SOMATISATION DISORDER

SOMATISATION DISORDER

• Somatic System Disorder

• Hypochondriasis

• BDD Nose

• BDD Breast

• Conversion Aphonia

• Conversion paralyses

• Globus Pharyngeus Hystericus

Case • You are seeing a 26 year old female, Jane who comes to you for

review of the result of MRI brain which was requested by the

neurologist specialist. Jane undergone MRI as she has headache

associated with severe neck spasm. She has past history of

abdominal pain and nausea. Investigation with blood tests, CT and

U/S were all normal. Colonoscopy and upper GI endoscopy were

normal too. Past history revealed she had a feeling that she had a

breast lump on investigation that was normal as well, history of

chest pain investigation ECG stress test echo and

• Holter and MRI revealed normal.

• Tasks:

1. Take a history from the patient

2. Explain the Diagnosis to the patient

3. Counsel the patient regarding the management

Task 1: History• Introduce

• Ask for specific concerns

• Headache Q’s? Duration?

• Criteria of Somatization Disorder + Duration

1. Any other pain aside from headache? Abdominal? Back? Muscle? Joints? Chest? (4)

2. GI symptoms: N/V/Bloating/Food intolerance (2)

3. Sexual: loss in interest, irregular menses, erectile dysfunction (1)

4. Pseudoneurological: impaired balance, paralysis, aphonia, urinary retention (1)

• Differentials Questions:

1. Organic Disease:

2. Hypochodriasis: are you more concered about the synmptoms or the possible serious underlying disease you might have?

• Psychosocial

• HEADSSS/SADMA/PMH/FH

• Mood is flat.

• Dad and mom left job and looking after her.

• Met the criteria for somatization disorder

• Anxious and worried.

• Married before and now divorced.

• Period regular, not sexually active (not interested) Been like this for 6-7 years.

Criteria

• Features:• History of symptoms for which significant medical

treatments have been sought for years

• Appear before the age of 30

Criteria:

1. 4 pain symptoms,

2. 2 GIT

3. 1 Sexual

4. 1 Pseudoneurologic symptom

Task 2: Diagnosis

• Jane, based from the history that I’ve gathered and the investigation results, it is highly likely that you are suffering from the condition called Somatization Disorder. Do you know what this condition means?

• Before I explain it to you, I would like to tell you that you pain is real but we can relate it to the condition that you have.

• Somatization Disorder is part of the Somatic System Disorder. In this condition, the patient experience pain, several problems related to your tummy area such as nausea and bloating. It is also related to your lost of interest in sexual activity and problems in urination.

• The sadness that you have can manifest in your body and there is connection between this and your symptoms.

• The exact cause is unknown but it can be attributed both in familial and environmental factors.

Task 3: Management

• Pain Management• Lifestyle Modification• Psychologist: CBT• Family meeting with consent• Support groups• If fail: Psychiatrist and SSRI• Reading materials• Review• Redflags

Case

You are a GP when a 39 year old female came in your clinic with complaints of left sided abdominal pain since last year. She had been investigated in detail including USD and colonoscopy but all investigations were negative and she wants you to refer her for another US and colonoscopy.

Task:1. Take relevant history from the patient

2. Explain the diagnosis and management to the patient

Task 1: History• Rule out medical condition Request for USD and Colonoscopy: We’ll assess you and we will decide later on.• Details of the pain:

1. Since how long have you been having pain?2. Is it on and off or continuous?3. Where exactly the pain?4. What type of pain? Like colicky? Tense or dull?5. Does it go somewhere else?6. How sever your pain is? 4-57. Anything that makes it worse? Better? 8. What do you usually do when you have pain?9. Any associated symptoms such as v/d/n10. How’s your waterworks11. Do you open your bowel regularly? Any constipation or diarrhea?12. Weight loss, lumps and bumps any unexplained fever

Ensure confidentiality

SPECIFIC QUESTIONS FOR HYPOCHONDRIASIS1. Do you think that you have a serious underlying disease?

2. Anybody in your family has been diagnosed with cancer?

3. How is your mom now? She passed away

PSYCHOSOCIAL History1. How’s your mood? Worried about condition

2. Do you feel that life is worth living for you? Any thoughts of harming yourself?

3. Are you eating well?

4. How’s your sleep? (difficulty initiating), Does the pain wakes you up at night?

5. Do you think someone is spying on you?

6. Do you see or hear things that others don’t.

7. If there is a fire in the room, what will you do?

HEADSSS1. Are you in a stable relationship?, any children? Any stress

at home? Or relationship problem?2. Do you work? What type? Any stress at work?3. Any hobbies for you? And do you still enjoy doing these

hobbies?4. Do you go out and meet up with friends?

