should deal with one doctors, and we put him on regular visits (every 2 weeks or every month)
  
• 
  Treat other disorder: anxiety or depression
  
• 
  The patient needs individual and/ or group psychotherapy
  

Hypochonriasis:

Hypochonriasis is a morbid concern health, preoccupation with food, medicine an illness. It pursues health as away of life. It is a strong conviction of the actual presence of disease of fear of developing serious

Clinical features:

It is unrealistic belief of having disease, the most commonly involved areas are head, neck, chest, abdomen and skeleton. It may be fear of having illness (illness phobia) or re-having illness.

Differential diagnosis:

• 
  Somatimzation: the patient with hypochonriasis choose one disease, onset age is older (after 35-40), and female to male ration is equal .
  
• 
  Real illness should always be excluded.
  
• 
  Phobia (illness phobia): patient with illness phobia avoid doctors, hospital and reading books about disease with fear of re-illness. Patient with hypochondriasis are addicts
  
• 
  Munchausen's syndrome: the patient pleasure in deceiving doctors, and may be extremely impressive, some may have laprotomy for many times, and some may create hemoptysis by him self. Those patients when faced by the reality (that they are liars) they will run away.
  
• 
  Malingerer: those have no organic disease, they act voluntarily to have a purpose, and they have no symptoms after achieveing their goals.
  
• 
  Acute stress reaction:
  

• 
  Occur after a major event - dizziness
  
• 
  Impaired ability to comprehend and answer question
  
• 
  Autonomic signs of anxiety - sometimes stupor
  

Pain syndrome: according to (DSMIV)

• 
  Precaution with pain (well or ill-defined) for at least 6 mounths
  
• 
  Appropriate evaluation uncovers no organic pathology or pathophysiological mechanism
  
• 
  Or when there is related oranic pathology, the complaint is in the excess of what would be expected from the physical findings.
  

Clinical features:

1. 
   Its frequently associated with psychosocial stress or secondary gain.
   
2. 
   Patient seeks many doctors of drugs may be present.
   
3. 
   Iatrogenic effect of drugs may be present
   
4. 
   The patient avoid being diagnosed as psychiatric patients and reject psychotherapy
   
5. 
   They avoid a heaithy role and accept invalid roles.
   

Epidemiology:

Is unknown, because the disease is difficult to define. In case , chronic pain of 1/3 of them have psychiatric disorder. It may occur at any age or sex.

Treatment:

• 
  We should educate the primary care physicians to established specialized pain clinic.
  
• 
  Detoxification of antidepressant drug, such as amytriptaline
  

( trpizol) to relief pain of (RA or CA), I will act in mechanism other than anti-depression.

• 
  Cognitive behavioral therapy
  

Technical rehabilation to the patient, especially for invalid patients to increase functional and occupational ability.

Somatoform disorder:

Hysteria related disorder

Hysteria proper Hysteria related disorder

Conversion disorder dissociative disorder Hypochondriasis

Somatization

Chronic disorder

Body dimorphic disorders

Chronic fatigue syndrome

Facitiuous disorder(hospital addition)

Conversion disorder

Motor symptom: invol. movement

Blepharospasm

Opsthonus

Seizure

Paralysis

Weakness

Sensory symptoms: anesthesia of extremities

Midline anesthesia

Blindness

Tunnel vision

Deafness

Visceral symptom psychogenic vomiting

Pseudocyesis

Globus hysericus

Swooning retention

Diarrhea

Dissociated disorder:

1. 
   Dissociative Amnesia
   
2. 
   Dissociative fugues
   
3. 
   Twilight states
   
4. 
   Dissociative identity disorder (multiple personality)
   
5. 
   Depersonalization disorder
   
6. 
   Dissociative and trance disorder
   
7. 
   Ganser syndrome
   
8. 
   Epidemic hysteria
   
9. 
   Brain washing (thought reform, persuation, mind control
   

Trance dissociative:

Altered states of consciousness › diminish respartory to environmental stimuli