Mind & Body Relationship

A. Firoozabadi, M.D. Shiraz University of Medical Sciences Hafez Hospital, Department of

Somatoform Disorders

• Disorder (Briquet’s) • • • • DSM5: Somatic symptom and related disorders

• Somatic symptom disorder • Illness • Conversion disorder (functional neurological symptom disorder) • Psychological factors affecting other medical conditions • • Other specified somatic symptom and related disorder • Unspecified somatic symptom and related disorder Somatic symptom disorder

• The previous criteria overemphasized the centrality of “ medically unexplained symptoms”. Such symptoms are presented in various degree particularly in conversion disorder, but somatic symptom disorder can also accompany diagnosed medical disorders Somatic symptom disorder

• 75% of individuals previously diagnosed with hypochondriasis are subsumed under the diagnosis of “somatic symptom disorder”. • Pain disorder Vs. somatic symptom disorder with predominant pain • Prevalence: 5-7% Illness Anxiety Disorder • Preoccupation with having or acquiring a serious, undiagnosed medical illness. • Somatic symptoms are not present or, if present, are only mild in intensity. • M=F • 6months-1year prevalence: 3-8% Conversion Disorder

• With: • Weakness or paralysis • Abnormal movement • Swallowing symptoms • Speech symptoms • Attacks or seizure • Anesthesia or sensory loss • Special sensory symptom • Mixed symptoms Other specified somatic symptom and related disorder

• Brief somatic symptom disorder • Brief illness anxiety disorder • Illness anxiety disorder without excessive health-related behavior • Pseudocyrsis Patients with :

• Appear initially to suffer from a neurological • There turns out, however, to be no evidence of a neurological disease • Don’t appear to • A psychological cause for the symptoms is plausibly suspected Hysteria-history

1900bc-Egyptians Discover Certain Health Problems Seem to Occur Mainly in Women…They Blame These Disorders on the Presumed Discontent of the Womb Which They Believe Could Move Around the Body. Treatment: Get the Womb Back to the Proper Position Hysteria-history

• 400BC- the Greeks named this disorder HYSTERIA from their word for womb. • Treatment focuses on attempts to appease this “starved” organ by marriage for single women and increased conjugal activity for the married Hysteria-History

• 1500- In the Middle Ages: symptoms are often attributed to possession and witchcraft • It is still viewed as principally a female problem. Hysteria-History

• 1780-Mesmer: Animal magnetism • 1885-Charcot: Concluded if a person could be hypnotized that was sufficient evidence to diagnosis HYSTERIA باب خناق الرحم )هدایه المتعلمین فی الطب- ابوبکر ربیع بن احمد االخوینی البخاری- قرن پنجم(

زنان را یکی بیماری آید که خفه گردند و دمشان کوتاه شود و از سخن گفتن بمانند و چون بی هوش گردند به آخر؛ و این علتی بود ماننده به صرع و فرق آن بود میان ایشان که این زن را عقل به جای بود و آن زن را نبود و لکن سخن نتواند گفتن و ماننده بود به غش و خداوندان صرع را از دهان کف برآید و این علت را کف نبود و چنان داند که از ناحیت زهدان چون بخاری کنده به سوی دل ایشان بر آیدی و باز خفه گردندی و غش افتدی شان و لکن چون علت صعب نبود چون به هوش بازآیند حکایت تواندد کردن به تمامی و اما چون صعب بود آن حکایت نتواند کردن از آن حال که به ایشان رسیده بود و سبب این علت گریختن رحم بود به سوی تن و بیشتر این علت زنان بی شوی را بود و یا آن زنان که به کودکی بی شوی شوند و بود که دوشیزگان را افتد و پیش از آنکه این بیماری پدید آید کاهل گردند و ساق هایشان به درد آید و آغازند سخنان یاوه گفتن چنانکه دیوانگان گویند و رخهاشان سرخ شود و چون علت نزدیک آید آغازند سخنان بی هشانه گفتن و شتاب کردن و رمیدن و باز خیره گردند و حس از ایشان برود و باز بیفتند چون اصحاب صرع و بود که یک روز و دو روز افتاده بر آن حال بمانند. Hysteria-History

• 1895- Studies in Hysteria was published by Freud & Breuer. • Freud introduce the idea that the disorder can occur in man as well as women. • But the disorder’s traditional association with sexuality remains Anna O.’s symptoms: Temporary visual and auditory deficits

Eating disorders; Persistent temporary loss of nervous cough ability to speak German (but could speak English)

Then the other arm

Temporary paralysis of one arm Temporary dissociations from reality Freud in Studies in Hysteria showed three main things: (see Goodwin, p 371)