SADMA• Look, smoking can be harmful for you. I can arrange an

appointment if you are motivated.PMH/FH

1. Any past medical or surgical illness? Ay past history of mental disturbance?

2. Are you on any medications?3. Any family history of mental disturbances.

CRITERIA:

• Preoccupying serious disease

• Preoccupation despite adequate medical evaluation

• Causes significant distresses and impairment that lasts atleast for 6 months

DIFFERENTIAL:

• Anxiety disorder

• Somatization disorder

• Conversion disorder

• Depression with somatic symptoms

• Substance abuse

• Body dysmorphic disorder

Task 2: Diagnosis and Management

• It is a somatic system disorder or an illness anxiety disorder whereby you misinterpret the symptoms that you have and correlates it to a serious underlying disease.

• The exact cause is unknown,.• You may relate the symptoms you are having a serious underlying disease like cancer. • Later it starts interfering with your lifestyle as well. • But the pain that you are experiencing is real. • There is always a relation between the mind and the body and it functions as a single

axis.• When there is a disturbance in the mind, it starts showing in the body as different

physical symptoms.• It is actually the cry of the mind for help.• The emotional disturbance associated with shock and grieve of your mom passing away

due to bowel cancer had created a fear in you which is manifesting in the body as pain

Task 2: Diagnosis and Management

• Look ultrasound and colonoscopy are very sensitive investigations done by experts, which can even pick a minor disturbance within in your body, let alone cancer.

• At this point, doing Ultrasound and Colonoscopy won’t help• What I need to do now, if you agree with it, I will refer you

to a psychologist for CBT and intensive psychotherapy• Lifestyle modifications: healthy diet, regular exercise which

helps in improving mood and can also decrease stress that is associated with this

• Sleep hygiene• Relaxation techniques like yoga • Arrange a family meeting with your consent • You might require a psychiatric referral : they might consider

starting you on medications: SSRI• Arrange a review in one month

Case

• You are working as a GP in a clinic when a 25 year old Kira came for her appointment. The receptionist noticed that she is quite restlessand that she noticed her visiting the toilet several times.

• Tasks:1. Ask relevant history from the patient

2. Explain the probable diagnosis to Akira

3. Explain further management plan to the patient

Task 1: History

• Nice to meet you• Can you elaborate your problem?• Ensure confidentiality• Do you have any specific concerns? Nose crooked and ugly• Since how long have you had this? Since adolescent• Is it progressing? More and more crooked now• Anything that you do to check the situation? Every 2

hours, she checks it • Do you have concerns about any other body parts?• Any interventions done for this so far? gone to massage

and beauty parlor nothing has work, wants to go under the knife, plastic surgeon

PSYCHOSOCIAL history• Mood? Disturbed • Life worth living?• How’s appetite? And weight?• How’s sleep?• Anything you hear or see that is strange?• Anyone spying on you?• Do you think you need help?• Judgment?HEADSSS• Living with parents, had fight with family because they said nose is alright• Employment at risk? Why? Keep checking herself in the mirror, work are

compromised• Still enjoys her hobbies?• SADMA• Social activities?• PMH• FH

Task 2: Diagnosis

• Akira, I think you have a Body Dysmorphic Disorder. • KIRA, BDD is a form of somatoform disorder where you

become very much preoccupied about your appearance, and your perception of your body image is different from others

• Becoming concerned about once appearance is quite a normal thing, especially at the time of adolescents but in BDD, you become extremely concerned about an slight changes of your body then it becomes difficult for you to control these thoughts which leads to repetitive and time consuming behaviors having little or no effect.

• Then it starts interfering with your daily activities. • If it persists, it can lead to low self esteem and fear of

rejection.

Task 3: Management

• We are here to help you, we’ll work as a team and we will refer you to Psychologist for CBT which includes Psychoeducation cognitive challenge and restructuring anxiety management training.

• With your consent, the family could also be involve in the psychoeducation part

• We will also require to refer you to a psychiatrist• He may start you on SSR’s for 3 months• Remove the mirrors in your room• Reading materials• Review in one month time

• Please read the Clinical

Handbook Condition 084

BDD

Case

• A 27 year old Sarah came in your surgery where you work as a General Practitioner. She is asking you to refer her to a surgeon for breast reduction surgery.

• Your tasks are:1. Take a history from the patient

2. Counsel her accordingly

Differentials

• Body Dysmorphic Dysmorphic Disorder

• Enlarged Breast

• Organic Causes:

1. Breast Cancer

2. Depression

• Grief Reaction

• Adjustment Disorder

History

• Hi Sarah, I’m the General Practitioner here and I am here to help you. I read from the notes that you are here to request for breast reduction.

• Can you tell me the reason why you want to undergo breast reduction?

