Physical symptoms with a physical cause
Physical symptoms without identifiable physiological cause (e.g. headache)
Physical symptoms with psychological cause (e.g. nausea, diarrhoea, eczema)
expression of emotional problems in somatic symptoms
bias towards medicalisation of symptoms
Common symptoms presentations where an identifiable physiological cause is not found
Pain GI: nausea, bloating, vomiting, intolerance Sexual: irregular periods, difficulties in arousal Pseudoneurological: voice loss, hallucination, balance/coordination
Characteristics of somatoform disorders
A class of disorders defined by:
presence of physical symptoms not fully explained by the presence of a medical condition
symptoms cause clinically significant distress and impairment
psychological factors important in symptom onset and severity
- symptoms are chronic and not normally intentionally produced
Name 3 somatoform disorders
Somatisation disorder (Briquets syndrome)
Hypochondriacal disorder (hypochondriasis)
Somatoform pain disorder (psychogenic pain)
Body dysmorphic disorder (dysmorphophobia)
Somatisation disorder (Briquet's syndrome)
History of many physical complains starting before the age of 30 that occur over a period of several years and result in treatment seeking.
Patients feel they have been sick most of their lives
Very vague or dramatic description of medical history given. Often jump from one symptom to another in the conversation and will not give a detailed account of a specific symptom.
More common in females
Symptom onset and amplification with stress
Chronic fluctuating pattern, diagnosed before the age of 25.
Symptoms or deficits affecting voluntary motor or sensory function (e.g. numbness or paralysis) with no neurological explanation
Rare condition with onset in adolescence or early adulthood.
Recurrent symptoms with short duration. Prone to seizures and convulsions, weakness of movement.
Onset caused by an inability to cope with traumatic events and stress
Fears of developing or having a serious disease based on misinterpretation of bodily symptoms which persist despite medical reassurance. Symptoms last for more than 6 months
Onset at any age, typically adulthood
Heightened awareness of physical self; symptoms amplified when stressed.
Patients tend to Dr. shop, lots of background expertise
Somatoform Pain Disorder
Severe pain which causes clinically significant distress or impairment for treatment to be sought. Chronic pain is due to psychological factors.
Chronic fluctuating pain. Often develops from illness or accidental injury or stress.
Patients often Dr. shop which is precipitated when maximum doses for pain relief is reached. Risk of addiction to prescribed pain medication if not taken correctly.
Body dysmorphic disorder
Patient have an imagined or real defect in appearance, diagnosed when it causes significant distress or disrputs daily functioning.
Obsessions can be with: moles or freckles, acne, scars, facial/body hair, breast size, small muscles
Onset is in early adulthood and becomes increasingly distressing. Patients may become reclusive, refusing to leave the house, covered up, have suicidal thoughts.
Typically remain single, examined potential for plastic surgery, often have other mental health problems.
How would you sreen for body dysmorphic disorder?
Are you very worried about your appearance in any way?
Are you unhappy with the way you look?
If yes - What is your concern?
Does this concern preoccupy you? How much time do you spend thinking about it?
What effect has this preoccupation had on your life?
What factors affect when somatisation occurs?
Precipitating factors - trigger increased physiological self-awareness e.g. stress, depression, anxiety, illness
Predisposing factors - increase the chance that particular symptoms may develop and/or become important
Perpetuating factors - make it more likely that somatoform symptoms will persist.
How do you distinguish between normal and abnormal somatisation?
Symptoms: are they beyond the norm? (multiplicity, severity, chronicity)
Coping: do symptoms significantly impair role functions? (social, familial and occupational roles)
Belief: is there resistance to explanation and reassurance?
Internalised: has the 'sick role' been accepted? Patients consider illness explanations as a way of life
Excessive: extensive but unsatisfactory service use. Patients consider consultations, providers and treatments.
What is the management for a patient with a somatoform disorder?
Proactive not reactive: arrange to see patients at regular, fixed intervals
Broaden agenda: establish a problem list and allow patients to discuss relevant problems
Minimise providers: only one or two providers to reduce iatrogenic harm
Co-opt a relative to help implement and monitor the management plan
Cope not cure: cure is an unrealistic expectation, instead aim for containment and damage limitation, and remind patient at each consultation