Somatic Symptom

& Related Disorders

Olivia P. Inoturan, MD
Aug. 5, 2020
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Learning Objectives

▸ At the end of the session, you should be able to demonstrate

some knowledge on the major characteristics of the different
Somatic Symptom & Related Disorders, and their corresponding
medical treatment and management

▸ A quiz will be given after studying the lecture to evaluate what

you have learned during the study session
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Somatic Symptom Disorder

▸ Also known as hypochondriasis, is characterized by 6 or
more months of a general and non-delusional
preoccupation with fears of having, or the idea that one
has, a serious disease based on the person’s
misinterpretation of bodily symptoms
▸ This preoccupation causes significant distress and
impairment in one’s life
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Somatic Symptom Disorder

▸ Epidemiology
▹ 6 month prevalence- 4-6%
▹ Men and women are equally affected
▹ Mostly commonly appears in persons 20 to 30 years of age
▸ Etiology
▹ Persons with this disorder augment and amplify their somatic
sensations
▹ Have low thresholds for, and low tolerance of, physical
discomfort
▹ May focus on bodily sensations, misinterpret them, and become
alarmed by them because of a faulty cognitive scheme
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Somatic Symptom Disorder

▸ Diagnosis
▹ The diagnostic criteria for somatic symptom disorder require
that patients be preoccupied with the false belief that they
have a serious disease, based on their misinterpretation of
physical signs or sensations
▹ Belief must last at least 6 months, despite the absence of
pathological findings on medical and neurological
examinations
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Somatic Symptom Disorder

▸ Diagnosis
▹ The symptoms must be sufficiently intense to cause emotional
distress or impair the patient’s ability to function in important
areas of life
▹ Patients do not consistently recognize that their concerns
about disease are excessive
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Somatic Symptom Disorder

▸ Clinical Features
▹ Patients with somatic symptom disorder believe that they have
a serious disease that has not yet been detected and they
cannot be persuaded to the contrary
▹ May maintain a belief that they have a particular disease or, as
time progresses, they may transfer their belief to another
disease
▹ Their beliefs are not sufficiently fixed to be delusions
▹ Is often accompanied by symptoms of depression and anxiety
and commonly coexists with a depressive or anxiety disorder
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Somatic Symptom Disorder

▸ Clinical Features
▹ See table 13.2-1 DSM-5 Diagnostic Criteria for Somatic
Symptom Disorder
▹ Transient manifestations can occur after major stresses, most
commonly the death or serious illness of someone important
to the patient or a serious (perhaps life-threatening) illness that
has been resolved but that leaves the patient temporarily
affected in its wake
▹ Such states that last fewer that 6 months are diagnosed as
“Other Specified Somatic Symptom and Related Disorders” in
DSM-5
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Somatic Symptom Disorder

▸ Differential Diagnosis
▹ Somatic Symptom Disorder
▹ Conversion Disorder- “la belle indifference”
▹ Body Dysmorphic Disorder
▹ Can also occur in patients with depressive disorders and
anxiety disorders
▹ Panic Disorder
▹ Delusional Disorder
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Somatic Symptom Disorder

▸ Course and Prognosis
▹ Usually episodic
▹ Episodes last from months to years and are separated by equally
long quiescent periods, one third to one half of all patients with
somatic symptom disorder eventually improve significantly
▹ Good prognosis, is associated with high socioeconomic status,
treatment-responsive anxiety or depression, sudden onset of
symptoms, the absence of a personality disorder, and the
absence of a related non psychiatric medical condition
▹ Most children with the disorder recover by late adolescence or
early adulthood
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Somatic Symptom Disorder

▸ Treatment
▹ Group psychotherapy often benefits such patients, in part
because it provides the social support and social interaction
that seem to reduce their anxiety
▹ Individual insight-oriented psychotherapy
▹ Behavior therapy
▹ Cognitive therapy
▹ Pharmacotherapy alleviates somatic symptom disorder only
when a patient has an underlying drug-responsive condition,
such as an anxiety disorder of depressive disorder
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Illness Anxiety Disorder

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Illness Anxiety Disorder

▸ Applies to those persons who are preoccupied with
being sick or with developing a disease of some kind
▸ In describing the differential diagnosis between the two,
according to DSM-5, somatic symptom disorder is
diagnosed when somatic symptoms are present,
whereas in illness anxiety disorder there are few or no
somatic symptoms and persons are “primarily
concerned with the idea of being ill
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Illness Anxiety Disorder