• I have very big breast and it affects my life a lot.

• Can you tell me how these affects your life?• I had a recent divorce and my father passed away 6 months ago.• I am so sorry about this Sarah, my deepest condolences on your

los,, we are here to help and support you.• Here is some tissue and water.• Let me reassure you that whatever we talk about will remain

confidential unless there is a risk of harm of you or others.

• Can you tell me more about this Sarah?• When did you notice that your breast in enlarged?• Is it getting worst?• Is this the first time that you noticed your breast getting

bigger?• Have you consulted your general practitioner regarding this?• Did you felt any lump in your breast? Or noticed any changes

in the skin? Any unexplained fever? Lumps around your body?

• Anyone said that you have a big breast?• What have you done so far regarding this?• Are you doing any time consuming habits to check out this

situation? Like checking the mirror frequently?• Any part of your body that you are worried about?• Anything that seems to trigger this like stress at home or at

work?• Do you think that you might be overweight?• Do you also binge eat or sometimes eat more than usual?

• Psychosocial History

• HEADSS

• SADMA

• PMH

• FH

Diagnosis

• Sarah, I think you have a Body Dysmorphic Disorder. • BDD is a form of somatoform disorder where you

become very much preoccupied about your appearance, and your perception of your body image is different from others

• Becoming concerned about once appearance is quite a normal thing, especially at the time of adolescents but in BDD, you become extremely concerned about any particular part of your body then it becomes difficult for you to control these thoughts which leads to repetitive and time consuming behaviors then it starts interfering with your daily activities.

• If it persists, it can lead to low self esteem and fear of rejection.

Task 3: Management

• We are here to help you, we’ll work as a team and we will refer you to Psychologist for CBT which includes Psychoeducation cognitive challenge and restructuring anxiety management training.

• With your consent, the family could also be involve in the psychoeducation part

• We will also require to refer you to a psychiatrist• I will start you on SSRI’s for 3 months• Remove the mirrors in your room• Reading materials• Review in one month time

Case

• You are working as a GP and a 20-year-old Jessica has come to you at your surgery complaining with inability to speak since 1 day. Her father brought her and told the nurse that her mother is suffering from terminal liver disease and is awaiting liver transplant.

• Jessica visited her mother the previous day and she could not speak after hearing her mother screaming in pain.

Tasks: 1. Take Further history from the patient2. Explain the Diagnosis to the patient3. Explain further Management to the patient

Differentials:

• Acute Laryngitis

• Voice abuse

• Vocal cord hemorrhage

• Carcinoma of vocal cord

• Nodules in vocal cord

• Thyroidectomy

• Stroke

• Conversion Aphonia

Task 1:

• Hi I’m Dr. _____, I’m here to help you.• Confidentiality• I’m so sorry about what your mother’s been going

through, and it seems such a hard time for you and your family.

• I would like to let you know that if you or your family need some support, we will be here for you.

• I understand that you can’t speak. And I would like to help you with that.

• If it’s alright with, I would like you to nod your head if yes and shake if no.

Rule of Organic Causes:

• Is this the first time you lost your voice?

• Any sore throat?

• Any pain in your throat? Fever?

• Lumps or bumps around your neck?

• Have you cried or screamed at the top of your voice?

• Any difficulty in swallowing?

• Can you please cough or say ahhhhhhhh?

• Any difficulty in moving you leg? Any weakness?

PSYCHOSOCIAL HISTORY:• I am aware that your mom is having a difficult situation. Is your mood low

now days?• Any ideas of harming yourself?• Do you eat well?• Any weight loss?• Is your sleep disturbed?• Do you think somebody is spying on you?• Do you or hear strange things that others don’t?• I know that your mom is in the hospital and your father is with you,

anybody else who support you this time?• Are you studying?• How’s your uni performance?• Do you still enjoy your hobbies?• SADMA• Do you have a lot of friends? • Any past medical/surgical conditions• Any medications you are on?• Allergies?• Any previous history of mental disturbances?• Family history of mental disturbances

PE• GA: pallor, BMI, lymph node enlargements• VS: temp• ENT: Throat: any signs of infections: tonsillitis, pharyngitis• CNS: CN 9,10, 12: use the glass of water• CN9: GLOSSOPHARYNGEAL & CN10: VAGUS NERVES

1. Palate, uvular displacement2. Ahh: symmetrical movement of soft palate3. Gag reflexes4. Voice hoarseness and cough5. Sip and swallow

• CN12: HYPOGLOSSAL NERVE1. Tongue wasting or fasciculation2. Any deviation on protruding the tongue

• Rest of the CN examination• Upper and Lower Neurological examination• Quick review of all other systems:• GAIT

Task 3: Diagnosis

• What you are having is Conversion Aphonia, which is characterized by abnormal body function in response to an overwhelming emotional disturbance.