1. Memory of traumatic events can become repressed into the unconscious ------but can still influence behavior 2. The form of an hysterical symptom bears a symbolic relationship to the event that caused it

(e.g., Anna O.’s problem with drinking water from a glass) 3. A symptom can be alleviated if the person gains insight into the causal event Physiological Explanation

• Increased levels of physiological arousal • Increased arousal is interpreted as physical symptoms • Sensations interpreted as symptoms • Unusually high heart rate, muscle tension… • Higher levels of arousal during • More likely if there is a personal or familial history of real disorders

Hemispheric Dominance Explanation

• Interesting note • Conversion symptoms are more likely to occur on left side of body • Right side of brain controls left side of body, and right brain controls emotion • High emotional arousal levels disrupts normal function and symptoms appear on left side of body

Somatization Disorder

• Diagnostic Criteria • To be diagnosed a person must have reported at least the following: • Gastrointestinal symptoms (2) • Sexual symptoms (1) • Neurological symptoms (1) • Pain (4 locations) • These symptoms cannot be explained by a physical disorder

Somatization Disorder

• Key point: • It’s a chronic, recurrent, multi-symptom syndrome… here are some… • Vomiting, abdominal pain, nausea, bloating, diarrhea or constipation, pain in arms or legs, back pain, joint pain, pain during urination, headaches, shortness of breath, fainting, fatigue, palpitations, chest pain, dizziness, , difficulty swallowing, vision changes, paralysis or muscle weakness, sexual apathy, pain during intercourse, etc. etc. etc. Somatization Disorder

• Sex difference • F > M • Primarily a female disorder with about 1% suffering from this disorder • Onset • Usually by age 30 but its seen from childhood on up • Familial tendencies • 5 to 10 times more common in female first-degree relatives • Genetic links to antisocial personality and alcoholism

A typical scenario…

• Typically, patients are dramatic and emotional when recounting their symptoms, often referring to them as "unbearable," "beyond description," or "the worst imaginable" • Patients become extremely dependent in their personal relationships • They increasingly demand help and emotional support and may become enraged when they feel their needs are not being met • They are often described as exhibitionistic and seductive and self-centered • In an attempt to manipulate others, they may threaten or attempt suicide

These patients “doctor-shop”… • Often dissatisfied with their medical care, they go from one physician to another… • Treatment is extremely difficult…patients tend to be frustrated and angered by any suggestion that their symptoms are psychological • Drugs are largely ineffective, and even if a patient agrees to a psychiatric consultation, is rarely beneficial • Usually, the best treatment is a calm, firm, supportive relationship with a physician who offers symptomatic relief and protects the patient from unnecessary diagnostic or therapeutic procedures

Hypochondrasis • Unrealistic that a minor symptom reflects a serious disease • Excessive anxiety about one or two symptoms • Examination and reassurance by a physician does not relieve the concerns of the patient

• They believe the doctor has missed the real reason Hypochondrasis

• Symptoms adversely affect social and occupational functioning • Diagnosis is suggested by the history and examination and confirmed if symptoms persist for at least 6 months and cannot be attributed to another psychiatric disorder (such as ) Hypochondrasis • Gender difference • More common in women than men (I couldn’t find any stats though) • Onset • Usually in 30’s • But seen in all age groups Major Differences between Somatization Disorder and Hypochondrasis • Focus of Complaint • Style of Complaint • Interaction with Clinician • Age • Physical Appearance • Personality Style Pain Disorder

• The patient complains of pain without an identifiable physical cause to explain the symptoms the person is complaining about • Basically, the same as somatization disorder except that pain is the only symptom

General Symptoms

• Inability to work or attend school • Misuse of the health care system • Pain becomes major focus in person’s life • Reliance on medications • Relationship problems • Family problems Body Dysmorphic Disorder

• Preoccupation with an imagined or minor defect in one's physical appearance • It is distinguished from normal concerns about appearance because it is time-consuming, causes significant distress, and impairs functioning • Depression, , and OCD may accompany this disorder • Sex difference: Females > Males • Females: breasts, legs • Males: genitals, height, and body hair Symptoms • Major concerns involving especially the face or head but may involve any body part and often shifts from one to another • Examples: hair thinning, acne, wrinkles, scars, eyes, mouth, breasts, buttocks, etc. • They spend hours thinking about their perceived defect • Some are always checking themselves in the mirror • Others avoid mirrors at all costs • Still others alternate between the two More Symptoms…

• Many try to camouflage their imagined defects while others undergo surgical treatments • Skin picking • Elaborate grooming rituals • Repeatedly touching the defect • Often they avoid appearing in public • Some leave their homes just at night and others not at all ()