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General Considerations
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Somatoform disorders can occur focused on any organ system Vulnerability in one or more organ systems and exposure to family members with somatization problems play a major role in the development of particular symptoms, and the functional versus organic dichotomy is a hindrance to good treatment Clinicians should suspect psychiatric disorders in a number of conditions For example, 45% of patients complaining of palpitations had lifetime psychiatric diagnoses including generalized anxiety, depression, panic, and somatization disorders Similarly, 33 44% of patients who undergo coronary angiography for chest pain but have negative results have been found to have panic disorder In any patient presenting with a condition judged to be somatoform, depression must be considered in the diagnosis
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Clinical Findings
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A Conversion Disorder
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Conversion (formerly hysterical conversion ) of psychic conflict into physical symptoms in parts of the body innervated by the sensorimotor system (eg, paralysis, aphonia) is a disorder that is more common in individuals from lower socioeconomic classes and certain cultures The coping mechanisms used in this condition are repression (a barring from consciousness) and isolation (a splitting of the affect from the idea) The somatic manifestation that takes the place of anxiety is typically paralysis, and in some instances the organ dysfunction may have symbolic meaning (eg, arm paralysis in marked anger) Pseudoepileptic ( hysterical ) seizures are often difficult to differentiate from intoxication states or panic attacks Retention of consciousness, random flailing with asynchronous movements of the right and left sides, and resistance to having the nose and mouth pinched closed during the attack, all point toward a pseudoepileptic event Electroencephalography, particularly in a video-EEG assessment unit, during the attack is the most helpful diagnostic aid in excluding genuine seizure states Serum prolactin levels rise abruptly in the postictal state only in true epilepsy La belle indiff rence (an unconcerned affect) is not a significant iden-
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C Pain Disorder Associated with Psychological Factors (Formerly Somatoform Pain Disorder)
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This involves a long history of complaints of severe pain not consonant with anatomic and clinical signs This diagnosis must not be one of exclusion and should be made only after extended evaluation has established a clear correlation of psychogenic factors with exacerbations and remissions of complaints
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D Hypochondriasis
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This is a fear of disease and preoccupation with the body, with perceptual amplification and heightened responsiveness A process of social learning is usually involved, frequently with a role model who was a member of the family and may be a part of the underlying psychodynamic causation It is common in panic disorders
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E Factitious Disorders
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These disorders, in which symptom production is intentional, are not somatoform conditions in that symptoms are produced consciously, in contrast to the unconscious process of the above conditions They are characterized by self-induced symptoms or false physical and laboratory findings for the purpose of deceiving clinicians or other
CMDT 2008
both the primary clinician and the psychiatrist The patient s disorder is portrayed as a cry for help, and psychiatric treatment is recommended The second approach avoids direct confrontation and attempts to provide a face-saving way to relinquish the symptom without overt disclosure of the disorder s origin Techniques such as biofeedback and self-hypnosis may foster recovery using this strategy Another face-saving approach is to use a double bind with the patient For example, the patient is told there are two possible diagnoses: (1) an organic disease that should respond to the next medical intervention (usually modest and noninvasive), or (2) factitious disorder for which the patient will need psychiatric treatment Given these options, many patients will choose to recover and not have to admit the origin of their problem
hospital personnel The deceptions may involve self-mutilation, fever, hemorrhage, hypoglycemia, seizures, and an almost endless variety of manifestations often presented in an exaggerated and dramatic fashion (Munchausen syndrome) Munchausen by proxy is the term used when a parent creates an illness in a child so the adult (usually the mother) can maintain a relationship with clinicians The duplicity may be either simple or extremely complex and difficult to recognize The patients are frequently connected in some way with the health professions; they are often migratory; and there is no apparent external motivation other than achieving the patient role
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