▸ Epidemiology
▹ Prevalence is unknown

▸ Etiology
▹ unknown
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Illness Anxiety Disorder

▸ Diagnosis
▹ Patients may be preoccupied with the false belief that they
have or will develop a serious disease and there are few if
any physical signs or symptoms
▹ Belief must last at least 6 months and there are no
pathological findings on medical or neurological examination
▹ The anxiety about illness must be incapacitating and cause
emotional distress or impair the patient’s ability to function in
important areas of life
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Illness Anxiety Disorder

▸ Diagnosis
▹ Some persons with the disorder may visit physicians (care-
seeking type), while others may not (care-avoidant type)
▹ Majority of patients, however, make repeated visits to
physicians and other health care providers
▹ See table 13.3-1 Diagnostic Criteria for Illness Anxiety
Disorder
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Illness Anxiety Disorder

▸ Clinical Features
▹ Patients believe that they have a serious disease that not
yet been diagnosed, and they cannot be persuaded to the
contrary
▹ They may maintain a belief that they have a particular
disease or, a time progresses, they may transfer their belief
to another disease
▹ Often addicted to internet searches about their feared
illness, inferring the worst from information (or
misinformation) they find there
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Illness Anxiety Disorder

▸ Differential Diagnosis
▹ Somatic symptom disorder
▹ Conversion disorder
▹ Pain disorder
▹ Panic disorder
▹ Obsessive Compulsive Disorder
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Illness Anxiety Disorder

▸ Course and Prognosis
▹ Episodic
▹ Episodes last from months to years and are separated by
equally long quiescent periods
▹ As with hypochondriasis, a good prognosis is associated
with high socioeconomic status, treatment-responsive
anxiety or depression, sudden onset of symptoms, the
absence of a personality disorder, and the absence of a
related non-psychiatric medical condition
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Illness Anxiety Disorder

▸ Treatment
▹ Group psychotherapy may be of help especially if the group
is homogenous with patients suffering from the same
disorder
▹ Individual insight-oriented psychotherapy, behavior therapy
▹ Cognitive therapy
▹ Pharmacotherapy may be of help in alleviating the anxiety
generated by the fear that the patient has about illness,
especially if it is one that is life-threatening; but it is only
ameliorative and cannot provide lasting relief
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
 Functional Neurological Symptom Disorder
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(Conversion Disorder)

