Somatoform Disorders

HYACINTH C. MANOOD, M.D., F.P.P.A (Feb.2012)

Group of illnesses that have bodily signs and

symptoms as a major component;
Symptoms are not imaginary;
Somatization disorder
Conversion disorder
Hypochondriasis
Body Dysmorphic disorder
Pain disorder
Undifferentiated Somatoform disorder
Somatoform disorder not otherwise specified

Somatization Disorder

Characterized by multiple somatic complaints in

multiple organ systems that cannot be explained
adequately on the basis of physical and laboratory
examinations.
Chronic; excessive medical-help-seeking behaviors;
Briquets syndrome
Lifetime prevalence in the general population :
o 0.2 % to 2% in women
o 0.2 percent in men
Women outnumber men 5 to 20 times ;
Associated With little education and low income
Begins before the age of 30
4 pain symptoms
2 gastrointestinal symptoms
1 sexual symptom
1 pseudoneurological symptom
Cause is unknown
ETIOLOGY
A. PSYCHOSOCIAL
Interpretation of symptoms:
a. to avoid obligation
b. to express emotions
c. to symbolize a feeling or belief
o symptoms substitute for repressed instinctual
impulses.
B. BIOLOGICAL FACTORS
- Genetic loading
o 10 20% of first degree female relatives
o 29% concordance rate in monozygotic twins; 10% in
dizygotic twins

Hotchocolate M.D.
CLINICAL FEATURES:
o Many somatic complaints
o Long, complicated medical histories: circumstantial,
vague, inconsistent; disorganized
o Patients frequently believe that they have been
sickly most of their lives.
o Psychological distress and interpersonal problems
are prominent;
o anxiety and depression are the most prevalent
psychiatric conditions
o Suicide threats are common
o Patients may be perceived as dependent, selfcentered, hungry for admiration or praise, and
manipulative
o major depressive disorder, personality disorders,
substance-related disorders, generalized anxiety
disorder, and phobias
o Nausea/vomiting, difficulty swallowing, pain in the
arms and legs, shortness of breath unrelated to
exertion, amnesia, complications of pregnancy and
menstruation
o chronic, undulating, and relapsing disorder that
rarely remits completely;
o There should be a single identified physician as
primary caretaker;
o Individual and Group Psychotherapy
o Listen to somatic complaints as emotional
expressions rather than medical complaints

Conversion Disorder

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.
The disturbance does not conform to current
concepts of anatomy and physiology of the CNS and
PNS.
not intentionally produced, are not caused by
substance use, are not limited to pain or sexual
symptoms, and the gain is primarily psychological and
not social, monetary, or legal;
women to men : 2-10 to 1
Symptoms are more common on the left than on the
right side of the body in women
Prevalence is variable:
o 1/3 of general pop mild symptoms
o 11 500/100.000 pop.
o 2:1 female male ratio
o In children, higher predominance in girls
Page 1 of 8

Affected males often involved in occupational or

military accidents;
Onset at any time; most common in adolescents and
young adults
Comorbidity
o Medical and, especially, neurological disorders
o Depressive disorders, anxiety disorders, and
somatization disorders
o Personality disorders: histrionic type & passivedependent type
ETIOLOGY
According to psychoanalytic theory, conversion
disorder is caused by repression of unconscious
intrapsychic conflict and conversion of anxiety into
a physical symptom.
o conflict is between an instinctual impulse (e.g.,
aggression or sexuality) and the prohibitions
against its expression
In terms of conditioned 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.
hypometabolism of the dominant hemisphere and
hypermetabolism of the nondominant hemisphere
excessive cortical arousal that sets off negative
feedback loops between the cerebral cortex and the
brainstem reticular formation
Paralysis, blindness, and mutism are the most
common conversion disorder symptoms
Anesthesia and paresthesia are common, especially
of the extremities.
Pseudoseizures
Patients achieve primary gain by keeping internal
conflicts outside their awareness.
tangible advantages and benefits as a result of
being sick
La belle indifference is a patient's inappropriately
cavalier attitude toward serious symptoms
The onset of conversion disorder is usually acute,
but a crescendo of symptomatology may also occur;
approximately 95 percent of acute cases remit
spontaneously, usually within 2 weeks in
hospitalized patients
Recurrence occurs in one fifth to one fourth of
people within 1 year of the first episode
A good prognosis is heralded by acute onset,
presence of clearly identifiable stressors at the time

Hotchocolate M.D.
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, whereas tremor and seizures
are poor prognostic factors.
Resolution of the conversion disorder symptom is
usually spontaneous;
Insight-oriented supportive or behavior therapy

