modul somatoform disorder student guidance 2015x

Block VII : The Nervous System & Psychiatry

Module : Somatoform Disorder

Course Period : Academic Year 2014 2015

4th Semester

Name :

Student Guidance

Faculty of Medicine Brawijaya University

2015

Module : Somatoform Disorder 2015 Page 2

STUDENT GUIDANCE

Course Period : 4th Semester

MODULE : The Nervous System & Psychiatry

SUBMODULE: PSYCHIATRY

TOPIC : Somatoform Disorder

1. SUB-TOPICS :

1. Somatoform disorders

2. Etiology

3. Diagnosis and Clinical Features

2. CONTRIBUTORS

1. Wisnu Wahjuni, Department of Psychiatry

2. Sri Fuad Hidajati, Department of Psychiatry

3. Happy Indah, Department of Psychiatry

4. Frilya Rachma Putri, Department of Psychiatry 5. Roekani Hadisepoetro, Department of Psychiatry

6. COMPETENCY ARE

This module is a part of the elaboration of

1. The area of competence 2 ie. The Clinical Skill

2. The area of competence 3 ie. The Scientific-Base of Medical Sciences .

3. The area of competence 4 ie. The Management of Health Problems

4. The area of competence 7 ie. The Professionalism.

7. COMPETENCY COMPONENT

1. The Clinical Skill : Psychiatry examination

2. The Scientific-Base of Medical Sciences : To apply the concepts and principle of

Biomedical Sciences, Clinical Sciences and Public Health in appropiate with

Primary Health Care.

3. The area of competence 4 i.e. Management of Health Problems: To manage the

diseases, illness and patients problem as a individual person, a part of family and

community and to prevent diseases and illness.

4. The Professionalism: to have professional attitude

8. CLINICAL COMPETENCE

In a vignette of a patient with a suspected somatoform disorder the student be able

to:

1. Make a clinical diagnosis of somatoform disorder, to make simple aids and

additional investigation requested by student himself.

2. Make a judgement that an initial treatment is required before being referred and

describe to carry out an initial treatment and immediately refer to the relevant

specialist.


9. LEARNING OBJECTIVES

At the end of the Teaching-Learning Process of this topic, in a vignette of a patient

with a suspected somatoform disorder the student should be able to:

Student can describe of definition, epidemiology, etiology, diagnosis & clinical features,

and treatment of somatoform disorder.

10. LECTURE DESCRIPTION

This topic is a part of Module of The Nervous System integratedly designed for

medical student of the 4th semester through Teaching-Learning Process in the 7th Bloc

both in Lecture and Small Group Discussion. This part of Module will facilitate the

student to have an understanding and approach to the patient with somatoform

disorder.

11. OVERVIEW

Seven somatoform disorders are listed in:

- somatization disorder

- conversion disorder

- hypochondriasis

- body dysmorphic disorder

- pain disorder

- undifferentiated somatoform disorder

- somatoform disorder not otherwise specified

DEFINITION

From a nosological perspective, somatoform disorders were grouped together for the first

time in 1980 in the third edition of DSM (DSM-III) as those disorders in which bodily

sensations or functions, as the patient's predominant focus, are influenced by a disorder

of the mind. This clustering was not based on theoretical construct or laboratory findings.

In fact, physical and laboratory examinations persistently fail to show significant

substantiating data about the patient's complaints, which, nevertheless, are vigorous and

sincere. Patients with somatoform disorders are convinced that their suffering comes from

some type of presumably undetected and untreated bodily derangement. As Charles

Beard stated about neurasthenia in 1881: The complaints are not imaginary. The

modern physician who dismisses his or her patient with the statement that the complaint

is imaginary does a disservice to both the patient and the profession.

Seven somatoform disorders are listed in the revised fourth edition of the Diagnostic and

Statistical Manual of Mental Disorders (DSM-IV-TR): (1) somatization disorder, characterized

by many physical complaints affecting many organ systems; (2) conversion disorder,

characterized by one or two neurological complaints; (3) hypochondriasis, characterized

less by a focus on symptoms than by patients' beliefs that they have a specific disease;

(4) body dysmorphic disorder, characterized by a false belief or exaggerated perception

that a body part is defective; (5) pain disorder, characterized by symptoms of pain that

are either solely related to, or significantly exacerbated by, psychological factors; (6)


undifferentiated somatoform disorder, which includes somatoform disorders not otherwise

described that have been present for 6 months or longer; and (7) somatoform disorder

not otherwise specified, which is the category for somatoform symptoms that do not meet

any of the somatoform disorder diagnoses mentioned above (Table 17-1).

Etiology

1. Psychosocial Factors

The cause of somatization disorder is unknown. Psychosocial formulations

of the cause involve interpretations of the symptoms as social communication

whose result is to avoid obligations (e.g., going to a job a person does not like), to

express emotions (e.g., anger at a spouse), or to symbolize a feeling or a belief

(e.g., a pain in the gut). Strict psychoanalytic interpretations of symptoms rest on

the hypothesis that the symptoms substitute for repressed instinctual impulses.

A behavioral perspective on somatization disorder emphasizes that parental

teaching, parental example, and ethnic mores may teach some children to

somatize more than others. In addition, some patients with somatization disorder

come from unstable homes and have been physically abused. Social, cultural, and

ethnic factors may also be involved in the development of symptoms.

2. Biological Factors

Some studies point to a neuropsychological basis for somatization disorder.