▸ Is an illness of symptoms or deficits that affect

voluntary motor or sensory functions, which suggest
another medical condition, but that is judged to be
caused by psychological factors because the illness is
preceded by conflicts or other stressors
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Epidemiology
▹ The ratio of women to men among adult patients is at
least 2 to 1 and as much as 10 to 1
▹ Symptoms are more common on the left than on the right
side of the body in women
▹ Who present with conversion symptoms are more likely
subsequently to develop somatization disorder than
women who have not had conversion symptoms
▹ An association exists between conversion disorder and
antisocial personality disorder in men
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Epidemiology
▹ Men with conversion disorder have often been involved in
occupational or military accidents
▹ Onset is generally from late childhood to early adulthood
and is rare before 10 years of age or after 35 years of age
▹ Conversion symptoms in children younger than 10 years
of age are usually limited to gait problems or seizures
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Epidemiology
▹ Most common among rural populations, persons with
little education, those with low intelligence quotients
those in low socioeconomic groups and military
personnel who have been exposed to combat situations
▹ Commonly associated with comorbid diagnoses of major
depressive disorder, anxiety disorders and schizophrenia
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Comorbidity
▹ Medical and especially, neurological disorders occur
frequently among patients with conversion disorders
▹ Depressive disorders, anxiety disorders, and somatization
disorders are especially noted for their association with
conversion disorder
▹ Personality disorders also frequently accompany
conversion disorder especially the histrionic type and the
passive-dependent type
▹ Conversion disorder can occur in persons with no
predisposing medical, neurological, or psychiatric disorder
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
Etiology
▸ Psychoanalytic Factors
▹ According to psychoanalytic theory, conversion disorder is
caused by repression of unconscious intrapsychic conflict
and conversion of anxiety into a physical symptom
▹ The conflict is between an instinctual impulse and the
inhibitions against its expression
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
Etiology
▸ Psychoanalytic Factors
▹ The symptoms allow partial expression of the forbidden wish
or urge but disguise it so that the patients can avoid
consciously confronting their unacceptable impulses
▹ The conversion disorder symptom has a symbolic relation to
the unconscious conflict (e.g., vaginismus- protects the
patient from expressing unacceptable sexual wishes)
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
Etiology
▸ Psychoanalytic Factors
▹ Also allows patients to communicate that they need special
consideration and special treatment
▹ Symptoms may function as a non-verbal means of controlling or
manipulating others
▸ Learning theory
▹ A conversion symptom can be seen as a piece of classically
conditioned learned behavior; symptoms of illness, learned in
childhood, are called forth as a means of coping with an
otherwise impossible situation
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
Etiology
▸ Biological Factors
▹ Preliminary brain-imaging studies have found
hypometabolism of the dominant hemisphere and
hypermetabolism of the non-dominant hemisphere and have
implicated impaired hemispheric communication in the cause
of conversion disorder
▹ Symptoms may be caused by an excessive cortical arousal
that sets off negative feedback loops between the cerebral
cortex and the brainstem reticular formation
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
Etiology
▸ Biological Factors
▹ Neuropsychological tests sometimes reveal subtle cerebral
impairments in verbal communication, memory, vigilance
affective incongruity, and attention in these patients
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Diagnosis
▹ The DSM-5 limits the diagnosis of conversion disorder to
those symptoms that affect a voluntary motor sensory
function, that is, neurological symptoms
▹ Diagnosis of conversion disorder requires that clinicians
find a necessary and critical association between the
cause of the neurological symptoms and psychological
factors, although the symptoms cannot result from
malingering or factitious disorder
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Diagnosis
▹ The diagnosis of conversion disorder also excludes
symptoms of pain and sexual dysfunction and symptoms
that occur only in somatization disorder
▹ DSM-5 allows specification of the type of symptom or
deficit seen in conversion disorder, for example, with
weakness or paralysis, with abnormal movements, or with
attacks or seizures
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Clinical Features
▹ Paralysis, blindness, and mutism are the most common
conversion disorder symptoms
▹ May be most commonly associated with passive-
aggressive, dependent, antisocial, and histrionic
personality disorders
▹ Depressive and anxiety disorder symptoms often
accompany the symptoms of conversion disorder, and
affected patients are at risk for suicide
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Sensory Symptoms
▹ Anesthesia and paresthesia are common, especially in the
extremities all sensory modalities can be involved, and the
distribution of the disturbance is usually inconsistent with
either central or peripheral neurological disease
▹ Clinicians may see the characteristic stocking-and0glove
anesthesia of the hands or feet or the hemianesthesia of
the body beginning precisely along the midline
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Sensory Symptoms
▹ Conversion symptoms may involve the organs of special
sense and can produce deafness, blindness, and tunnel
vision. These symptoms can be unilateral or bilateral, but
neurological evaluation reveals intact sensory pathways
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Motor Symptoms
▹ Include abnormal movements, gait disturbance, weakness,
and paralysis
▹ Movements generally worsen when attention is called to
them
▹ astasia-abasia a gait disturbance seen in conversion
disorder which is a wildly ataxic, staggering gait
accompanied by gross, irregular, jerky truncal movements
and thrashing and waving arm movements. Patients with
the symptoms rarely fall; if they do they are generally not
injured
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Motor Symptoms
▹ Other common motor disturbances are paralysis and
paresis involving one, two or all four limbs, although the
distribution of the involved muscles does not conform to
the neural pathways
▹ Reflexes remain intact
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Seizure Symptoms
▹ Pseudoseizures are another symptom in conversion
disorder
▹ Tongue-biting, urinary incontinence, and injuries after
failing can occur in pseudoseizures, although these
symptoms are generally not present
▹ Pupillary and gag reflexes are retained after
pseudoseizures, and patients have no postseizure increase
I prolactin concentrations
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Other Associated Features
▹ Primary Gain
▹ Keeping internal conflicts outside their awareness
▹ Symptoms have symbolic value; they represent an
unconscious psychological conflict
▹ Secondary Gain
▹ Patients accrue tangible advantages and benefits as a
result of being sick
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Other Associated Features
▹ La Belle Indifference
▹ Is a patient’s inappropriately cavalier attitude toward
serious symptoms
▹ Is not pathognomonic of conversion disorder, but it is
often associated with the condition
▹ Identification
▹ May unconsciously model their symptoms on those of
someone important to them
▹ During pathological grief reaction, bereaved persons
commonly have symptoms of the deceased
 Functional Neurological Symptom Disorder
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(Conversion Disorder)