Hypochondriasis

characterized by a general and nondelusional

preoccupation with fears of having, or the idea that
one has, a serious disease based on the person's
misinterpretation of bodily symptoms
6-month prevalence of 4 to 6% up to 15% in a general
medical clinic population
Men and women are equally affected
most commonly appears in persons 20 to 30 years of
age
low thresholds for, and low tolerance of, physical
discomfort.
viewed as a request for admission to the sick role
made by a person facing seemingly insurmountable
and insolvable problems.
a variant form of other mental disorders, among
which depressive disorders and anxiety disorders
Psychodynamic School of Thought:
aggressive and hostile wishes toward others are
transferred (through repression and displacement) into
physical complaints.
also viewed as a defense against guilt, a sense of
innate badness, an expression of low self-esteem, and a
sign of excessive self-concern.
CLINICAL FEATURES
o Patients believe that they have a serious disease that
has not yet been detected, and they cannot be
persuaded to the contrary.
o often accompanied by symptoms of depression and
anxiety and commonly coexists with a depressive or
anxiety disorder.
o course is usually episodic;
o 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;
o usually resist psychiatric treatment
o Group psychotherapy often benefits such patients,
Page 2 of 8

Body Dysmorphic Disorder

characterized by a preoccupation with an imagined

defect in appearance that causes clinically significant
distress or impairment in important areas of
functioning. ; concern is excessive and bothersome.
a poorly studied condition
most common age of onset is between 15 and 30
years
women are affected somewhat more often than men
commonly coexists with other mental disorders
may involve serotonin
reflecting the displacement of a sexual or emotional
conflict onto a nonrelated body part
defense mechanisms of repression, dissociation,
distortion, symbolization, and projection.
facial flaws, particularly those involving specific parts
(e.g., the nose).
ideas or frank delusions of reference (usually about
persons' noticing the alleged body flaw
either excessive mirror checking or avoidance of
reflective surfaces
attempts to hide the presumed deformity (with
makeup or clothing).
usually begins during adolescence
usually has a long and undulating course with few
symptom-free intervals
clomipramine (Anafranil) and fluoxetine (Prozac)
reduce symptoms in at least 50 percent of patients
Augmentation with clomipramine (Anafranil),
buspirone
(BuSpar),
lithium
(Eskalith),
methylphenidate (Ritalin), or antipsychotics may
improve the response rate.

Pain Disorder

characterized by the presence of, and focus on, pain

in one or more body sites and is sufficiently severe to
come to clinical attention.
somatoform pain disorder, psychogenic pain disorder,
idiopathic pain disorder, and atypical pain disorder
Lifetime prevalence is approximately 12%
Associated
with other psychiatric disorders,
especially 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.
may be symbolically expressing an intrapsychic
conflict through the body.

Hotchocolate M.D.
symbolic meaning of body disturbances may also
relate to atonement for perceived sin, to expiation of
guilt, or to suppressed aggression.
displacement, substitution, and repression.
Pain behaviors are reinforced when rewarded and are
inhibited when ignored or punished.
Intractable pain has been conceptualized as a means
for manipulation and gaining advantage in
interpersonal relationships, for example, to ensure
the devotion of a family member or to stabilize a
fragile marriage.
often have long histories of medical and surgical care.
completely preoccupied with their pain and cite it as
the source of all their misery
Major depressive disorder is present in about 25 to 50
percent of patients with pain disorder
generally begins abruptly and increases in severity for
a few weeks or months.
treatment approach must address rehabilitation.
Antidepressants, such as tricyclics and SSRIs, are the
most effective pharmacological agents.
psychodynamic psychotherapy

Undifferentiated Somatoform Disorder

characterized by one or more unexplained physical

symptoms of at least 6 months' duration, which are
below the threshold for a diagnosis of somatization
disorder
autonomic nervous system and fatigue or weakness.
autonomic arousal disorder

Somatoform Disorder Not Otherwise

Specified

a residual category for patients who have symptoms

suggesting a somatoform disorder, but do not meet
the specific diagnostic criteria for other somatoform
disorders
e.g., pseudocyesis
Pseudocyesis - a false belief of being pregnant that is
associated with objective signs of pregnancy, which
may include abdominal enlargement (although the
umbilicus does not become everted), reduced
menstrual flow, amenorrhea, subjective sensation of
fetal movement, nausea, breast engorgement and
secretions, and labor pains at the expected date of
delivery.

Page 3 of 8

SUBSTANCE ABUSE DISORDER

Dr. Rene Yat (2012)

ALCOHOL
MARIJUANA
METHAMPHETAMINE
OPIATES
COCAINE
BENZODIAZEPINES
BARBITURATES
KETAMINE
FACTS ABOUT ALCOHOLISM
Alcohol intoxication, dependence, and abuse are
among the most prevalent mental disorders in the
general populations
Alcoholism knows no racial barriers
It is the #1 drug of abuse in the USA
At least 15 million have serious alcohol-related
problems
At least 4.6 million adolescents have serious alcohol
related problems
Alcohol related cause is second to heart disease and
cancer
Alcohol Intoxication
is defined by the presence of important maladaptive
behavioral or psychological changes due to alcohol
ingestion; Inappropriate sexual or aggressive behavior,
mood lability, impaired judgment, impaired social,
educational or occupational functioning.
Signs of alcohol intoxication
Slurred speech
Lack of coordination
Unsteady gait
Nystagmus
Impairment in attention and memory
Stupor or coma
Alcohol Withdrawal Syndrome
It developed after cessation of heavy and
prolonged alcohol use.
Tremulousness
Insomnia
Nausea and vomiting
Autonomic hyperarousal

