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Somatoform Disorders
    Dr.Balan Stephen

A group of ilnesses where the patients complain of multiple bodily signs and symptoms, but there is no detectable physical disorder.
Stress is always associated with the onset of the symptoms.
This group of illness includes :-
Somatization disorder
Hypochondriacal disorder
Somatoform autonomic disorder
Persistent somatoform pain disorder.

These are more common in the medical outpatient settings.

Clinical Significance
Psychiatric disorder should not be missed when it accompanies physical illness.
Severe conditions are likely to need psychiatric treatment
They may carry a risk of suicide.
Moderately severe disorder requires treatment
If persistent, it may delay recovery from physical illness.
Even mild disorders may cause suffering which could be alleviated.
Psychiatric disorder in patients with chronic medical conditions is associated with markedly worse quality of life.
It may be a cause of poor compliance with medical treatment and of excessive and or inappropriate use of medical services.

Nature of Association between Psychiatric and Physical Disorders
Psychological Factors as cause of Physical Illness
Psychosomatic theory :
Emotional changes in human beings are accompanied by physiological changes
When emotional changes were persistent or frequent, pathological physical changes follow.
Once physical pathology is established, psychological factors maintain or aggravate it or to trigger relapse. Physicalconditions induced in this way would improve if the psychological disturbance improved, either spontaneously or as a result of psychological treatment.

Psychosomatic Diseases
Bronchial asthma
Rheumatoid arthritis
Ulcerative colitis
Essential hypertension
Neuro dermatitis
Peptic ulcer.
Hostility, excessive competitive drive, ambitiousness, a chronic sense of urgency and a preoccupation with deadliness- are risk factors for IHD.
Brief changes in blood pressure occur in course of temporary emotional states. Prolonged emotional changes can lead to sustained hypertension.
Emotions such as anger, fear, and excitement can provoke and exacerbate attacks of asthma.
Gastric and duodenal ulcers are common at times of environmental stress.
Psychological stressors can provoke relapse of established ulcerative colitis in some patients.
Skin disorders such as acne, psoriasis and eczema may reflect embarrassment and lack of confidence on their social lives.  Behavioural treatment is sometimes effective in reducing scratching and exacerbation of skin disorder.
In majority of patients with cancer pancreas, depression had preceded the onset of  physical symptoms and signs.

Social support groups, self-help groups
Anxiety management
Cognitive therapy
Relaxation training
Family therapy
Stress management.

Psychiatric Disorders presenting with Physical Symptoms
Various names : Hypochondriasis/Somatization/Functional somatic symptoms/ Somatization/Functional somatic symptoms:  a syndrome with prominent somatic symptoms.
Symptoms with no medical explanation occur frequently
Symptoms transient
Not associated with psychiatric disorder.
Improve with reassurance.
Psychological and behavioural treatments may be effective in a minority

Predisposing factors.
                 . Personality
                  . Briefs about illness
                  . Previous physical illness.
Precipitating factors
Physiological and pathological factors,
minor physical pathology,
muscle tension,
hyper ventilation,
autonomic arousal,
side effects of medications,
Psychiatric disorder
Stressful events
Perpetuating factors
Psychiatric illness
Continuing physical and psychological factors
Lack of confidence
Attitudes of relations and friends,
Iatrogenic factors.

First ensure that all those involved in care have a consistent approach.
Make sure that patients understand that, although their symptoms are not due to physical illness, their complaints are accepted as real and are taken seriously.
Explain clearly the purpose and results of all investigations, and the likely value of psychological assessment and referral.
When all necessary investigations have been carried out, the patient should be clearly told that no further investigation is required. Explanation and reassurance are usually effective in cases of recent onset.
In chronic cases, however reassurance seldom helps.
Specific treatments include antidepressant medication for an underlying mood disorder and specific behavioural techniques such as anxiety management, and cognitive therapy.

Somatoform Disorder
The essential feature is multiple somatic complaints of long duration, beginning before the age of 30.
Conversion disorder
Symptoms or deficits involving voluntary motor or sensory functions,
Excessive concern about symptoms resulting from a physical disorder as well as to symptoms for which no disorder can be found.
Patient is convinced that some part of his body is too large, too small or misshapen.
Pain disorder
Chronic pain which is not caused by any physical or specific psychiatric disorder.

Intentional production or feigning of physiological or psychological symptoms which can be attributed to a need to assure the sick role.
1.    Munchausen syndrome - patients who is admitted to hospital with apparent acute illness supported by a plausible or dramatic history largely made up of falsehoods.
2.    Munchausen syndrome by proxy - a form of child abuse in which parents give false account of symptoms in their children and may fake false signs of illness.

Fraudulent simulation or exaggeration of symptoms. The production of symptoms is motivated by external incentives.

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