Somatoform Disorders: Types and Approach to Symptoms
Table 5-1
Types of Somatoform Disorders Somatoform Disorders*
Disorder Features
Somatization disorder
Chronic multisystem disorder characterized by complaints of pain, gastrointestinal and sexual dysfunction, and pseudoneurologic symptoms.
Onset is usually early in life, and psychosocial and vocational achievements are limited.
Conversion disorder Syndrome of symptoms of deficits mimicking neurologic or medical illness in which psychological factors are judged to be of etiologic importance Pain disorder Clinical syndrome characterized predominantly by
pain in which psychological factors are judged to be of etiologic importance
Hypochondriasis Chronic preoccupation with the idea of having a serious disease. The preoccupation is usually poorly amenable to reassurance
Body dysmorphic disorder
Preoccupation with an imagined or exaggerated defect in physical appearance
Other Somatoform-like Disorders
Factitious disorder Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are not clearly present
Malingering Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are present Dissociative
disorders
Disruptions of consciousness, memory, identity, or perception judged to be due to psychological factors Approach to Somatic and Unexplained Symptoms
Stepped Care Approach to Somatic Symptoms in Primary Care† Is the somatic
symptom likely to be . . . Clinician action might be . . . Acutely serious?
(<5% of cases) Expedited diagnostic workup Minor/self-limited?
(70%–75% of cases)
Address patient expectations Symptom-specific therapy Follow-up in 2–6 weeks
Is the somatic
symptom likely to be . . . Clinician action might be . . . Chronic or
recurrent? (20%–
25% of cases)
Screen for depression and anxiety
Caused or aggravated by a depressive or anxiety disorder?
Antidepressant therapy and/or cognitive–behavioral therapy (CBT)
Due to a functional somatic syndrome?
Syndrome-specific therapy Antidepressant therapy and/or CBT Persistent and
medically unexplained?
Regular, time-limited clinic visits Consider mental health referral
Symptom management strategies, if evidence-based (e.g., behavioral treatments, pain self-management programs, pain or other specialty clinics, complementary and alternative medicine) Rehabilitative rather than disability approach Management Guidelines for Patients With Medically Unexplained Symptoms‡
General Aspects Show empathy and understanding for the complaints and frustrating experiences the patient has had so far (e.g., explain that medically unexplained symptoms are common).
Develop a good patient–physician relationship; try to be the “coordinator” of diagnostic procedures and care.
Diagnosis Explore not only the history of complaints and former treatments, but any impairment, anxiety, and psychosocial issues.
Use screeners and self-report questionnaires to enhance detection; use symptom diaries to assess course and factors influencing symptoms.
When the patient presents with a new symptom, examine the relevant organ system.
Provide the results of investigations to give clear reassurance that there is no serious physical disease.
Avoid unnecessary diagnostic tests or surgical procedures.
Treatment Provide regularly scheduled visits (e.g., every 4–6 weeks), especially in the case of a history of very frequent healthcare utilization.
Explain that treatment is coping, not curing (when pathology cannot be found or does not explain degree of complaints).
Somatoform Disorders: Types and Approach to Symptoms (continued)
Table 5-1
(continued)
Is the somatic
symptom likely to be . . . Clinician action might be . . .
Referral Suggest coping strategies like regular physical activity, relaxation, distraction.
If referral is necessary to start psychotherapy or psychopharmacotherapy, prepare the patient for the treatment and provide reassurance that you will continue to be the patient’s doctor.
Sources: *Schiffer RB. Psychiatric disorders in medical practice. In: Goldman L, Ausiello D, eds. Cecil Textbook of Medicine. 22nd ed. Philadelphia: Saunders 2004, pp. 2628–2639; †Kroenke K. Patients presenting with somatic complaints:
epidemiology, psychiatric comorbidity, and management. Int J Methods Psychiatr Res 2003;12(1):34–43. ‡Reif W, Martin A, Rauh E, et al. Evaluation of general practitioners’ training: how to manage patients with unexplained physical symptoms.
Psychosomatics 2006;47(4):304–311.
