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Somatization

by Helen Farrell, MD
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    00:00 We’re going to review Somatization now. So, what are somatoform disorders? Well, they are a constellation of physical symptoms that are distressing to an individual and they have no organic cause. Patients tend to be convinced that their symptoms are due to a medical disorder and they absolutely refused to acknowledge that there could be a psychiatric component. There are 2 types of gain that you’ll want to familiarize yourself with. Primary gain and secondary gain.

    00:33 So let’s start here with primary gain. This is an expression of unacceptable feelings as physical symptoms in order to avoid facing the actual emotional disturbance and the patient here actually wants to assume the sick role so they want to be a patient and cared for. Whereas secondary gain is the use of symptoms to benefit the patient through obvious external incentives. Things like getting free housing, disability, evading criminal charges, etc. So, why can lead to being misunderstood by doctors? This is an important point because people who present with a somatoform disorder are often very much misunderstood by their doctors. There tends to be a clash because remember patients are presenting with physical symptoms but physical problems are ruled out by the doctor and they are left with the diagnosis of some kind of emotional disturbance but the patient doesn’t want to accept that so there’s a real struggle in forming a therapeutic alliance.

    01:38 Some examples of somatoform disorders include somatization, conversion, hypochondriasis, pain disorder, body dysmorphic disorder and also malingering. Somatoform disorders, again, in these disorders, patients do not intentionally create symptoms. Now, this is different from factitious disorders where patients do create physical symptoms in an effort to assume the role of the sick patient. Also in malingering, patients do consciously feign physical symptoms but here it’s an effort to avoid some kind of problem or gain some kind of external incentive. So, when it comes to somatoform disorders, females tend to be more affected than males and half of patients have a comorbid mental disorder, something like anxiety or depression. There is an evolution in terms of the diagnostic criteria for somatoform disorders and because it’s evolved so much and very recently, I want to take a moment to point out some of the new ones _____. So in the ICD-10 classification of diseases, this still recognizes somatoform disorders and its subsets.

    02:58 The DSM-IV, the American Psychiatric Association's Diagnostic and Statistical Manual previously described somatoform disorders; however, in DSM-5, the APA’s most recent book on diagnosis, they actually do not any longer use the term somatization and they’ve actually eliminated the category of somatoform disorders. They believe that medically unexplained symptoms have been de-emphasized because it’s really difficult to prove that a symptom is not caused by a general medical condition and they’ve felt in the DSM-5 that many somatoform diagnosis actually lacked the validity and therefore eliminated the category. It’s still historically very important and it may come up on your exam so we’re going to take a little bit of time to review it. In the DSM-5, they actually replaced the category of somatoform disorders with something called somatic symptom and related disorders. So we’re going to focus a little bit on these ideas. So somatic symptom disorder, this is something where psychological factors can actually affect other medical conditions so can an illness anxiety disorder, psychological factors and there’s also a disorder that affects other medical conditions, conversion disorder and factitious disorder. So we’ll talk a little bit about these. The first step when you’re suspecting a somatoform disorder is actually to rule out an organic cause of symptoms. Now this can be very challenging to do and practice but it’s very critical that every patient receive a thorough medical work-up. So you’re going to take a thorough history, do a physical exam, some baseline blood work and maybe some imaging as well to look for central nervous system problem. You’re also going to look for endocrine abnormalities and connective tissue diseases. So again, really can’t overemphasize this point enough. Whenever it comes to a psychiatric illness, you have to rule out general medical conditions before labeling somebody with an emotional or psychological problem. When you do baseline blood work, you’re going to be checking a complete blood count, kidneys, a liver panel, you’re going to check the thyroid function, probably do a urinalysis and a urine tox screen and consider a head CT scan.


    About the Lecture

    The lecture Somatization by Helen Farrell, MD is from the course Dissociative Disorders and Somatoform Disorders . It contains the following chapters:

    • Somatization
    • Types of Somatoform
    • The First Step

    Included Quiz Questions

    1. Somatoform disorder.
    2. Bipolar disease.
    3. Brain tumor
    4. Schizophrenia
    5. Paranoid personality disorder.
    1. Expression of unacceptable feelings as physical symptoms in order to avoid facing them.
    2. Expression of unacceptable feelings as psychiatric symptoms in order to assume a sick role.
    3. Creating imaginary symptoms in order to assume the sick role.
    4. Relating physical symptoms to unacceptable and unnatural circumstances.
    5. Use of symptoms to benefit the patient through obvious external incentives.
    1. Dissociative fugue
    2. Somatization
    3. Conversion
    4. Hypochondriasis
    5. Malingering
    1. Rule out an organic cause of symptoms.
    2. Start treatment with low-dose benzodiazepines.
    3. Refer to an Internist to rule out other medical conditions.
    4. Admit the patient for a constant 1:1 observation.
    5. Reassure the patient that the symptoms would subside with time.

    Author of lecture Somatization

     Helen Farrell, MD

    Helen Farrell, MD


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