Somatoform Disorders

Psychosomatic refers to the connection between the mind and body.

A psychosomatic disorder is an illness that involves both psychological and physiological aspects.

Also known as a Psychophysiologic disorder, it is a condition where psychological stresses negatively impact physiological (somatic) functioning significantly.

These disorders manifest as real physical illnesses, largely influenced by psychological factors such as stress and anxiety.

Examples include ulcers, headaches, allergies, asthma, high blood pressure, etc.

They have a valid physical basis.

These disorders are thought to be caused or intensified by stress, anxiety, and other psychological factors.

Modern medicine suggests that all physical ailments are, to some extent, psychosomatic. This implies that stress, anxiety, and various emotional states can alter body chemistry, organs, and the immune system.

Psychosomatic illnesses can be classified into three general forms:

1. The first form includes individuals who experience both mental and medical illnesses, complicating the symptoms and management of each other.
2. The second form involves those who experience psychiatric issues directly resulting from a medical illness or its treatment. For example, depression due to cancer and its treatment.
3. The third form is "somatoform" disorders.

Somatoform disorders are psychiatric conditions manifested through physical issues.

They are mental illnesses characterized by presenting physical symptoms without medical explanations.

These symptoms are severe enough to interfere with the patient’s ability to function in social settings. Somatoform disorders are described as a category of psychiatric disorders where emotional distress is converted into physical symptoms.

They are also defined as symptoms of physical illness without discernable organic causes. In some cases, there are apparent physical illnesses with no organic basis.

These disorders involve physical symptoms of serious bodily issues without any physical evidence of organic causes, and the symptoms are real and not under voluntary control.

• Somatization Disorder
• Conversion Disorder
• Body Dysmorphic Disorder
• Hypochondriasis
• Munchausen Syndrome by Proxy
• Pain Disorder

Somatization Disorder

• Multiple somatic symptoms in absence of any physical disorder.
• The symptoms are recurrent and chronic (a minimum of 2 years is required for diagnosis).
• It usually begins before the age of 30 years.
• Could be a means of coping with a stressful situation.
• They feel vague, recurring physical symptoms for which medical attention has been sought repeatedly but no organic cause found.
• Examples include back pain, body pain, migraine, vomiting, dizziness, partial paralysis, abdominal pains.
• The disorder is often associated with comorbid anxiety and depression.

Conversion Disorder

• Significant loss of physical function with no organic basis.
• An expression of psychological conflict or need that involves an alteration or loss of physical functioning, suggesting a bodily cause.
• This occurs in the absence of a medical reason.
• A dramatic specific disability which has no physical cause but instead seems related to psychological problems.
• Described as psychological problems converted into a physical illness.
• Examples include paralysis, blindness, deafness, seizures, laryngitis, loss of sensations, false pregnancy.
• Muscles and nerves are intact.
• Glove anesthesia.
• La Belle Indifference (Beautiful Indifference).
• Involves motor and sensory symptoms.
• May suggest a neurological condition.
• Impaired social, occupational, and personal ability to function.
• Sensory impairment; tingling sensations.
• Motor impairment; arms, legs, vocal cords tremors, involuntary twitches.

Body Dysmorphic Disorder

• An obsession or preoccupation with an imaginary or minor flaw, such as wrinkles, small breasts, or the size or shape of another part of the person’s body.
• Body Dysmorphic Disorder causes severe anxiety and might impact a person’s ability to function as usual in their daily life.

Hypochondriasis

• Preoccupation with Having or Contracting a Serious Disease in the Absence of a Medical Reason.
• Individuals worry constantly about developing a physical illness.
• They interpret insignificant symptoms (e.g., cough, bruise, or perspiration) as signs of serious illness in the absence of any organic evidence of such illness.
• Psychologists suggest that the illness resolves a difficult conflict or relieves the patient of the need to confront a difficult situation.
• Behaviourist Theory for Hypochondriasis:
• Being sick in the past might have been used to avoid unpleasant situations.
• Also, it may be based on the belief that someone who is ill gets more attention.
• Biological Theory for Hypochondriasis:
• Research suggests hypochondriacs seem to be unusually sensitive to their own internal processes.
• There is a hereditary basis for somatoform disorders.

