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Key Features

Essentials of Diagnosis

  • Prominent physical symptoms may involve one or more organ systems and are associated with distress and/or impairment

  • Sometimes able to correlate symptom development with psychosocial stresses

  • Combination of biogenetic and developmental patterns

General Considerations

  • This diagnostic grouping includes conversion disorder, hypochondriasis, and somatic symptom disorder

  • Vulnerability in an organ system and exposure to family members with somatization problems are thought to interact in the development of symptoms

Demographics

  • Conversion disorder is more common in lower socioeconomic classes and certain cultures

  • Somatic symptom disorder usually occurs before age 30 and is ten times more common in women

Clinical Findings

Symptoms and Signs

  • A precipitating emotional event often precedes somatic symptoms

  • Conversion disorder

    • Psychic conflict is converted into physical neurologic symptoms

    • The somatic symptom is often paralysis

    • The dysfunction may have symbolic meaning (eg, arm paralysis in marked anger so the individual cannot use the arm to strike someone)

  • Somatic symptom disorder

    • Multiple physical complaints are referable to several organ systems

    • Anxiety, panic disorder, and depression are often present

    • Preoccupation with medical and surgical issues often precludes other life activities

    • Patients have often undergone multiple surgeries and have evidence of long-standing symptoms

    • Multiple symptoms that frequently change and have eluded diagnosis by three or more physicians support this diagnosis

Differential Diagnosis

  • Depression must be considered in any patient with a condition judged to be somatoform

  • Factitious disorders, which differ from this grouping in that symptom production is intentional

  • Intoxication states

Diagnosis

Diagnostic Procedures

  • In conversion disorder with pseudoseizures, video-electroencephalography may be necessary to rule out epilepsy

  • Since all somatic disorders are diagnoses of exclusion, a workup sufficient to rule out physical illness is required

Treatment

Medications

  • Medications should not be prescribed in place of frequent appointments

Therapeutic Procedures

  • Behavioral therapy

    • Biofeedback can be helpful in training patients to recognize symptoms and learn countermaneuvers that provide relief

  • Psychotherapy

    • Psychological intervention by the primary clinician should focus on pragmatic changes

    • Analytic approaches focused on exploration of early experiences often fail, since patients do not relate these to their current distress

    • Group therapy sometimes allows ventilation, improves coping, and focuses on interpersonal adjustment

    • Conversion disorder is sometimes helped by hypnosis or amobarbital interviews

  • Social therapeutic procedures

    • Family members should attend appointments to learn how best to live with the patient

    • Peer support groups can encourage patients to accept and live with their problem

    • Communication with employers may be necessary to encourage long-term interest in the employee/patient

Outcome

Follow-Up

  • Regular appointments are helpful. These should be brief ...

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