Table of contents:
- Historical and conceptual approach
- Somatoform pain
- Classification of somatoform disorders
- Somatoform disorders: Somatization disorder
- Undifferentiated somatoform disorder
The disorders that we today call somatoform stem from the concept of hysterical neurosis. Term used by Greeks and Romans to describe an alteration typical of women (of the uterus), its incorporation into psychopathology is due to the work carried out in the French school by Charcot (first to recognize and describe hysterical symptoms) and Janet, but on all to the influence of Freud's psychoanalytic school.
According to Freud, the mechanism of the conversion of psychological traumas (of a sexual nature that occurred in childhood) constituted the central nucleus of hysteria and became the starting point of all later theoretical formulations regarding the formation of neurotic symptoms.
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- Classification of somatoform disorders
- Somatoform disorders: Somatization disorder
- Undifferentiated somatoform disorder
Historical and conceptual approach
Chodoff outlined five different meanings of the term hysteria:
- Conversion disorder
- Briquet syndrome
- A personality disorder
- A psychodynamic pattern manifesting itself as a personality trait.
- A colloquial word used to describe undesirable behavior.
In the DSM-II, the hysterical neurosis group was categorized into two types of disorders, the conversion disorder and the dissociative type, and hypochondria was considered a category of neurosis independent of hysterical neurosis. In DSM-III, the term hysteria is abandoned and replaced by two discrete diagnostic categories of so-called somatoform and dissociative disorders.
The first one focuses more on somatic issues, dissociative disorders are more related to cognitive phenomena, involving changes in consciousness, memory and personality, which suggest neurological problems. Characteristics of somatoform disorders: presence of physical symptoms, such as headache, blindness, paralysis, etc. in which it is not possible to identify an apparent organic pathology or dysfunction, although its link with psychological factors is evident.
Main characteristics referring to some of the most relevant somatoform disorders described according to DSM-III-R. Somatization Complaints about multiple physical symptoms (fainting, nausea, weakness, urinary problems, etc.) which are not based on any organic cause. Hypochondria Preoccupation, fear or belief of suffering a serious illness that arises after interpreting the corporal signs (lumps, pain, etc.) incorrectly. Conversion Loss or alteration in physiological functioning (paralysis, deafness, blindness) suggesting a physical disorder, for which there is no underlying organic pathology.
Somatoform pain
Severe and prolonged pain that is either inconsistent with the anatomical distribution of the nervous system, or cannot be explained from an organic pathology. Dysmorphobia Excessive preoccupation with some imaginary defect in physical appearance. These five types of disorders could be grouped into two more general categories:
- Conversion disorder, somatization disorder, and somatoform pain disorder all involve a real loss or alteration of physical functioning, which is very difficult to distinguish from problems that have an organic basis. Therefore, they can be included in the name somatoform hysterical disorders.
- Hypochondria and dysmorphophobia are characterized by their concern for possible bodily problems, such as alteration or loss of physical functioning is minimal. Somatoform disorders must be differentiated from psychosomatic ones (ulcers, headaches, cardiac disorders), although the psychological trigger and the physical symptoms appear as common phenomena in both types of disorders, the difference between them is that, while in in psychosomatic disorders there is damage to the corresponding physiological system (eg stomach ulcer), in somatoform disorders there is no demonstrable organic pathology.
Somatoform disorders have been investigated considerably less than other psychopathological problems and studies indicate very different prevalence rates, ranging between 0.2 and 2% in women, there are no reliable data related to the prevalence of somatoform pain, dysmorphic disorder and conversion disorder, although it does seem true that these disorders are more frequent in women than in men. Holmes (1991) refers to three important reasons to explain this phenomenon:
- The historical background of the disorder itself has biased clinicians in favor of diagnosing it more frequently in women.
- Men may seek less specialist help with these types of disorders than women.
- It is also possible that there is some genetic or physiological factor underlying the conversion disorder that will predispose the woman to suffer from this disorder.
Hypochondriasis or hypochondria: it has been more related to men, although it is currently assumed that there are no sex differences. Many cases of hypochondriasis overlap with cases of anxiety (patients with panic disorder meet the criteria for a secondary diagnosis of hypochondriasis).
