somatization (physical symptom with emotion)

alexithymia

somatothymia

• chronic syndrome of multiple unexplained somatic symptoms which begin before age 50
  • 4 pain symptoms
  • 2 GI symptoms
  • 1 sexual symptom
  • 1 pseudoneurologic symptoms

• more common in rural areas
• cultural differences
• higher among women
• genetic factors (29% concordance rate)

• unknown
  • emotonal states do affect somatosensory cortex
  • studies shown attentional and cognitive impairments causing faulty perception and assessment of somatosensory input (what feels like a twing to me may feel like a spasm to somebody with this disorder)
  • strong association with history of trauma

• number of medical illnesses have diffuse symptoms, so evaluate for:
  • lupus
  • MS
  • porphyria
  • lyme disease
• rely on medical records to establish diagnosis
• avoid repetition of diagnostic work up

• establish one physician
• regular apt's are essential, even if patient is doing well
• regular physical examinations, offer reassurance
• after diagnosis made, avoid mega work ups to pursue somatic complaints unless there is objective evidence of disease
• work with family (spouses of these patients tend to have antisocial PD)
• watch for drug abuse
• treat comorbid anxiety and depression
• listen for psychological stressors while attending to somatic presentations (teach patient how to interpret somatothymia and do not infer symptom is not real)
• psychotherapy/pharmacological interventions (avoid benzodiazapene due to abuse potential)

• preoccupation with fears of having or the idea that one has a serious disease based on the person's misinterpretation of bodily symptoms
• preoccupation persist for at least six months depsite appropriate medical evaluations and reassurance
• belief not delusional intensity

• unknown
  • high comorbidity with anxiety and depression
  • high frequency with alexithymia
  • perceptual theory (lowered thresdhold for sensation)

• medical disorders
• depression
• anxiety
• psychotic disorders
• OCD

• frequent regularly scheduled exams
• cognitive behavioral therapy
• supportive group psychotherapy
• antidepressants, antianxiety agents can reduce ruminations

• preoccupation with an imagined defect in appearance
  • patients report marked distress over supposed deformity, feeling it was devasting, reuinous
  • cannot control preoccupation to the point that thoughts about the defect may dominate their lives
• non delusional

if it is of delusional intensity, they may also be diagnosed with delusional disorder, somatic type

• delusional disorder, somatic type
• anorexia
• schizophrenia
• depression
• OCD

• surgical procedures ineffective
• avoid trying to convince the patient that the defect is not real
• group and individual cognitive behavioral therapy reduces symptoms
• SSRI reduce symptoms in 50% of cases

• young age requesting surgery, repeat surgery
• frequent mirror checkin, frequent seeking of reassurance
• feel the defect has significantly affected social life, school, work, job, family, friends

• one or more symptoms affecting voluntary motor or sensory function
• psychological factors judged to be associated with symptom because of initiation or exacerbation of symptom preceeded by conflicts or stressors

• historically understodd as repression of unconscious intrapsychic conflict and the conversion of anxiety into physical symptom
• increasing data implicates neuropsyc factors
  • brain imaging studies suggest impaired interhemispheric communcation
  • increase incidence in patients with frontal lobe trauma

• rule out organic pathology
• symptoms dont conform to known anatomical pathways and physiological mechanisms such as:
  • pseudoseizures (EEG normal, PRL levels post seizure normal)
  • conversion anesthesia (doesnt follow dermatomes, may follow stocking glove distribution)

• resolution usually spontaneous
• telling patient symptoms are imaginary makes them worse
• reassurance
• address precipitant stressors
• hypnosis, anxiolytics, behavioral relaxations

• pain in one or more sites is the main focus of clinical presentation
• psychological factors are judged to have an important role in onset, severity, exacerbation or maintenance of the plan

• acute and chronic pain different
  • in chornic, avoid narcotics
  • antidepressants are helpful to control
  • biofeedback, relaxation training, hypnosis, multidisciplinary team approach
  • focus on reducing pain, not removing it
• pain sensitivity and expression vary with cultural and personal background
• pain is highly sensitive to emotional, cognitive, attentional, situational influences
• pain fluctuates in intensity, pain never varies is likely psychogenic
• pain not relieved is strongly psychogenic

• report symptoms without having them
• produce false evidence of illness
• intentionally produce symptoms

• early deprivation or serious illness where they learn nurturing from health care workers
• higher incidence of early exposure to serious family member illness

• nonpunitive, non judgemental confrontation w/ psychiatrist present
• view disorder as cry for help
• treatment best focused on management

• grossly exaggerating, lying, or faking physical or psychological symptoms for the purpose of a concrete, recognizable secondary pain

• medico-legal context
• marked discrepancy between findings and presentations
• lack of cooperation with evaluation
• presence of antisocial PD

• physical conditions which are caused or aggravated by psychological stimuli
• close temporal association between the stimulus and initiation or exacerbation of symptoms