These studies propose that the patients have characteristic attention and cognitive

impairments that result in the faulty perception and assessment of somatosensory

inputs. The reported impairments include excessive distractibility, inability to

habituate to repetitive stimuli, grouping of cognitive constructs on an

impressionistic basis, partial and circumstantial associations, and lack of selectivity,

as indicated in some studies of evoked potentials. A limited number of brain-

imaging studies have reported decreased metabolism in the frontal lobes and the

nondominant hemisphere.

3. Genetics

Genetic data indicate that, in at least some families, the transmission of

somatization disorder has genetic components. Somatization disorder tends to run

in families and occurs in 10 to 20 percent of the first-degree female relatives of

probands of patients with somatization disorder. Within these families, first-degree

male relatives are susceptible to substance abuse and antisocial personality

disorder. One study also reported a concordance rate of 29 percent in monozygotic

twins and 10 percent in dizygotic twins, an indication of a genetic effect. The male

relatives of women with somatization disorder show an increased risk of antisocial

personality disorder and substance-related disorders. Having a biological or

adoptive parent with any of these three disorders increases the risk of developing

antisocial personality disorder, a substance-related disorder, or somatization

disorder.

4. Cytokines

Cytokines are messenger molecules that the immune system uses to

communicate within itself and with the nervous system, including the brain.

Examples of cytokines are interleukins, tumor necrosis factor, and interferons.


Some preliminary experiments indicate that cytokines contribute to some of the

nonspecific symptoms of disease, such as hypersomnia, anorexia, fatigue, and

depression. The hypothesis that abnormal regulation of the cytokine system may

result in some of the symptoms seen in somatoform disorders is under

investigation.

Diagnosis and Clinical Features

Table 17-2 DSM-IV-TR Diagnostic Criteria for Somatization Disorder

A. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant

impairment in social, occupational, or other important areas of functioning.

B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

1. four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum,

during menstruation, during sexual intercourse, or during urination)

2. two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than

during pregnancy, diarrhea, or intolerance of several different foods)

3. one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory

dysfunction, irregular menses, excessive menstrual bleeding, vomiting

throughout pregnancy)

4. one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion

symptoms such as impaired coordination or balance, paralysis or localized

weakness, difficulty swallowing or lump in throat, aphonia, urinary

retention, hallucinations, loss of touch or pain sensation, double vision,

blindness, deafness, seizures; dissociative symptoms such as amnesia; or

loss of consciousness other than fainting)

C. Either (1) or (2):

1. after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct

effects of a substance (e.g., a drug of abuse, a medication)

2. when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would

be expected from the history, physical examination, or laboratory findings

D. The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).

(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)

Clinical Features

Patients with somatization disorder have many somatic complaints and long, complicated

medical histories. Nausea and vomiting (other than during pregnancy), difficulty


swallowing, pain in the arms and legs, shortness of breath unrelated to exertion, amnesia,

and complications of pregnancy and menstruation are among the most common

symptoms. Patients frequently believe that they have been sickly most of their lives.

Pseudoneurological symptoms suggest, but are not pathognomonic of, a neurological

disorder. According to DSM-IV-TR, they include impaired coordination or balance, paralysis

or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention,

hallucinations, loss of touch or pain sensation, double vision, blindness, deafness,

seizures, or loss of consciousness other than fainting.

III. MODUL TASK

1. Describe about diagnosis, clinical presentation, demographic and epidemiological

features, diagnostic features, management strategy, prognosis, associated

disturbances, primary differential presentation, psychological processes

contributing to symptoms and motivation for symptom :

a) -somatization disorder

b) -conversion disorder

c) -hypochondriasis

d) -body dysmorphic disorder

e) -pain disorder

2. What are differential diagnosis of the somatizing patient ?

3. What is treatmant for somatizing patient ?

4. What are common symptoms of conversion disorder ?

5. What are diagnostic criteria for conversion disorder ?

6. Distinctive physical examination findings in conversion disorder !

7. A 17-year-old woman -student at senior high school- was brought to an

emergency department by her friends, complaining that she had seizure after

she followed basketball league at her school. She recalls having some problems

during the game, she had a fight with her boyfriend and failure for mid test

examination. When the league was ended, she felt down and got seizure attack,

after she was brought in to car back seat, the seizure had stopped. By the time

she got to the emergency department, she heard her boyfriends voice then

suddenly she got seizure again. On examination, she had seizures for 5 minutes,

no pathological reflex founded, her extremities was flexi condition, grasping

hand, without incontinence, and got her awareness after the seizures was ended.

Pupillary, occulomotor, and general sensorymotor examinations were normal.

Her bodyweight is 40 kg and his height is 150 cm. Routine laboratory

examination showed: RBS 110 mg/dl, WBC 5500 /mm3, ALT 15 /L, AST 16 /L,

Cr 0,8 mmol/L, BUN 9 mmol/L, potassium 3,4 mmol/L, sodium 132 mmol/L.

History of seizure was not found in the past medical history.

a. What is the main problem of the patient?

b. What is possibility cause of seizure in this woman?

c. Mention some differential diagnosis for this case!

d. What kind of therapy can be given for this patient?


e. How about the prognosis for this case?

8. What is the different between seizure due to epilepsy and conversion?

9. What kind of comorbidity can follow or held on conversion patient?

10. Describe about the pathophysiology of seizure on conversion patient!

IV. SUGGESTED READINGS

1. Kaplan & Sadocks Synopsis Psychiatry. Behavioral Sciences / Clinical Psychiatry, 10th Ed

2. Chamay-Weber C, Narring F, Michaud PA. Partial eating disorders among adolescents: A

review. J Adolesc Health. 2005

Andersen AE, Yager J. Eating Disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Vol. 1. Baltimore: Lippincott Williams & Wilkins;

2005:2002.

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