II Somatoform disorder:
A. General:
I conversion disorder
II somatization disorder
III hypochondriasis
B. Specific:
I dysmorphophobia
II Somaloform pain disorder
III chronic fatigue syndrome
I. Dissociative (conversion) disorder:
Is also called "hysteria or hysterical disorder" and the predominant
symptoms are physical. It has been called "conversion disorder"
because the anxiety is converted into physical symptoms. It's also
called "dissociative disorder" because the symptoms result from a lack
of coordination of different psychological function.
Note: trails has been made to stop the use of hysteria "hys." But there
are a large number of doctors who still use term especially in the
emergency department and also clinics.
The dissociative symptoms ( or conversion symptoms) suggest
physical illness but occur in the absence of relevant physical
pathology, and is produced through unconscious psychological
mechanisms. There are two obvious difficulties with this concept:
- Exclusion of physical pathology is not easy here, especially when
the pt consults for the first time.
- It's not always easy to be certain that the symptoms are produced
unconsciously rather than consciously and deliberately
(malingering), so an unconscious element is necessary in hysteria.
The prevalence of hysteria varies according to certain considerations; it's
more common in female an children (inferior social position) and is
probably greater in less industrialized societies (i.e. more common in
eastern countries) and more in low socioeconomics.
The common features (criteria) of dissociative disorder:
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 This disorder is characterized by predominantly physical
symptoms (no insight)
 It's produced through unconscious psychological mechanisms
 It's must be differentiated from malingering (consciously and
deliberately ) and underlying real physical illness must be
excluded
 The pt gets primary gain by relieving the conflict and secondary
gain by obtaining sympathy and attention from others or by
avoiding everyday responsibilities.
 The disorder occurs mainly in less industrialized countries, low
socioeconomic and in woman an children and less common in
men.
 The pt has apparent unconcern (belle indifference) even in the face
of gross physical disability.
 The conversion (dissociative) symptoms may be primary
(conversion or dissociative) or called hysteria proper, and
secondary to other psychiatric disorders like anxiety disorders and
organic mental disorders. So it's important to search carefully for
symptoms of these disorders before any final conclusion of the
condition.
Note: secondary hysteria is more common (about 90%)
 Although the disorder symptoms are not produced deliberately ,
they'er shaped by the patient concepts of illness. Sometimes they
resemble those of relative or friend who has been ill or in relationship
with previous experience (ex. Amnesia after years of head injury
accident)
 The symptoms may closely resemble symptoms of physical illness
in some people and less in children and mentally retarded.
 There is usually discrepancies b/t the signs and symptoms of the
disorder and those of organic disease (ex. A pattern of sensory loss
that does not correspond to the anatomical innervations of the part)
 Conflicts which had occurred during childhood (according to are
Freud) are repressed in the unconsciousness but the tongue slips,
dreams and creative work refer to the presence of such conflict. These
can appear to the outside when stressful life events occur.
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Note: the symptoms types of dissociative disorder are important
especially the convulsions ( hysterical fits and its difference from
epilepsy)
Types and symptoms of dissociative (conversion) disorder:
I. Motor symptoms:
1. Voluntary muscle paralysis
2. Tremor and tics
3. Disordered gait
4. Aphonia and mutism
5. Convulsion
Note: The paralysis is the inability to move a part of body due to
simultaneous action of extensor and flexor muscled in the hysterical pts.
Dissociative convulsions differ from epilepsy by:
 The pt does not become unconscious.
 The pattern of movement is not regular and stereotyped
 No incontinence, no cyanosis, no injury, no tongue bite, no
fractures, no dislocations
 EEG is normal
 It occurs in front of people and does not occur when the pt is alone
 It's usually preceded by emotional upset and underlying depression
is not uncommon
 Others (e. g. no aura, presence of gain, …etc)
2. Sensory symptoms:
1. Hyperesthesia and paraesthesia
2. Anesthesia
3. Pain
4. Blindness and tunnel vision
5. Deafness
3. Mental symptoms it includes
 Dissociative amnesia : it usually develops acutely and the memory
loss is patchy and inconsistent (e. g. amnesia of personal identity; so
that the pt is unable to recall his name, address, or other family and
personal details)
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 Dissociative fugue: here, the pt loses memory and wanders aimlessly
away from usual surroundings
 Dissociative stupor: here, the pt is motionless and mute and does not
respond to stimulation (see; hysterical stupor) and other types of
stupor should be excluded.