Munchausen Syndrome by Proxy

• Involves a caregiver’s persistent fabrication of medical symptoms and signs in the person cared for (typically a mother/child relationship).
• This leads to illness, endangerment, and unnecessary invasive or hazardous treatments.

Pain Disorder

Preoccupation with Pain in the Absence of an Adequate Physical Basis for It.

• Symptoms Range from Pain, Gastrointestinal, Sexual, and Pseudoneurological.
• Abnormalities in Menstruation, Urination, and Sexual Intercourse.
• Patients Experience at Least 8 Different Symptoms.

Pain Symptoms

• They Experience 4 or More Pain Symptoms; in the Head, Abdomen, Back, Joints.
• Can Also Feel Uncomfortable Pain in Her Rectum.

Gastrointestinal Symptoms

• Experiences 2 or More GI Symptoms.
• Nausea and Vomiting.
• Diarrhea.
• Intolerance of Foods.
• Heartburn and Constipation.

Sexual Symptoms

• At Least One Sexual Symptom Is Experienced.
• There Is Indifference to Sex.
• Difficulties with Erections and Ejaculation.
• Excessive Menstrual Bleeding.
• Painful Urination.

Pseudoneurological Symptoms

• Patient Experiences at Least One of These Symptoms.
• Impaired Balance.
• Weak or Paralyzed Muscles.
• Lump in Throat or Trouble Swallowing.
• Loss of Voice.
• Double Vision and Dizziness.
• Seizures Are Common.

Causes

• Nerve Impulses That Send Signals of Pain, Pressure, and Other Unpleasant Sensations to the Brain.
• Symptoms Are Real and Not Imagined.
• Physical as Well as Sexual Abuse.

• Individuals exhibit specific physiological responses to certain emotions.
• For instance, a person in response to the emotion of anger, may experience peripheral vasoconstriction, resulting in an increase in blood pressure.

Family Dynamic Theory

Pathogenic family pattern in childhood, stressful, and conflicting interpersonal relationship among family members.

Personality Theory

Individuals with specific personality traits are predisposed to certain disease processes:

Personality Characteristics/Traits	Psychosomatic Disorder
Dependent personality	Asthma
Repressed, angry	Peptic ulcer and HTN
Aggressive, ambitious	Coronary heart disease
Compulsive and perfectionism	Migraine
Self sacrificing and inhibited	Rheumatoid arthritis and ulcerative colitis

Biological Theory (Genetic Predisposition)

First degree relatives, monozygotic twins of patients with psychosomatic disorders are prone to developing the disorder.

BRONCHIAL ASTHMA

• Asthmatic symptoms are induced by emotional stress.
• Bronchial asthma is common in fear, rejection, mourning, or pent-up emotion or being upset.

CARDIOVASCULAR DISORDERS

• Hypertension increases the risk for coronary heart disease (CHD), as well as other serious disorders such as stroke.
• Type “A” personality is found to be linked with CHD.
• Type “A” personality includes excessive ambition, high performance standards, persistence, urgency, competitiveness, aggressiveness, and hostility.

PEPTIC ULCER

• Stress and emotional disturbance lead to:
• Increased adreno-cortical secretion.
• Increased acidity.
• Progressive erosion of the mucosal wall in the esophagus, stomach, duodenum, or jejunum.
• Increased inflammation and severe laceration resulting in an ulcer.

IRRITABLE BOWEL SYNDROME (IBS)

• Stress and anxiety may make the mind more aware of spasms in the colon.
• IBS may be triggered by the immune system, which is affected by stress.

ULCERATIVE COLITIS

• Patients have a predominance of compulsive personality traits and narcissistic personality traits.
• Being neat, orderly, clean, punctual, hyper-intellectual, and inhibited in expressing anger are features found in individuals who have ulcerative colitis.

• Disturbed Personal Relationship Resulting in Feelings of Helplessness and Hopelessness →
• Stress: Grief, Anxiety, Disappointment, Guilt, Frustration, Suppression of Emotions →
• Triggers Hypothalamic Pituitary Thyroid and Adrenal Axis →
• Lowers Immunity.

MIGRAINE AND TENSION TYPE HEADACHE

• A severe recurring headache, usually affecting only one side of the head.
• Characterized by a sharp throbbing pain.
• Often accompanied by nausea, vomiting, sensitivity to light, and visual disturbances.
• Vasodilation in the brain causes inflammation that results in pain, but the exact cause is unknown.

