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What somatization is
a process by which an individual consciously or unconsciously uses the body or bodily symptoms for psychological purposes of personal gain
The distinction between symptoms and signs
Symptoms is a problem the patient reports
A sign is something you directly observe
How to tell the somatoform disorders from each other and from factitious disorders and both of these from malingering
- Somatoform disorder: the physical symptom is originally generated solely by unconsious psychological forces
- Factitious disorders: the patient is consciously producing symptoms with the primary intent of obtaining or maintaining the status of a patient
- Malingering: the patient is consciously producing false symptoms with the primary intent of avoiding external situations
The reasons people may employ somatization
- Excused from responsibilty
- Manipulation of interpersonal relationship
- Sanctioned dependency
- Financial gain
- Resolution of intrapsychic conflicts
The difference between primary and secondary gain
Primary gain: the benefit is a psychological one: reduction of potential inner tension, anxiety, conflict, or dilemma
- Secondary gain: benefit are the tangible advantages
Family factors predisposing the use of somatization
- Grew up in a family of somatisizers
- Had parents who were caring and loving the child was ill but demanding and unrewarding when the child was well
- Had one or both parents suffer illness
- Did not learn more adaptive coping skills
- Observed in their families the conscious feigning of illness to achieve or avoid something
Why somatisizers make doctors mad
- They don't follow the rules
- They resist your efforts to make them better
- The tests all came back normal is not good news to them
- You feel helpless, frustrated
Principles of management of somatization
- Initally, insure that a thorough evaluation of possible physical illness had been done
- Give medication only to new signs
- Discourage utilization of multiple doctors and specialist
- Shift focus to help patient cope with it/them
- Do not require a new or worsened symptom as a ticket for admission
- Obtain good social history
- Ask about support system
- Discuss referral to a psychiatrist for severe and chronic cases
- Monitor potential for addiction and suicidality
The pathways and brain structures involved in pain sensation
- Peripheral nociceptors
- Spinothalmic tract
- Periaqueductal gray matter

Interventions which can reduce pain sensation
- Augmetation of serotonin or opiate systems or blockade of glutamate all reduce pain
The differences in the way acute and chronic pain presents
- Acute pain: obvious distress manifested in facial expressions and body movements. ANS arousal: sweating, increased pulse and BP

- Chronic pain: No CNS arousal, Fewer pain expressions and gestures, Often the people with chronic pain don't look to be having as much pain as they are reporting
Pain disorder - Its essential and commonly associated features
Essential features
- Preoccupation with pain in the absence of adequate medical or neurological explanation to account for its presence or its intensity
- Psychological factors are judged to have an important role in the onset, severity, or maintenance of the pain
Pain disorder - common psychological pattern seen
- Start with trauma, persist long after the actual injuries could account for it
- Depression is very common in these patients
- Long histories of multiple doctor visits
- Pain can be viewed as the source of all their difficulties
Pain disorder - ways it can relate to depression
- Some argue that some cases are simply depression presenting with a more acceptable symptom
Pain disorder - principles of management
- Realize that the pain is real
- Establish an understanding rapport
- Psychotherapy
- Biofeedback
- Physcial therapy
- Anesthesia
- Transcutaneous nerve stimulators
- Pain management techniques
Hypochrondriasis - its essential and associated features
- Preoccupation with the fear or idea that one has a serious disease
- Fear or idea is based on inaccurate or unrealistic interpretation of minor physical sensations or abnormalities
- The fear or idea does not resolved with medical reassurance
- It is not of delusional intensity