Kellner-states that between 20 and 84 percent of patients who are cared for by doctors and surgeons have hypochondriacal symptoms or phobias of the disease as a central problem
Somatization: constitutes an essential diagnostic characteristic of somatoform disorders and is an unresolved problem in medicine, taking into account the implications of said clinical condition: personal consequences at the psychological level (emotional suffering), physical (excess medication) and social (deterioration of interpersonal relationships) and also impact on costs (financial, time and personnel) and the operation of health care programs
The term somatization was introduced by Stekel to refer to a hypothetical process by which a deep-seated neurosis could cause a bodily disorder. Lipowski criticizes traditional definitions, such as Stekel's, since they include in their concept hypothetical processes that denote the existence of unconscious defense mechanisms, which would be referring to etiological hypotheses. This author conceives somatization as a tendency to experience and express psychological distress in the form of somatic symptoms that the subject mistakenly interprets as a sign of a severe physical illness, for which he requests medical assistance for them. The concept comprises three basic elements:
- Experiential: it refers to what the subjects perceive about their own body (painful, annoying or unusual sensations and dysfunctions or variations in physical appearance.
- Cognitive: the subjective meaning that such perceptions have for them and the decision-making process in relation to the assessment of the symptoms.
- Behavioral: the actions and communications (both verbal and non-verbal) that people undertake and that are derived from the attributions of their perceptions. Lipowski, considers that somatization does not suppose a specific diagnostic category nor does it imply that somatizing people necessarily suffer from a psychiatric disorder.
It proposes that it is possible to distinguish several dimensions of somatization: Duration (somatization can be transient or persistent). The degree of hypochondria (somatizing patients vary in their concern for their health and symptoms and in the fear or conviction that they are physically ill).
Manifest emotionality (since they can range from indifference to perceived somatic discomfort to panic or agitated depression focused on the presentiment of being on the verge of death or any negative and disabling event). Ability to describe feelings and develop fantasies (occurs with all somatizing patients as they are a heterogeneous group).
The author estimates that the essential characteristic of these patients is that when faced with stress and emotional arousal they exhibit a mainly somatic rather than a cognitive response pattern.
According to Lipowski, somatization is not identified with any diagnostic label, although it can be linked to multiple psychiatric disorders and according to Escobar it can be:
- A nuclear problem as it is in somatoform disorders A problem associated with a non-somatoform psychiatric disorder, such as major depression
- A "masked disorder", as occurs in so-called masked depression.
A personality trait. At present the concept of somatization is not clear enough, although it seems that a common idea comes to consider somatization as a bodily distress, not medically explained, that is related to psychiatric, psychological or social problems.
Kirmayer and Robbins, from an integrative point of view, have differentiated three forms of somatization: As a functional somatic symptom As a hypochondriacal concern As a somatic element present in some psychopathological disorders of anxiety and major depression Kellner, following some criteria of the DSM-III-R, conceptualizes the somatization from one or more somatic complaints (fatigue, gastrointestinal symptoms): That the appropriate evaluation does not uncover a pathology or pathophysiological mechanisms (a physical disorder or the effect of an injury) that account for the physical complaints.
That even when there is a related organic pathology, the physical complaints or the resulting occupational and / or social alteration notably exceed what would be expected from the physical findings. Somatization can be understood as a pattern of disease behavior since symptoms are perceived, evaluated and represented differently by each person. It is a tendency to adopt the role of sick person, which may be due to lower thresholds for the recognition of damage, so they seek medical help for relatively innocuous conditions.
The concept of disease behavior was first applied to the context of somatoform disorders by Pilowski (1969), who considered such disorders as a special variant of abnormal disease behavior.
Classification of somatoform disorders
In DSM-I all those of psychogenic origin were grouped under the general category of Psychoneurotic disorders, in DSM-II the name of the category was replaced by Neurosis to describe those disorders in which anxiety was a striking characteristic and It included the following neuroses: anxiety, hysterical (conversion and dissociative), phobic, obsessive-compulsive, depressive, neurasthenic, depersonalization, and hypochondriac.
Anxiety, phobic, and obsessive-compulsive neuroses were classified in DSM-III as subtypes of anxiety disorders; depressive neurosis in affective disorders; hysterical (conversion type) and hypochondriac as somatoform disorders; hysterical neurosis (dissociative type) and depersonalization as subcategories of dissociative disorders; and the neurasthenic neurosis was eliminated.
The DSM-III attributed as an essential feature to somatoform disorders the presence of physical symptoms that suggest a physical alteration (hence the word somatoform), in which there are no demonstrable organic findings or known physiological mechanisms and in which there is positive or positive evidence. firm assumptions that symptoms are linked to psychological factors or conflicts. Five subgroups are found in this category: T. somatization, T. conversion, psychogenic pain, hypochondria, and atypical T. somatoform. In DSM-III-R, some modifications were made:
- Regarding somatization disorder, the list of physical symptoms was revised in order to equal the number required for men and women and seven symptoms were emphasized when estimating that the presence of two or more of them indicated a high probability of suffering from the disorder. For those conditions that did not meet the criteria for somatization, a new category undifferentiated somatoform disorder was created.
