Somatoform Disorder

Gangguan Somatisasi• A 34-year-old female temporary clerk presented with chronic and intermittent

dizziness, paresthesias, pain in multiple areas of her body, and intermittent nausea and diarrhea. On further history, the patient said that the symptoms had been present most of the time, although they had been undulating since she was approximately 24 years of age. In addition to the symptoms previously mentioned, she had mild depression, was disinterested in many things in life, including sexual activity, and had been to many doctors to try to find out what was wrong with her. Even though she had seen many doctors and had many tests, she stated that no one can find out what's wrong†with her. She wanted another opinion. She �commented that she had been sick a lot. since childhood and had been on various medications on and off. Physical examination revealed a normotensive, slightly overweight female in no acute distress. She had diffuse and mild abdominal tenderness, without true guarding or rebound tenderness. Her neurological examination was normal. She winced when physical examination was conducted on various parts of her body, although this wincing went away when the physician was speaking with her while conducting the examination.

Reaksi Konversi• Mr. J is a 28-year-old single man who is employed in a factory. He was brought to

an emergency department by his father, complaining that he had lost his vision while sitting in the back seat on the way home from a family gathering. He had been playing volleyball at the gathering but had sustained no significant injury except for the volleyball hitting him in the head a few times. As was usual for this man, he had been reluctant to play volleyball because of the lack of his athletic skills, and was placed on a team at the last moment. He recalls having some problems with seeing during the game, but his vision did not become ablated until he was in the car on the way home. By the time he got to the emergency department, his vision was improving, although he still complained of blurriness and mild diplopia. The double vision could be attenuated by having him focus on items at different distances.

• On examination, Mr. J was fully cooperative, somewhat uncertain about why this would have occurred, and rather nonchalant. Pupillary, oculomotor, and general sensorimotor examinations were normal. After being cleared medically, the patient was sent to a mental health center for further evaluation.

• Tiba tiba lemas• Tiba tiba buta• Tiba tiba tuli• Tiba tiba pingsan• Tiba tiba kejang

Condition Test Conversion FindingsAnesthesia Map dermatomes Sensory loss does not conform to recognized pattern of

distributionHemianesthesia

Check midline Strict half-body split

Astasia-abasia Walking, dancing With suggestion, those who cannot walk may still be able to dance; alteration of sensory and motor findings with suggestion

Paralysis, paresis

Drop paralyzed hand onto face Hand falls next to face, not on itHoover test Pressure noted in examiner's hand under paralyzed leg

when attempting straight leg raisingCheck motor strength Give-away weakness

Coma Examiner attempts to open eyes Resists opening; gaze preference is away from doctor

Ocular cephalic maneuver Eyes stare straight ahead, do not move from side to side

Aphonia Request a cough Essentially normal coughing sound indicates cords are closing

Intractable sneezing

Observe Short nasal grunts with little or no sneezing on inspiratory phase; little or no aerosolization of secretions: minimal facial expression; eyes open; stops when asleep; abates when alone

Syncope Head-up tilt test Magnitude of changes in vital signs and venous pooling do not explain continuing symptoms

Tunnel vision Visual fields Changing pattern on multiple examinations

Profound monocular blindness

Swinging flashlight sign (Marcus Gunn)Binocular visual fields

Absence of relative afferent pupillary defectSufficient vision in “bad eye†precludes plotting �normal physiological blind spot in good eye

Severe bilateral blindness

“Wiggle your fingers, I'm just testing coordination�

Patient may begin to mimic new movements before realizing the slip

Sudden flash of bright light Patient flinches“Look at your hand†� Patient does not look there“Touch your index fingers†� Even blind patients can do this by proprioception

Hypochondriasis

• “Dok kok saya sering sembelit ya, kayaknya saya punya sakit di perut deh”

• “Ya pokoknya saya sakit di perut, tapi gak tau sakit apa, ih parah deh kayaknya sakit di perut saya”

Somatoform disorder

• Sakit perut saat mau ujian• Nyeri kepala saat membicarakan tetangganya• Deg degan saat ketemu boss

Somatoform Pain disorder