A 46-year-old man is seen by an occupation health doctor due to long-term sickness leave. He states chronic lower back pain prevents him from working but examination findings are inconsistent and the doctor suspects a non-organic cause of his symptoms. This is an example of a:
Somatoform and Dissociative disorders
Somatoform disorders
The somatoform disorders are a group of disorders characterised by physical symptoms that are presumed to have a psychiatric origin.
They are classified slightly differently by the ICD-10 and DSM-IV, see below
| Categories of somatoform disorders in the ICD-10 |
|---|
| Somatisation disorder |
| Undifferentiated somatoform disorder |
| Hypochondriacal disorder |
| Somatoform autonomic dysfunction |
| Persistent somatoform pain disorder |
| Other somatoform disorder |
| Somatoform disorder unspecified |
| Categories of somatoform disorders in the DSM-IV |
|---|
| Somatisation disorder |
| Conversion disorder |
| Hypochondriasis |
| Body dysmorphic disorder |
| Pain disorder |
| Undifferentiated somatoform disorder |
| Somatoform disorder not otherwise specified |
Questions on these are common. Usually they test a candidate's ability to differentiate between the different types of somatoform disorder.
Somatisation disorder (Briquet's syndrome) is characterised by multiple physical complaints affecting many organ systems that cannot be explained by physical disorders. It is more common in women, and normally begins before the age of 30. It is inversely related to social class, and is therefore more common in those with low education and limited incomes.
Conversion disorder (referred to as dissociative disorders in the ICD-10) is characterised by a neurological complaint that is related to stress or conflict. It is more common in women and is uncommon in the elderly. It usually presents with weakness, paralysis, pseudoseizures, involuntary movements and sensory disturbances (e.g. Blindness). It is classically associated with the term La belle indifference which refers to the absence of distress despite the presence of a distressing symptom.
Hypochondriasis is characterized by a patient's insistence that they suffer with a particular disease, despite evidence to the contrary.
Body dysmorphic disorder is characterized by the false belief or exaggerated perception that a part of the body is in some way defective. The most common area perceived to be affected is the skin, followed by the hair, nose, toes, and then weight.
Somatoform autonomic dysfunction includes:-
- Da Costa's syndrome
- Cardiac neurosis
- Neurocirculatory asthenia
- Dyspepsia
- Pylorospasm
- Irritable bowel syndrome
- Psychogenic flatulence
- Psychogenic cough
- Hyperventilation
- Psychogenic frequency
- Dysuria
Do not confuse the above with factitious disorder. In factitious disorder a patient will intentionally (deliberately) feign symptoms. Munchausen syndrome is another name for factitious disorder.
Dissociative disorders
Dissociative disorders are characterised by the loss of integration between memories, identity, immediate sensations, and control of bodily movements.
Previously referred to as 'hysteria' (a term best avoided now), dissociative disorders usually occur suddenly in response to a trauma or other intolerable situation. They tend to remit spontaneously after a few weeks to months.
A diagnosis requires (ICD-10):
- Loss of integration (partial or complete) between memories, identity, sensations and control of bodily movements
- No evidence of a physical cause to explain the symptoms
- Evidence for psychological causation (if none then the diagnosis should remain provisional)
Subtypes include:
- Dissociative amnesia
- Dissociative fugue
- Dissociative stupor
- Trance and possession disorders
- Dissociative disorders of movement and sensation
- Dissociative motor disorders
- Dissociative convulsions (pseudoseizures)
- Dissociative anaesthesia and sensory loss
- Mixed dissociative disorders
- Other dissociative disorders (includes Gansers syndrome and multiple personality disorder)