Somatoform Disorders: Types and Approach to Symptoms (continued)
Table 5-1
Disorders of Mood Table 5-2
Major Depressive Episode Manic Episode At least five of the symptoms listed
below (including one of the first two) must be present during the same 2-week period; they must represent a change from the person’s previous state.
●Depressed mood (may be an irritable mood in children and adolescents) most of the day, nearly every day
●Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day
●Significant weight gain or loss (not dieting) or increased or decreased appetite nearly every day
A distinct period of abnormally and persistently elevated, expansive, or irritable mood must be present for at least a week (any duration if hospitalization is necessary). During this time, at least three of the symptoms listed below have been persistent and significant. (Four symptoms are required if the mood is only irritable.)
●Inflated self-esteem or grandiosity
●Decreased need for sleep (feels rested after sleeping 3 hours)
●More talkative than usual or pressure to keep talking
Disorders of Mood (continued)
Table 5-2
Major Depressive Episode Manic Episode
●Insomnia or hypersomnia nearly every day
●Psychomotor agitation or retardation nearly every day
●Fatigue or loss of energy nearly every day
●Feelings of worthlessness or inappropriate guilt nearly every day
●Inability to think or concentrate or indecisiveness nearly every day
●Recurrent thoughts of death or suicide, or a specific plan for or attempt at suicide
The symptoms cause significant distress or impair social, occupational, or other important functions. In severe cases, hallucinations and delusions may occur.
●Flight of ideas or racing thoughts
●Distractibility
●Increased goal-directed activity (either socially at work or school, or sexually) or psychomotor agitation
●Excessive involvement in pleasurable high-risk activities (buying sprees, foolish business ventures, sexual indiscretions)
The disturbance is severe enough to impair social or occupational functions or relationships. It may necessitate hospitalization for the protection of self or others. In severe cases, hallucinations and delusions may occur.
Mixed Episode Hypomanic Episode
A mixed episode, which must last at least 1 week, meets the criteria for both major and manic depressive episodes.
The mood and symptoms resemble those in a manic episode but are less impairing, do not require hospitalization, do not include hallucinations or delusions, and have a shorter minimum duration—4 days.
Dysthymic Disorder Cyclothymic Episode A depressed mood and symptoms for
most of the day, for more days than not, over at least 2 years (1 year in children and adolescents). Freedom from symptoms lasts no more than 2 months at a time.
Numerous periods of hypomanic and depressive symptoms that last for at least 2 years (1 year in children and adolescents).
Freedom from symptoms lasts no more than 2 months at a time.
Tables 5-2 to 5-4 are based, with permission, on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision [DSM IV-TR]. Washington, DC: American Psychiatric Association, 2000. For further details and criteria, the reader should consult this manual, its successor, or comprehensive textbooks of psychiatry.
Anxiety Disorders Table 5-3
Panic Disorder. Recurrent, unexpected panic attacks, at least one of which has been followed by a month or more of persistent concern about further attacks, worry over their implications or consequences, or a significant change in behavior in relation to the attacks.
A panic attack is a discrete period of intense fear or discomfort that develops abruptly and peaks within 10 minutes. It involves at least four of the following symptoms: (1) palpitations, pounding heart, or accelerated heart rate; (2) sweating; (3) trembling or shaking;
(4) shortness of breath or a sense of smothering; (5) a feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) feelings of unreality or depersonalization; (10) fear of losing control or going crazy; (11) fear of dying; (12) paresthesias (numbness or tingling);
and (13) chills or hot flushes.
Agoraphobia. Anxiety about being in places or situations where escape may be difficult or embarrassing or help for sudden symptoms unavailable. Such situations are avoided, require a companion, or cause marked anxiety.
Specific Phobia. A marked, persistent, and excessive or unreasonable fear that is cued by the presence or anticipation of a specific object or situation, such as dogs, injections, or flying. The person recognizes the fear as excessive or unreasonable, but exposure to the cue provokes immediate anxiety. Avoidance or fear impairs the person’s normal routine, occupational or academic functioning, or social activities or relationships.