 Ganser syndrome: it's a rare condition in which dissociative
memory disorder is accompanied by psychogenic physical
symptoms, visual hallucination and apparent clouding of
consciousness. It has been described among prisoners.
Note: organic brain disease should be excluded.
 Multiple personality: it's an exceedingly rare condition in which
there are sudden alternations between the pt's normal state and
another complex pattern of behavior (a 2nd personality). Each is
forgotten by the pt when the other is present.
 Epidemic hysteria:
Dissociative or conversion disorders occasionally spread as an epidemic
within a group of people. The epidemic occurs most often in closed
groups of young women (e. g. in a girls school, a nurse's home and
occasionally it happens in a group of men)
It usually occurs at a time of heightened anxiety in the group, sometimes
there's of involvement in an epidemic of physical disease already
present in the outside community.
Usually epidemic hysteria begins with a person who's highly
suggestible, histrionic and already the focus of attention for some
reason. Another suggestible person responds in the same way and the
other cases follow, first in the more suggestible people and then among
those with less predisposition. The symptoms are variable, but fainting
and dizziness are common.
Treatment of patients with hysterical disorder (conversion or
dissociative disorder):
- It's important to exclude underlying real physical illness especially
organic disease of CNS.
- The pt present in general practice or hospital causality departments
respond well to "resolve any provoking stressful circumstances"
combined with strong suggestion that the symptoms will recover
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- It should be explained to the pt that the disability is caused not by a
physical disease but by an interference with conscious control over
action disease perception, or memory.
- The staff should concern for the pt, but also encourage self-help(e.g.
a pt with a dissociative disorder of gait should be encouraged to
walk unaided and should not be offered a wheelchair.
In addition to that, psychological treatment can be of benefit which
includes the following:
Exploratory psychotherapy
Abreaction: expression of emotion
Behavior therapy: it has a minor role.
Note: medication has no part to play in the treatment of these conditions,
except when the symptoms are secondary to depressive disorder or other
psychiatric disorders that require treatment.
II Somalization disorder
The main feature of this disorder are multiple, recurrent and changing
physical symptoms which are not accounted for by physical pathology or
autonomic arousal.
The condition begins in adolescence or early adult life and runs a chronic
and often fluctuating course. Pts usually consult many doctors, seeking
repeated reassurance and demanding more investigations. The pt may
have underlying depression or anxiety symptoms. The treatment is mainly
reassurance and limit of additional harm through inappropriate drugs or
procedures.
III Hypochondriacal disorder
The essential feature of this disorder is persistent pre-occupation with the
possibility of having a serious physical illness, despite negative results of
investigations and appropriate explanation and reassurance. Pts may be
concerned about a single symptom, such as fatigue or headache, or about
several symptoms. They have fewer symptoms than pts with somatization
disorder. They may be underlying depressive or anxiety symptoms. The
disorder takes usually a chronic course through less so than somatization
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disorder . Re-assurance and advice to avoid further investigation are
necessary
B. Specific somatoform disorder
I Dysmorphophobia: it refer to persistent and inappropriate concern
About the appearance of the body, for example about the shape and size
of the nose or the breasts. Some of those consulting plastic surgery and
dermatology clinics also demand surgical intervention (plastic surgery).
Surgery can sometimes be beneficial but should be avoid in:
- Patient who have been dissatisfied with previous cosmetic surgery.
- Patients with a history of psychological problems
- Patients with very unrealistic expectation of surgery
Note: most of those pts must be reassured to reduce distress and
persuaded about the un-necessity of surgery.
II Somatoform pain disorder :
In this poorly defined condition chronic pain can not be explained by any
Physical or mental disorder. The cause is unknown.
Social or psychological factors could be the underlying cause.