• Somatoform disorder• Look, your mom has this sort of situation because of the

emotional disturbance it has caused the lost of your voice.• THIS DOES NOT MEAN THAT YOUR SYMPTOMS ARE UNREAL

OR NON GENUINE• When you have an extreme emotional disturbance, it

manifest in your body unintentionally and unconsciously and the physical manifestation is an abnormal defense mechanism to relieve the patient’s inner conflict

Task 4: Management

• Normally this should resolve in few days time, but I have to refer you to ENT specialist to rule out other organic causes.

• Ill arrange a family meeting with your father with your consent

• Referral to the Psychologists for CBT and counseling and to Speech therapists for Psychogenic speech therapy

• If not working start SSRI’s• Consider referral to Psychiatrist if this is not working• Review in one week time

Can I see my mom now?

It is a good idea to spend time with your mother, but before doing so, it will be best for you to see your Psychologist first.

• Please read the Clinical Handbook Condition 089

Conversion Disorder

Case

Your next patient in general practice is a 50 year old Mrs. Denise Young presenting with the feeling of having a lump in her throat for the last two weeks.

Tasks:1. Take a further history

2. Examination Findings will be provided

3. Arrange for appropriate investigations

4. Discuss the diagnosis and management with the patient

Differentials:

1. Thyroid Enlargement

2. Esophageal Cancer

3. Globus Pharyngeus Hystericus

4. Mediatinal Tumours

5. Achalasia

6. Esophageal Stricture

Task 1:

• HOPC

• Differentials

• Systems Review

• SADMAPMH/FH

• HOPC: Denise noticed a feeling of a lump or something stuck in her throat first two weeks ago and it has been coming and going since. It is situated more at the front of her neck and often moves up and down. Eating and drinking does not make it worse actually sometimes it can make it better but she noticed that the feeling of a lump in her throat can be aggravated when she swallows saliva.

•

• PHx. + FHx.: unremarkable •

• SHx: recently (4 weeks ago) divorced high school teacher with 3 children after having been separated from her husband for 2 years.

• She has had considerable financial and personal stresses during the last two years, exacerbated through the divorce procedure.

• Non smoker, little alcohol, NKA, no medication.

Task 2: PE

• GA:LAD BMI

• VS:

• ENT:

• NECK: inspection, palpation, swallowing: solid and liquid

• Laryngoscopy

• CN 9, 10, 12

• EXAMINATION: Quite well looking lady with normal vital signs.

• The neck and floor of the mouth are palpated for masses. The oropharynx is inspected (including by direct laryngoscopy). Swallowing (of water and a solid food such as crackers) should be observed. Neurologic examination with particular attention to motor function is important.

• No pathological finding in her!

Task 3: INVESTIGATIONS:

• CXR (to exclude mediastinal tumours).

• Barium Swallow

• Videofluoroscopy / oesophagography.

• Ambulatory pH monitoring

• Oesophagogastroscopy.

• Oesophageal manometry

Task 4: Diagnosis

• DIAGNOSIS: GLOBUS HYSTERICUS

• Globus sensation is a subjective feeling of a lump or something being stuck or having a foreign body in the throat, more common in females than males.

• It is believed to be associated with psychogenic factors like a type of somatization disorder presenting with pseudoneurological symptoms.Although another theory is that the globus sensation can have underlying physiological or anatomical causes like:

1. GORD (can cause irritation and inflammation of the laryngopharynx, increased tone in the upper oesophageal sphincter)

2. Oesophageal motor disorders.

3. Pharyngitis, tonsillitis, and post nasal drip secondary to chronic sinusitis

4. Hypertrophy of the base of the tongue.

5. A retroverted epiglottis.

• Psychological factors. Some studies have shown that stress may exacerbate symptoms of globus.However, others have not supported psychological factors as a cause.

• The diagnosis requires a very careful history and examination so not to miss underlying organic causes and may justify investigations if the diagnosis is in doubt or any “red flags” are present, although tests are not needed unless symptoms are related to swallowing, examination is abnormal, or there are red flag findings (weight loss, muscular dysfunction etc).

Task 5: MANAGEMENT:

• Education, reassurance and support for some time• Empirical therapy with a proton pump inhibitor may be

started if there is suspicion of gastro-oesophageal reflux disease and if history taking, neck examination and nasolaryngoscopy have not revealed any red flag symptoms or abnormal findings.

• Referral to a speech and language therapist may be helpful. They can suggest neck, shoulder and voice exercises as well as relaxation techniques that may help to relieve symptoms.

• Cognitive behavioural therapy and antidepressants may be helpful for some people with concomitant psychiatric disorders.