- In the T. conversion, the specification of the presence of a single or recurrent episode and the consideration that the symptom could not be explained by cultural factors was introduced.
- The criteria for exclusion of somatization disorder and schizophrenia were removed. The term psychogenic pain was replaced by somatoform pain and the criterion relating to psychological factors involved in the etiology of pain was deleted.
- In relation to hypochondria, a time criterion was incorporated that required a minimum duration of six months. Dysmorphophobia, which was an example of atypical somatoform disorder, became a separate category under the name of T. Dysmorphic.
- The atypical T. somatoforme was replaced by unspecified T. somatoforme.
CATEGORIZATION ACCORDING TO DSM-IV The DSM-IV
He estimates that the common characteristic of the group of somatoform disorders is the presence of physical symptoms that suggest a general medical condition, but are not explained by a general medical condition, by the direct effects of a substance, or by another mental disorder. The DSM-IV maintains the same categories as in the DSM-III-R, but elements of simplification and clarification of the diagnostic criteria are introduced.
Somatization disorder Presence of a pattern of multiple and recurrent somatic symptoms, which occurs over a period of several years, and which begins before the age of 30. They lead to seeking medical attention and cause significant disability.
Changes compared to DSM-III-R: The list of 35 items has been grouped into 4 categories of physical symptoms: pain symptoms. gastrointestinal symptoms. sexual symptom. pseudoneurological symptom.
Somatoform disorders: Somatization disorder
History of multiple physical symptoms, which begins before the age of 30, persists for several years and forces the search for medical attention or causes a significant deterioration in social, work, or other important areas of the individual's activity.
All of the criteria below must be met, and each symptom can appear at any time during the disturbance:
- four painful symptoms: history of pain related to at least four body areas or four functions (eg, head, abdomen, back, joints, extremities, chest, rectum; during menstruation, intercourse, or urination)
- two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (eg, nausea, bloating, vomiting, diarrhea, or intolerance to different foods)
- a sexual symptom: a history of at least one sexual or reproductive symptom other than pain (eg, sexual indifference, erectile or ejaculatory dysfunction, irregular periods, excessive menstrual loss, vomiting during pregnancy)
- a pseudoneurological symptom: history of at least one symptom or deficit suggesting a neurological disorder not limited to pain (conversion symptoms such as impaired psychomotor coordination or balance, localized muscle paralysis or weakness, difficulty swallowing, feeling of lump in throat, aphonia, urinary retention, hallucinations, loss of tactile and painful sensitivity, diplopia, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)
Either of the following two characteristics: Upon proper examination, none of the symptoms in Criterion B can be explained by the presence of a known general medical condition or by the direct effects of a substance (eg drugs, drugs) if there is a medical illness, physical symptoms, or social or occupational impairment are excessive compared to what might be expected from the medical history, physical examination, or laboratory findings D. Symptoms are not intentionally produced and are not simulated (unlike what happens in factitious disorder and simulation).
The requirement of at least 13 somatic symptoms required by the DSM-III-R, is reduced to 8 in the DSM-IV. Eliminate the note relating to 7 symptoms whose presence was indicative of a high probability that the disorder existed, and the indication that the symptoms did not occur exclusively during panic attacks. It adds that the production of symptoms is not under the voluntary control of the subject.
Undifferentiated Somatoform Disorder For DSM-III-R this was a category for clinical conditions that did not meet the full criteria for somatization disorder. The DSM-IV continues to consider it as a residual category, but adds 2 new diagnostic criteria: One, referring to the negative consequences caused by the symptoms (C), and the other, to the deliberate production of these (F).
Undifferentiated somatoform disorder
One or more physical symptoms (eg, fatigue, loss of appetite, gastrointestinal or urinary symptoms).
Either of the following two characteristics: upon proper examination, symptoms cannot be explained by the presence of a known medical condition or by the direct effects of a substance (eg drug of abuse / medication) if there is a general medical condition, physical symptoms or social or occupational impairment are excessive compared to what might be expected from the medical history, physical examination, or laboratory findings
Symptoms cause significant clinical distress or impairment in social, occupational, or other important areas of the individual's activity.
The duration of the disorder is at least 6 months.
The disturbance is not better explained by the presence of another mental disorder (eg, another somatoform disorder, sexual dysfunctions, mood disorders, anxiety disorders, sleep disorders, or psychotic disorder).
Symptoms are neither intentionally produced nor simulated (unlike in factitious disorder or simulation).
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