Associated features

- History of frustrating doctor-patient relationship
- Anxiety or depression disorders  present in 80%
Hypochrondriasis - research findings regarding sensitivity to sensations
- Research indicates these patients have a lower threshold for noticing bodily sensations and experience greater discomfort from minor sensations
Hypochrondriasis - principles of management
- Do not discount or dispute the fear; acknowledge and accept it, noting at this point there is no objective evidence for illness
- Agree to follow the patient regularly to monitor for any new signs or developments
Conversion disorder - its essential features
- Alteration or loss of voluntary motor or sensory functioning that cannot be explained by a known medical or neurologic disorder
- Symptoms are not intentionally produced
- A psychosocial stressor or psychological conflict leads to the initiation or worsening of the symptoms
Conversion disorder - the usual course
Short lives, but occasionally the symptom can become chronic
Conversion disorder - common symptoms
- Paralysis
- Blindness
- Mutism
- Impaired coordination
- Inabilty to feel sensations
- Seizures
Conversion disorder - common psychological factors involved
- Symbolic relationship
- Keep the focus off the internal conflicts
- Relief from diffcult life situations
- Unconciously model after someone important to the patient
Conversion disorder - General treatment approach
- Psychotherapy focusing on the current stresses and coping skills
- Suggrestive therapy- hypnosis, amobarbital interviews, etc
Somatization disorder - its essential features
- Chronic presence of recurrent and multiple somatic complaints beginning before age of 30
- Symptoms have no adequate physical explaination
- The symptom have cause the person to take action
- Multiple symptoms
a) 4 pain symptoms
b) 2 GI symptoms
c) 1 sexual symptoms
d) 1 pseudoneurologic symptom
Somatization disorder - its prevalence in primary care populations
- 5-10% in primary care setting
- Prevalence 1-2%
- Female more than male by as much as 20:1

Somatization disorder - its gender ratio
- Female to male - 20:1
Somatization disorder - the disorders clustered in these patient's families
- Family studies show a cluster of disorders in these patient's families: somatization in the women; antisocial personality and addiction in the men
Somatization disorder - typical features of these patient's life histories and medical histories
- Doctor shopping/doctor hopping
- Multiple unnecessary procedures, tests, and surgeries
- Frequent dependence on prescription medications (benzodiazepines, narcotics)
Somatization disorder - principles of management
- Most of these paitient resist psychiatric referral
Body dysmorphic disorder - its essential features
- Preoccupation with imagined defect in apperance of a normal appearing person
Body dysmorphic disorder - complications and consequences
- Repeated visits to plastic surgeons or dermatologist
- Significant avoidance of social and occupational situations due to anxiety about the defect
Body dysmorphic disorder - reasons for theorized relationship to OCD
- The preoccupation can be of obsessional intensity
- About 50% of patients have reduced symptoms when treated with medications helpful in OCD
Body dysmorphic disorder - priciples of management
- Identify if clear anxiety or depressive syndrome also present. This and/or the suggestion of needing help to cope with the concern may help patient accept psychiatric referral
Factitious disorder - the essential features
- concious, intentional mimicking, or production of physical illness with the goal of adopting the sick role
Factitious disorder - the part of the disorder that has compulsive quality
- There is a compulsive quality to their need to be in the sick role
Factitious disorder - the most common demographic profile seen in these patients
- Socially conforming young women of higher socioeconomic class, who are intelligent, educated, and often in a medically related field
- Often had discruptive childhoods and also meet criteria for a personality disorder, especially borderline
Factitious disorder - three psychological factors which may contribute to this behavior
- Mastery and control
- Masochism: an enjoyment of invasive procedures
- Dependency
Factitious disorder - the definition of "Munchausen's Syndrome"
- Dramtic flair in presentation of symptoms
- Pathologic (seemingly compulsive) lying
- Wandering from hospital to hospital, city to city
Factitious disorder - principle of management
- Obtain thorough life history and seek understand the role, place, and function of the sick role for this patient
- Obtain psychiatric evaluation and dtermine whether other psychiatric syndromes or a personality disorder
- Use a non-punitive and supportive manner, framing their behavior
Malingering - its essential feature
Intentional feigning of illness motivated by external incentives: "the fraudulent simulation or exaggeration of phsycial or mental disease or defect consciously produced to achieve a specific goal
Malingering - common reasons for malingering
- Avoid military duty or work
- Financial compensation
- Evading criminal prosecution
- Obtaining drugs
- Securing a warm place to stay with regular meals
Malingering - warning signs of its possible presence
- Presence of a disability evaluation or legal situation involving the illness
- Marked discrepancy between what the patient reports and the phsycial findings
- Lack of cooperation with diagnostic procedures or poor compliance with treatment
- Life history suggests antisocial personality disorders
Malingering - principles of management
- First, exam your own feeling
- Realize that this may represent a desperate means to manage a situation for whichi patient can find no other solution
- Confront the patient firmly, yet with empathy, your goal is to shift the focus from the feigned symtoms to the psychosocial factors and stresses present that create the need for the feigned symptoms
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