▸ Differential Diagnosis
▹ Neurological Disorder
▹ Systemic disease affecting the brain
▹ Somatization Disorder
▹ Malingering and Factitious Disorder
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Course and Prognosis
▹ Onset of conversion disorder is usually acute
▹ Symptoms or deficits are usually of short duration, and
approximately 95% of acute cases remit spontaneously,
usually within 2 weeks in hospitalized patients
▹ If symptoms have been present for 6 months or longer, the
prognosis for symptom resolution is less than 50
% and diminishes further the longer that conversion is present
▹ Recurrence occurs in one fifth to one fourth of people within 1
year of the first episode
▹ One episode is a predictor for future episodes
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Course and Prognosis
▹ Good prognosis: acute onset, presence of clearly identifiable
stressors at the time of onset, a short interval between onset
and the institution of treatment, and above average intelligence
▹ Paralysis, aphonia, and blindness are associated with a good
prognosis
▹ Poor prognostic factors: tremor and seizures
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Treatment
▹ Resolution is usually spontaneous, although it is probably
facilitated by insight-oriented supportive therapy or behavior
therapy
▹ Most important feature of the therapy is a relationship with a
caring and confident therapist
▹ With patients who are resistant to the idea of psychotherapy,
physicians can suggest that the psychotherapy will focus on
issues of stress and coping
 Functional Neurological Symptom Disorder
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(Conversion Disorder)
▸ Treatment
▹ Hypnosis, anxiolytics, and behavioral relation exercises are
effective in some cases
▹ The longer the duration of these patients’ sick role and the
more they have regresses, the more difficult the treatment
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Factitious Disorder
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Factitious Disorder
▸ Patients with factitious disorder, simulate, induce, or aggravate
illness to receive medical attention, regardless of whether or not
they are ill
▸ May inflict painful, deforming, or even life-threatening injury on
themselves, their children, or other dependents
▸ Motivation is simply to receive medical care and to partake in the
medical system
▸ “Munchausen syndrome” to refer to a syndrome in which
patients embellish their personal history, chronically fabricate
symptoms to gain hospital admission, and move from hospital
to hospital
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Factitious Disorder
▸ Epidemiology
▹ Approximately 0.8 to 1.0%
▹ Approximately two thirds of patients with Munchausen
syndrome are male
▹ They tend to be white, middle-aged, unemployed, unmarried,
and without significant social or family attachments
▹ Patients diagnosed with factitious disorders with physical
signs and symptoms are mostly women, who outnumber
men 3 to 1. Usually 2- to 40 years of age with a history of
employment or education in nursing or a health care
occupation
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Factitious Disorder
▸ Epidemiology
▹ Factitious disorder by proxy (called factitious disorder
imposed on another in DSM-5) is most commonly
perpetrated by mothers against infants or young children
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Factitious Disorder
▸ Comorbidity
▹ Many persons diagnosed with factitious disorder have
comorbid psychiatric diagnoses
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Factitious Disorder
▸ Etiology
▹ Psychosocial Factors
▹ Anecdotal case reports indicate that many of the patients
suffered childhood abuse or deprivation, resulting in
frequent hospitalizations during early development. In such
circumstances, an inpatient stay may have been regarded
as an escape from a traumatic home situation, and the
patient may have found a series of caretakers to be loving
in caring
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Factitious Disorder
▸ Etiology
▹ Psychosocial Factors
▹ The usual history reveals that the patient perceives one or
both parents as rejecting figures who are unable to form
close relationships. The facsimile of genuine illness,
therefore, is used to re-crease the desired positive parent-
child bond
▹ The disorders are a form of repetitional compulsion,
repeating the basic conflict of needing and seeking
acceptance and love while expecting that they will not be
forthcoming
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Factitious Disorder
▸ Etiology
▹ Psychosocial Factors
▹ Patients who seek out painful procedures, such as surgical
operations and invasive diagnostic tests, may have a
masochistic personality makeup in which pain serves as
punishment for past sins, imagined or real
▹ Biological Factors
▹ It has been hypothesized that impaired information
processing contributes to the pseudologia fantastica and
aberrant behavior of patients with Munchausen disorder
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Factitious Disorder
▸ Diagnosis and Clinical Features
▹ Factitious disorder is the faking of physical of psychological
signs and symptoms
▹ Table 13.6-1 Clues that should trigger suspicion of the disorder
▹ Psychiatric examination should emphasize securing
information from any available friends, relatives, or other
informants, because interviews with reliable outside sources
often reveal the false nature of the patient’s illness
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Factitious Disorder
▸ Factitious Disorder with Predominantly Psychological Signs and
Symptoms
▹ Feigned symptoms frequently include depression,
hallucinations, dissociative and conversion symptoms, and
bizarre behavior
▹ Presence of simulated psychosis as a feature of other
disorders, such as mood disorders, indicates a poor overall
prognosis
▹ Patients may appear depressed and explain their depression by
offering a false history of the recent death of a significant
friend or relative
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Factitious Disorder
▸ Factitious Disorder with Predominantly Psychological Signs and
Symptoms
▹ Some patients may use psychoactive substances for the
purpose of producing symptoms, such as stimulants to
produce restlessness or insomnia
▸ Chronic Factitious Disorder with Predominantly Physical Signs and
Symptoms
▹ Is the best-known type of Munchausen syndrome
▹ Also been called hospital addiction, polysurgical addiction-
producing the so-called washboard abdomen and professional
patient syndrome
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Factitious Disorder
▸ Chronic Factitious Disorder with Predominantly Physical Signs and
Symptoms
▹ Essential feature of these patients is the ability to present
physical symptoms so well that they can gain admission to, and
stay in, a hospital
▹ Patients may feign symptoms suggesting a disorder involving
any organ system
▹ Such patients often insist on surgery and claim adhesions from
previous surgical procedures
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Factitious Disorder
▸ Chronic Factitious Disorder with Predominantly Physical Signs and
Symptoms
▹ Complaints of pain, especially that simulating renal colic, are
common with the patients wanting narcotics
▹ Specific predisposing factors are true physical disorders during
childhood leading to extensive medical treatment, a grudge
against the medical profession, employment as a medical
paraprofessional, and an important relationship with a
physician in the past
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Factitious Disorder
▸ Factitious Disorder by Proxy
▹ One apparent purpose of the behavior is for the caretaker to
indirectly assume the sick role; another is to be relieved of the
caretaking role by having the child hospitalized
▹ The most common case of factitious disorder by proxy involves
a mother who deceives medical personnel into believing that
her child is ill. The deception may involve a false medical
history, contamination of laboratory samples, alteration of
records, or induction of injury and illness in the child
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Factitious Disorder
▸ Pathology and Laboratory Examination
▹ Psychological testing may reveal underlying pathology in
individual patients
▹ Features that are overrepresented in patients with factitious
disorder include normal or above-average intelligence quotient,
absence of a formal thought disorder poor sense of identity
including confusion over sexual identity, poor sexual
adjustment, poor frustration tolerance, strong dependence
needs, and narcissism
▹ No laboratory or pathology tests are diagnostic of factitious
disorders, although they may help to confirm the diagnosis by
demonstrating deception
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Factitious Disorder
▸ Differential Diagnosis
▹ Conversion Disorder
▹ Personality Disorders: antisocial, histrionic, borderline
▹ Schizophrenia
▹ Malingering
▹ Substance Abuse
▹ Ganser’s Syndrome- a controversial condition most typically
associated with prison inmates, is characterized by the use of
approximate answers. Persons with the syndrome respond to
simple questions with astonishingly incorrect answers
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Factitious Disorder
▸ Course and Prognosis
▹ Typically begins in early adulthood
▹ Onset of the disorder or of discrete episodes of seeking
treatment may follow real illness, loss, rejection, or
abandonment
▹ Factitious disorders are incapacitating to the patient and often
produce severe trauma or untoward reactions related to
treatment
▹ A course of repeated or long-term hospitalization is
incompatible with meaningful vocational work and sustained
interpersonal relationships
▹ The prognosis in most cases is poor
64