III chronic fatigue syndrome: it's characterized by symptoms of chronic
fatigue, malaise and depression which are common after viral infections
(e.g. influenza, hepatitis, infectious mononucleosis). Numerous viruses
including EBV have been incriminated but non has been proved to cause
the condition. Different methods have been used to treat the condition:
Antidepressant drugs
Graduated increase in activity
Cognitive behavioral therapy
 Other conditions including
Munchausen syndrome (hospital addiction):
It's an uncommon and extreme form of factitious disorder in which pts
give plausible and often dramatic histories of an acute illness with
feigned symptoms and signs. The pt may attend a series of hospitals and
present under different names at each of them. They frequently demand
under strong analgesics for pain. The etiology of this condition is
unknown and the pts usually have abnormal personalities .
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"Munchausen syndrome of proxy": refers to a condition of unknown
cause in which a parent gives a false account of symptoms in a child and
may fake a physical fake a physical signs.
Malingering: it's the fraudulent imitation or exaggeration of symptoms
with the intention of gaining financial or other rewards rewards and
differs from factitious disorder (Munchausen disorder) in which no gain
is present.
This condition is more commonly seen among prisoners, the military and
people seeking compensation for accidents. When the diagnosis is
certain, the pt should be informed tactfully of this conclusion and should
be encourage to deal more appropriately with any problems that have
contributed to the behavior.
Somatization disorder (Hysteria-Briquet's Syndrome):
These are somatic symptoms that can't be explained adequately on the
basis of physical and laboratory examinations. These symptoms appear as
expression for internal physical stress. Somatization is not purely a
psychiatric disorder; they are seen in every branch of medicine. Its caused
by chronic significant psychological stress. It causes impairment of social
occupational functioning.
Criteria for diagnosis:
1- History of many physical complains or belief that is sticky,
beginning before the age of 30, and persisting for several years.
2- At least 13 symptoms of the list below, first there must be:
a) No organic pathology (physical disorder, effect of injury,
medication, drug or alcohol abuse or withdrawal. To account for
the symptoms or when there is related organic pathology, the
complaint or resulting social or occupational impairment is
grossly
b) Not occurred during panic attack
c) Has caused the person no take medicine.
The patient has excessive medical help seeking behavior, the changes
doctors very frequently (doctors shopping). He has multiple symptoms
that not stick to one organ, the disease is vague history (no onset, no
aggravating or relieving factors) and not improved by medication.
Epidemiology :
Life time province in general population is 0.1-0.2 % and may reach up to
0.5% female are more than males in about 5-20 times. It occur usually in
people with low education and low socio-economic status and occurs
mostly in rural area, 2/3 of patient have psychological symptoms of many
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disorders (e.g. depression), either as cause or as result of disease. In a
female somatization, there is 1-2% increase in the incidence of having
other males of her family with other neurotic illnesses.
It is chronic relapsing disease, usually associated with symptoms of
anxiety, and sometimes there is a suicide attempt.
Cause: definite causes are unknown, but some factors may play a role,
and there are:
 Job obligation
 Parent teaching
 Ethnic mores
 Physical abuse
 Biological factors
Symptoms: there is a long list contains many symptoms, and it is
arranged according to systems, and these are:
 Git: abdominal pain, vomiting, diarrhea, abdominal distention..
 Pain: in the extremities, back ,joints, pain during urination.
 Cardio- pulmonary: shortness of breath (not related to exertion),
palpitation, chest pain, dizziness.
 Urinary: burning sensation during micturation , urinary retention
 Sexual: burning sensation in sexual oragans or rectum, sexual
indifference( frigidity, dyspareunia (painful coitus), impotence,
dysmenorrhea, irregular period, heavy bleeding and excessive
vomiting during pregnancy.
 CNS (pseudo neurotic symptoms); amnesia, difficulty in
swallowing (dysphagia), loss of voice (aphonia), double vision,
blurred vision, fainting (loss of consciousness), trouble walking,
paralysis or muscle weakness, urinary retention.
 Personality: the patient may have antisocial behavior, may be
psychopathic or histrionic, may be associated with drug or alcohol
abuse, and sometimes there is family history of antisocial behavior.