PAIN DISORDERS

• A pain disorder is characterized by the presence of, and focus on, pain in one or more body parts.
• And is sufficiently severe to come to clinical attention.
• Patients experiencing bodily pain without identifiable and adequate physical causes may be symbolically expressing an intrapsychic conflict through the body.
• Pain behaviors are reinforced when rewarded and inhibited when ignored or punished.
• Can be used as a means for manipulating and gaining advantage in interpersonal relationships.
• Such secondary gain is most important to patients with pain disorder.
• Serotonin and endorphins play a role in pain disorders.

MALINGERING

• Involves the intentional reporting of physical or psychological symptoms in order to achieve personal gains.
• Common external motivations include avoiding the police, receiving room and board, obtaining narcotics, and receiving monetary compensation.

FACTITIOUS DISORDER

• Occurs when physical or psychological symptoms are intentionally produced or feigned to gain attention.
• Sole purpose is to draw other people’s attention because of their sickness.
• Clinical Features:
• Specific sensations such as pain or shortness of breath.
• There could be more general symptoms, such as fatigue or weakness.
• These symptoms are unrelated to any medical cause that can be identified.
• Sometimes can be related to a medical condition such as cancer or heart disease, but more significant than what is usually expected.
• They can present with a single, multiple, or varying symptoms.
• Mild, moderate, or severe.
• Constant worry about potential illness.
• Viewing normal physical sensations as a sign of severe physical illness.
• Having the fear that symptoms are serious, even when there is no evidence.
• Thinking that physical sensations are threatening or harmful.
• Feeling that medical evaluation and treatment have not been adequate.
• Fearing that physical activity may cause damage to one’s body.
• Repeatedly checking the body for abnormalities.
• Frequent health care visits that don’t relieve concerns or that make them worse.
• Being unresponsive to medical treatment or unusually sensitive to medication side effects.
• Having a more severe impairment than is usually expected from a medical condition.

• A major role of psychiatrists and other physicians working with patients with psychosomatic disorders is mobilizing the patient to change behavior in ways that optimize the process of healing.
• This may require a general change in lifestyle, e.g., taking vacations.
• Or a more specific behavioral change, e.g., giving up smoking.
• Whether or not this occurs depends in large measure on the quality of the relationship between doctor and patient.
• Failure of the physician to establish good rapport accounts for much of the ineffectiveness in getting patients to change.
• Ideally, both physician and patient collaborate and decide on a course of action.
• At times, this may resemble a negotiation in which doctor and patient discuss various options and reach a compromise about an agreed-on goal.

Direct Education

• Explain the Problem, Goals, and Methods to Achieve Goals.
• Every Effort Should Be Made to Convey to Belligerent Patients Both Understanding and Tolerance for Their Feelings.

Third-party Intervention

• Family Members, Friends, and Other Clinicians Can Provide Support and Encourage the Patient to Follow a Course of Action.

Exploration of Options

• There May Be Alternative Methods for Achieving a Desired Goal.
• For Example, Quitting Smoking Can Be Done with Support Groups, Nicotine Patches/Gums, or Psychotropic Drugs.
• Provision of Sample Treatment- If a Patient Fears a Particular Course of Action or Considers Change Impossible, a Treatment Trial Can Be Implemented.
• The Patient Always May Opt Out of the Prescribed Programme.

Control Sharing

• Some Patients Resent Any Approach That Appears to Be Authoritarian.
• They May Wish to Set the Pace of a Withdrawal Programme or Titrate Their Medication Depending on Adverse Effects.

Concession Making

• The Clinician May Grant the Patient Something That He or She Wants as a Bargaining Chip to Get the Patient to Comply with Advice.

Empathic Confrontation

Patients who resist change may do so because of fear or other uncomfortable emotions of which they are unaware.

• Stress Management
• Self Observation
• Cognitive Restructuring
• Relaxation Training
• Time Management
• Problem Solving

Relaxation Therapy

• JPMR (Jacobson Progressive Muscle Relaxation)
• Benson Relaxation Therapy
• Hypnosis
• Biofeedback

Problem Solving

The final step is problem-solving in which patients basically try to apply the best solution to the problem/situation.

And then review their progress with the therapist.