Factitious Disorder
▸ Treatment
▹ No specific psychiatric therapy has been effective in treating
factitious disorders
▹ Treatment, is best focused on management rather than on cure
▹ In general , working in concert with the patient’s primary care
physician is more effective than working with the patient in
isolation
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Pain Disorder
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Pain Disorder
▸ A pain disorder is characterized by the presence of, and
focus on, pain in one or more body sites and is sufficiently
severe to come to clinical attention
▸ The physician does not have to judge the pain to be
“inappropriate” or “in excess of what would be expected”
▸ Rather, the phenomenological and diagnostic focus is on the
importance of psychological factors and the degree of
impairment caused by the pain
▸ Pain disorder is diagnosed as “Unspecified Somatic
Symptom Disorder”
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Pain Disorder
▸ Epidemiology
▹ 6-month and lifetime prevalence is approximately 5 and
12 percent, respectively
▹ Can begin at any age
▹ Gender ration is unknown
▹ Often associated with affective and anxiety disorders
▹ Chronic pain appears to be most frequently associated
with depressive disorders, and acute pain appears to be
more commonly associated with anxiety disorders
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Pain Disorder
▸ Epidemiology
▹ Depressive disorders, alcohol dependence, and chronic
pain may be more common in relatives of individuals with
chronic pain disorder
▹ Individuals whose pain is associated with severe
depression and those whose pain is related to a terminal
illness such as cancer, are at increased risk for suicide
69