Differential diagnosis:
1. Always exclude organic diseases.
2. Other psychological illness: somatization may not be the only
problem; from the history we can diagnose other disorders as
anxiety, depression and schizophrenia.
3. TCN disturbance: organ brain syndrome or drug abuse or
withdrawal.
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Treatment:
 The doctors have skills in dealing with these patients, because
somatism is difficult to be treated
 We teach the doctors not to provoke the patient with the disease,
but we tell the patient in empathic way.
 We should listen to the patient, we ignore the previous complaint,
and we encourage the psychological factors.
 The patients should deal with one doctors, and we put him on
regular visits (every 2 weeks or every month)
 Treat other disorder: anxiety or depression
 The patient needs individual and/ or group psychotherapy
Hypochonriasis:
Hypochonriasis is a morbid concern health, preoccupation with food,
medicine an illness. It pursues health as away of life. It is a strong
conviction of the actual presence of disease of fear of developing serious
Clinical features:
It is unrealistic belief of having disease, the most commonly involved
areas are head, neck, chest, abdomen and skeleton. It may be fear of
having illness (illness phobia) or re-having illness.
Differential diagnosis:
 Somatimzation: the patient with hypochonriasis choose one
disease, onset age is older (after 35-40), and female to male ration
is equal .
 Real illness should always be excluded.
 Phobia (illness phobia): patient with illness phobia avoid doctors,
hospital and reading books about disease with fear of re-illness.
Patient with hypochondriasis are addicts
 Munchausen's syndrome: the patient pleasure in deceiving doctors,
and may be extremely impressive, some may have laprotomy for
many times, and some may create hemoptysis by him self. Those
patients when faced by the reality (that they are liars) they will run
away.
 Malingerer: those have no organic disease, they act voluntarily to
have a purpose, and they have no symptoms after achieveing their
goals.
 Acute stress reaction:
- Occur after a major event
- dizziness
- Impaired ability to comprehend and answer question
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- Autonomic signs of anxiety
- sometimes stupor
Pain syndrome: according to (DSMIV)
 Precaution with pain (well or ill-defined) for at least 6 mounths
 Appropriate evaluation uncovers no organic pathology or
pathophysiological mechanism
 Or when there is related oranic pathology, the complaint is in the
excess of what would be expected from the physical findings.
Clinical features:
1. Its frequently associated with psychosocial stress or secondary
gain.
2. Patient seeks many doctors of drugs may be present.
3. Iatrogenic effect of drugs may be present
4. The patient avoid being diagnosed as psychiatric patients and reject
psychotherapy
5. They avoid a heaithy role and accept invalid roles.
Epidemiology:
Is unknown, because the disease is difficult to define. In case , chronic
pain of 1/3 of them have psychiatric disorder. It may occur at any age or
sex.
Treatment:
 We should educate the primary care physicians to established
specialized pain clinic.
 Detoxification of antidepressant drug, such as amytriptaline
( trpizol) to relief pain of (RA or CA), I will act in mechanism
other than anti-depression.
 Cognitive behavioral therapy
Technical rehabilation to the patient, especially for invalid patients
to increase functional and occupational ability.
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Somatoform disorder:
Hysteria related disorder
Hysteria proper
Hysteria related disorder
Conversion disorder dissociative disorder
Hypochondriasis
Somatization
Chronic disorder
Body dimorphic disorders
Chronic fatigue syndrome
Facitiuous disorder(hospital addition)
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Conversion disorder
Motor symptom: invol. movement
Blepharospasm
Opsthonus
Seizure
Paralysis
Weakness
Sensory symptoms: anesthesia of extremities
Midline anesthesia
Blindness
Tunnel vision
Deafness
Visceral symptom
psychogenic vomiting
Pseudocyesis
Globus hysericus
Swooning retention
Diarrhea
Dissociated disorder:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Dissociative Amnesia
Dissociative fugues
Twilight states
Dissociative identity disorder (multiple personality)
Depersonalization disorder
Dissociative and trance disorder
Ganser syndrome
Epidemic hysteria
Brain washing (thought reform, persuation, mind control
Trance dissociative:
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Altered states of consciousness › diminish respartory to environmental
stimuli
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