Social Phobia. A marked, persistent fear of one or more social or performance situations that involve exposure to unfamiliar people or to scrutiny by others. Those afflicted fear that they will act in embarrassing or humiliating ways, as by showing their anxiety.
Exposure creates anxiety and possibly a panic attack, and the person avoids precipitating situations. He or she recognizes the fear as excessive or unreasonable. Normal functioning, social activities, or relationships are impaired.
Anxiety Disorders(continued)
Table 5-3
Obsessive–Compulsive Disorder. Obsessions or compulsions that cause marked anxiety or distress. Although recognized as excessive or unreasonable, they are time-consuming and interfere with the person’s normal routine and relationships.
Acute Stress Disorder. Exposure to a traumatic event that involved actual or threatened death or serious injury to self or others, leading to intense fear, helplessness, or horror. During or immediately after this event, the person has at least three dissociative symptoms: (1) a subjective sense of numbing, detachment, or absence of emotional responsiveness; (2) a reduced awareness of surroundings, as in a daze; (3) feelings of unreality; (4) feelings of depersonalization;
and (5) amnesia for an important part of the event. The event is persistently reexperienced, as in thoughts, images, dreams, illusions, and flashbacks. The person is anxious, shows increased arousal, and avoids stimuli that evoke memories of the event. Causes marked distress or impairs social, occupational, or other important functions.
Symptoms occur within 4 weeks of the event and last from 2 days to 4 weeks.
Posttraumatic Stress Disorder. The event, fearful response, and persistent reexperiencing of the traumatic event resemble acute stress disorder. Hallucinations may occur. The person has increased arousal, tries to avoid stimuli related to the trauma, and has numbing of general responsiveness. Causes marked distress and impaired social or occupational function, and lasts for more than a month.
Generalized Anxiety Disorder. Lacks a specific traumatic event or focus for concern. Excessive anxiety and worry are hard to control and generalize to a number of events or activities. At least three of the following symptoms are associated: (1) feeling restless, keyed up, or on edge; (2) being easily fatigued; (3) difficulty in concentrating or mind going blank; (4) irritability; (5) muscle tension; and (6) difficulty in falling or staying asleep, or restless, unsatisfying sleep.
Causes significant distress or impairs daily function.
Selected Psychotic Disorders Table 5-4
Schizophrenia. Impairs major functioning at work or school, in interpersonal relations, or in self-care. Performance of one or more of these functions must decrease for a significant time to a level markedly below prior achievement. Person displays at least two of the following for a significant part of 1 month: (1) delusions;
(2) hallucinations; (3) disorganized speech; (4) grossly disorganized or catatonic behavior; and (5) negative symptoms such as a flat affect, alogia (lack of content in speech), or avolition (lack of interest, drive, and ability to set and pursue goals). Continuous signs of the disturbance must persist for at least 6 months.
Subtypes of this disorder include paranoid, disorganized, and catatonic schizophrenia.
Schizophreniform Disorder. Symptoms are similar to those of schizophrenia but last <6 months. Functional impairment need not be present.
Schizoaffective Disorder. Features both a major mood disturbance and schizophrenia. Mood disturbance (depressive, manic, or mixed) present during most of the illness and must, for a time, be concurrent with symptoms of schizophrenia and demonstrate delusions or hallucinations for at least 2 weeks without prominent mood symptoms.
Delusional Disorder. Nonbizarre delusions involve situations in real life, such as having a disease, and persists for at least a month.
Functioning is not markedly impaired and behavior is not obviously odd or bizarre. Symptoms of schizophrenia, except for tactile and olfactory hallucinations, are not present.
Brief Psychotic Disorder. At least one of the following psychotic symptoms must be present: delusions, hallucinations, disordered speech such as frequent derailment or incoherence, or grossly disorganized or catatonic behavior. Disturbance lasts ≥1 day but
<1 month, and person returns to prior functional level.
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The Skin, Hair, and Nails 6
The Health History
Common or Concerning Symptoms
◗Hair loss
◗Rash
◗Growths