Pain Disorder
▸ Etiology
▹ Psychodynamic Factors
▹ Patients who experience bodily aches and pains without
identifiable and adequate physical causes may be
symbolically expressing an intrapsychic conflict through
the body
▹ Alexithymia- inability to articulate their internal feeling
states in words, express their feelings with their bodies
▹ Symbolic meaning of body disturbances may also relate to
atonement for perceived sin, to expiation of guilt, or to
suppressed, aggression
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Pain Disorder
▸ Etiology
▹ Psychodynamic Factors
▹ Many patients have intractable and unresponsive pain
because they are convinced they deserve to suffer
▹ Pain can function as a method of obtaining love, a
punishment for wrong doing, and a way of expiating guilt
and atoning for an innate sense of badness
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Pain Disorder
▹ Behavioral Factors
▹ Pain behaviors are reinforced when rewarded and are
inhibited when ignored or punished

▹ Interpersonal Factors
▹ Intractable pain has been conceptualized as a means for
manipulation and gaining advantage in interpersonal
relationships
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Pain Disorder
▹ Biological Factors
▹ Serotonin is probably the main neurotransmitter in the
descending inhibitory pathways, and endorphins also
play a role in the central nervous system modulation of
pain
▹ Endorphin deficiency seems to correlate with
augmentation of incoming sensory stimuli
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Pain Disorder
▸ Diagnosis and Clinical Features
▹ To meet a diagnosis of pain disorder, the disorder must have a
psychological factor judged to be significantly involved in the
pain symptoms and their ramifications
▹ Patients with disorder often have long histories of medical and
surgical care
▹ Their clinical picture can be complicated by substance-related
disorders, because these patients attempt to reduce the pain
through the use of alcohol and other substances
74

Pain Disorder
▸ Diagnosis and Clinical Features
▹ Major Depressive Disorder is present in about 25 to 50 percent
of patients with pain disorder, and dysthymic disorder or
depressive disorder symptoms are reported in 60 to 100
percent of the patients
▹ The most prominent depressive symptoms in patients with
pain disorder are anergia, anhedonia, decreased libido,
insomnia, and irritability; diurnal variation, weight loss, and
psychomotor retardation appear o be less common
75

Pain Disorder
▸ Differential Diagnosis
▹ Psychogenic pain- physical pain fluctuates in intensity and is
highly sensitive to emotional , cognitive, attentional, and
situational influences. Pin that does not vary and is insensitive
to any of these factors is likely to be psychogenic
▹ Hypochondriasis
▹ Conversion Disorder
▹ Malingering
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Pain Disorder
▸ Course and Prognosis
▹ The pain in pain disorder generally begins abruptly and
increases in severity for a few weeks or months
▹ Acute pain disorders have a more favorable prognosis than
chronic pain disorders
▹ People with a pain disorder who resume participation in
regularly scheduled activities, despite the pain, have a more
favorable prognosis than people who allow the pain to become
the determining factor in their lifestyle
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Pain Disorder
▸ Treatment
▹ Pharmacotherapy- antidepressants
▹ Psychotherapy- psychodynamic, cognitive
▹ Other Therapies- biofeedback, hypnosis, transcutaneous nerve
stimulation, and dorsal column stimulation; nerve blocks and
surgical ablative procedures
“