Somatization Disorder

last authored: Nov 2011, David LaPierre
last reviewed:

 

 

 

Introduction

Somatoform disorders are those in which physical signs and symptoms lack a known medical basis, in the presence of psychological factors judged to be important. They cause significant distress or impairment. Symptoms are produced unconsiously, not by malingering or factitious disorder.

The primary gain of somatoform disorder is a symbolic release of unconscious conflict, such as anxiety or anger. The secondary gain is the sick role, and external benefits that come along with being incapacitated.

 

early onset, chronic course, without physical or structural abnormalities

wide range of systems

no associated lab abnormalities

 

DSM-IV disorder

Conversion disorder

 

 

 

The Case of...

a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.

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Causes and Risk Factors

Somatization should never be diagnosed by exclusion

unconscious feelings can lead to unconscious defenses, ie conversion. They can also lead to unconscious anxiety

 

Abbass called this treatment "evangelism busted"

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Pathophysiology

Anger turned inwards

motor conversion

with a rise in feelings, instead of becoming tense, the person becomes weak in one or more areas. when conversion is active, there is no unconscious anxiety in the striated muscle

 

 

It sounds like the striated muscle pathway is more superficial than the smooth muscle pathway

tension becomes stored in the striated muscle pathway

• moves up the homunculus
• thumbs, hands, arms, shoulder, neck, intercostal (sighs), legs and feet
• fibromyalgia

this one guy could say he was feeling emotion (ie rage), but he could not explain how

 

smooth muscle pathway

ie hypertnesion, IBS, migraine

• GI
• vascular, coronary arteries
• bronchi
• bladder

when anxiety is going to the gut, the patient is not tense in muscles and is calm. this can fool the GP

 

Cognitive-perceptual disruption

• drifting, dissociation, going blank, losing track of thoughts, poor memory, fainting
• visual blurring, tunnel vision, blindness
• dysfunction/loss of other senses
• hallucinations in all 5 senses

these neurological symtpoms won't appear as tension

 

Somatization of emotions

"to the degree emotions are being experienced, they cannot simultaneously br somatized or converted into symptoms"

Get the emotions out

 

Diagnosis of Somatization

If they experience emotions AND simultaneously maintain physical symptoms, start looking for medical causes, as symptoms are likely

 

Conversion Disorder

Implicit processing errors: unconsciously remembered and processed response to the environment

Explicit processing errors: conscious response to the environment (questions, demands, conscious sense)

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Signs and Symptoms

Diagnosis requires at least 8 physical symptoms with no underlying pathology, including each of:

• four pain symptoms, at four dufferent sites/functions
• two GI symptoms, not including pain
• one sexual symptom, not including pain
• one pseudo-neurological symptom, not including pain (ie numbness, paresthesias)

if no signals?

• plans to injure or kill themself or others
• fear, paranoia, or no trust
• too sedated/drug use/meds/illness
• going along with you/defying you
• there is no unconscious process at work
• test is not done properly, with no emotions coming up

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Hypochondriasis

longstanding

not delusional

 

Investigations

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Differential Diagnosis

Vasculopathies

neuropathy

connective tissue disorders

MS

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Treatments

Management vs cure

main goals of treatment:

• reduce anxiety and distress regarding somatic symptoms
• avoid unwarranted investigations, treatments, or medications
• prevent the consequences of the 'sick role' and substance abuse

 

Relationship

Brief, frequent visits are helpful, as is limiting the number of physicians involved in care. Set parameters - 20 min visits q 6 weeks

"your suffering is real, and I'm interested in helping"

reassurance and support

 

Psychoeducation

Focus on the psychosocial experience, not the physical symptoms.

"you're not in danger"

distraction training and relaxation techniques

Minimize medical investigations while coordinating necessary tests.

move from symptoms to life stresses; attempt to identify these and the relationship

With conversion disorder, gradual physiotherapy and return to function is important.

 

Psychotherapy

Somatization can often be triggered by the therapist - just the new relationship itself

observe

ask what makes it worse or better (ie stressful things)

ask how strong emotions/anger affect them

observe the physical response

review what you observe with the patient

usually can be done in 15 minutes and will often bring some improvement

 

make sure you're on the same side as the patient - work with them to figure out what is going on

 

Medications

Be cautious

high potential of abuse or tolerance

high risk of unexpected side effects

Treat co-morbidities

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Consequences and Course

Somatization Disorder

Usual onset in adolescencece

criteria in early 20s

chronic, fluctuating course

most active in early adulthood

high morbidity and mortality, strongly assoicated with consequences of somatic symptoms

 

Conversion Disorder

Usual sudden onset following a trigger, then rapid deterioration to dysfunction, then often spontaneous resolution within 6 months. However, symptoms can return with return of the trigger.

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Resources and References

 

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Topic Development

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