SOMATOFORM DISORDERS

There are six Somatoform Disorders: Conversion Disorder, Somatization Disorder, Undifferentiated Somatoform Disorder, Pain Disorder, Hypochondriasis Disorder and Body Dysmorphic Disorder. These conditions present the common features of complaints concerning the patient’s physical state and somatic worry, neither of which can be attributed to a physiological cause or another mental disorder. Subjects affected by these conditions spend a lot of time going for medical checkups and submitting to psychiatric tests and this can often lead to wrong diagnoses being provided on both sides. In Somatoform Disorders, the cause of the physiological symptoms - which, we should remember, are neither simulated nor under the patient’s voluntary control - is psychological.

Conversion Disorder. In Conversion Disorder the patient presents various somatic symptoms, generally involving the voluntary motor or sensory functions. These symptoms will appear suddenly during a stressful event or situation and allow the person to abandon it or in any case avoid particular activities experienced as unpleasant. A further, secondary advantage (see glossary) is offered by the fact that through these symptoms the patient has an opportunity to concentrate on himself or on herself all of the attention for which he or she feels an extreme need. The different types of Conversion Disorder are classified in accordance with the presenting symptoms:

- Conversion Disorder with motor-type symptoms;
- Conversion Disorder with epileptiform symptoms (seizures or convulsions);
- Conversion Disorder with sensory deficits;
- Conversion Disorder with mixed presentations.

It should be noted that in a conversion disorder the symptoms presented are of a type that would suggest neurological damage, however in such cases clinical investigation reveals no dysfunction or alteration of any organs or of the nervous system. Thus, while these patients are physiologically normal, they may present serious symptoms such as blindness, paralysis, anaesthesia, aphonia and anosmia (see glossary). A further symptom, which suggests the psychological origin of these disturbances, can be identified in the behaviour of such patients with respect to their somatic complaints: they in fact appear to be serene and unworried and show no sign of being anxious to rid themselves of the disorder. They moreover show no sign of being able to link their ‘illness’ to the stressful circumstances in which the symptoms first occurred. Conversion symptoms generally present during adolescence or in early adulthood, and although an episode may suddenly end, the chance that it will reappear in the previous or in any other form is indeed quite high.

Somatization Disorder. Underlying this disorder there is a long history of recurrent physical complaints - which induce the patient to seek intervention and advice on the part of physicians - but for which no organic cause has ever been found. In cases where a physical cause may have been found, the related complaints of illness or the corresponding occupational or social impairment must be out of proportion. The symptoms can be of many different kinds, such as painful  symptoms appearing in the head, back and joints, gastrointestinal symptoms, sexual symptoms and pseudoneurological symptoms. The disturbances may moreover vary within different cultures: for example, burning sensations in the hands or a tingling sensation below the skin have been found to be more frequent amongst Asian and African populations than in that of North America.

Individuals affected by a Somatization Disorder tend to manifest their complaints in a rather exaggerated and even ‘histrionic’ manner. It is moreover believed that Somatization Disorder is more prevalent in cultures in which the expression of feelings and the emotions tends to be discouraged (3). The onset of the condition generally occurs in early adulthood and it will remain present for many years (4). It is also quite common to find the simultaneous presence of depressed mood and anxiety, as well as problematical interpersonal behaviour such as absenteeism or marital problems.
In the Somatization Disorder the existence of a familial pattern (see glossary) is rated at 20% for first-degree relations of an individual diagnosed with this form of pathology (5).

Undifferentiated Somatoform Disorder. This disorder is related to Somatization Disorder in terms of presenting symptoms but can be distinguished on account of a less extensive array of physical complaints, the lower intensity of symptoms and shorter duration.

Pain Disorder. This disorder is characterised by an intense pain localized in one or more anatomical regions, which causes significant distress and impairment in the patient’s life, compromising entire areas of his or her existence, such as occupational activities and interests, and making the individual dependent on pain-killers and tranquillizers. It is believed that a psychological factor plays an important role in the onset, severity, exacerbation or maintenance of the pain, which, in the process of differential diagnosis,  must not be produced intentionally or simulated. The disorder can be of two types, depending on duration:
-acute: lasting less than six months;
-chronic: lasting longer than six months.
The disorder is further subdivided into the types:
- associated with psychological factors;
- with psychological factors and a medical condition, when it is established that a medical disturbance has also been a determining factor in the onset or maintenance of the pain.
The pain can be linked to a stressful or contingent situation generating conflict or may allow patients to avoid activities seen as undesirable or also to attract attention to themselves.

Hypochondriasis. This disorder is characterised by a significant worry or conviction that one has contracted or is suffering from a serious disease. The worry persists despite adequate medical reassurance to the contrary. Affected subjects spend a great deal of time visiting general hospital facilities (not psychiatric units) in an attempt to obtain confirmation of their fears and assumptions. They react in a manner quite out of proportion with respect to bodily sensations or slight physiological alterations, which can be considered within the range of normal physical reactions, such as a fit of coughing or an occasional stomach upset. These patients believe that these conditions constitute confirmation of their fears. Such individuals moreover affirm that they are particularly sensitive to physiological signs and bodily sensations, but laboratory studies have ascertained that this is not so (2).

Body Dysmorphic Disorder. Individuals affected by this disorder present excessive worry concerning an imaginary or - when actually present - a slight physical defect, such as wrinkles or the shape of their nose. Some patients spend considerable amounts of time every day examining such supposed defects in a mirror, while others tend to entirely avoid any opportunity of seeing their reflected image and may also conceal or cover up all of the mirrors in their home. In any case, the disturbance involves a significant impairment of occupational and social functioning or other aspects of their existence. People suffering from the disorder often seek the assistance of aesthetic surgeons, but surgery generally fails to alleviate their suffering as the cause of their ailment is psychological and does not lie in their alleged physical defects (1). A fundamental role is played by subjective factors such as aesthetic values and personal tastes, as well as cultural and social factors.

>>> (Factitious Disorders)


Bibliographical references:

(1) Phillips, K.A., McElroy, S.L., Keck, P.E., Pope, H.G., & Hudson, J.L. (1993). Body dysmprphic disorder: 30 cases of imagined ugliness. American journal of Psychiatry, 150, 302-308.

(2) Barsky, A.J., Brener, J., Coeytaux, R.R., & Cleary, P.D. (1995). Accurate awareness of heartbeat in hypochondriacal and non-hypochondriacal patients. Journal of Psychosomatic Research, 39, 487-489;

(3) Ford, C.V., (1995). Dimensions of somatization and hypochondriasis. Special Issue: Malingering and conversion reactions. Neurological Clinics, 13, 241-253;

(4) Cloninger, R.C., Martin, R.L., Guze, S.B., & Clayton, P.L. (1986). A prospective follow-up and family study of somatization in men and women. American journal of Psychiatry, 143, 713-714;

(5) Guze, S.B. (1993). Genetics on Briquet's syndrome and somatization disorder: A review of family, adoption, and twin studies. Annals of Clinical Psychiatry, 5, 225-230.

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