Hotchocolate M.D.
Transient visual, auditory and
hallucinations
Illusions
Psychomotor agitation
Grand mal seizures

tactile

12 oz = 1 oz = 5 oz
MEDICAL FINDINGS OF ALCOHOLISM
DEPRESSION
ANXIETY
PHOBIAS
SUICIDAL THINKING
DELUSIONS AND HALLUCINATIONS
MEDICAL COMPLICATIONS OF ALCOHOLISM
CARDIOVASCULAR
GASTROINTESTINAL
NUTRITIONAL
VITAMIN DEFICIENCY
ENDOCRINOLOGIC DEFECTS
NEUROLOGIC COMPLICATIONS
ONCOLOGY
INFECTIONS
CARDIOVASCULAR EFFECT OF ALCOHOLISM
HYPERTENSION
INCREASED PULSE RATE
ALCOHOLIC CARDIOMYOPATHY
EKG FINDINGS OF ATRIAL AND VENTRICULAR
ARRYTHMIAS, INTRAVENTRICULA CONDUCTION
ANOMALIES
GASTROINTESTINAL EFFECT OF ALCOHOLISM
Reflux esophagitis
Gastric and esophageal ulcer
Mallory Weiss syndrome
Erosive gastritis, atrophic gastritis, gastric
hemorrhage
Chronic pancreatitis
Malabsorption and diarrhea
Fatty liver
Cirrhosis of the liver
Page 4 of 8

Nutritional effect of alcoholism

Folic acid deficiency
Pyridoxine deficiency
Thiamine deficiency
Iron deficiency
Zinc deficiency
Vitamin A,D,K deficiency
Endocrinologic Effect of Alcoholism
Adrenocortical function
Adrenomedullary function
Thyroid function
Gonadal function
Pituitary function
Alcoholic hypoglycemia
Alcohol ketosis
Neurological Effect of Alcoholism
A. Wernickes - Korsakoff psychosis
B. Cerebral atrophy
C. Peripheral neuropathy
D. Alcohol myopathy
Wernicke-Korsakoff syndrome
is a two-stage brain disorder caused by an alcohol
induced thiamine deficiency. Thiamine is needed for
cells to generate energy from sugar. If thiamine levels
drop too low, this ability ceases. Wernicke
encephalopathy is the first phase and Korsakoff
psychosis is the second chronic stage of the disorder.
Symptoms of the Wernicke-Korsakoff syndrome
include confusion, permanent gaps in memory,
problems with learning new information, vision
impairment,
stupor,
coma,
hypothermia,
hypotension, ataxia, and confabulation
Confabulation is a symptom where patients make up
stories to fill the missing gaps in their memories. They
may not be lying, but actually believe the newly
created memories.

Hotchocolate M.D.
Oncological Effects of Alcoholism
Cancer of the mouth
Cancer of the tongue
Cancer of the oropharynx
CA of the hypopharynx
CA of the larynx
CA of the esophagus
CA of the liver
Infections and alcoholism
Pneumonia
Tuberculosis
Meningitis
Peritonitis
Ascending cholangitis
Pharyngitis
Treatment for alcoholism
Acamprosate ( aotal )
Naltrexone
Disulfiram ( antabuse ) not used anymore because of
adverse side effect.
Metronidazole surreptitiously given by some doctor to
hasten up intoxication. ( dangerous practice )
JELLINEKS TYPE OF ALCOHOLISM
Alpha alcoholism: the earliest stage of the disease,
manifesting the purely psychological continual
dependence on the effects of alcohol to relieve bodily or
emotional pain. This is the "problem drinker", whose
drinking creates social and personal problems. Whilst
there are significant social and personal problems, these
people can stop if they really want to; thus, argued
Jellinek, they have not lost control, and as a
consequence, do not have a "disease".
Beta alcoholism: polyneuropathy, or cirrhosis of the
liver from alcohol without physical or psychological
dependence. These are the heavy drinkers that drink a
lot, almost every day. They do not have
physical addiction and
do
not
suffer withdrawal symptoms. This group do not have a
"disease".
Page 5 of 8

 Gamma alcoholism: involving acquired tissue

tolerance, physical dependence, and loss of control. This
is the AA alcoholic, who is very much out of control, and
does, by Jellinek's classification, have a "disease".[13]
Delta alcoholism: as in Gamma alcoholism, but with
inability to abstain, instead of loss of control.
Epsilon alcoholism: the most advanced stage of the
disease, manifesting as dipsomania, or periodic
alcoholism.

Serum blood alcohol level and its effect

0.02-0.03 BAC: No loss of coordination, slight
euphoria and loss of shyness. Depressant effects are
not apparent. Mildly relaxed and maybe a little
lightheaded.
0.04-0.06 BAC: Feeling of well-being, relaxation,
lower inhibitions, sensation of warmth. Euphoria.
Some minor impairment of reasoning and memory,
lowering of caution. Your behavior may become
exaggerated and emotions intensified (Good
emotions are better, bad emotions are worse)
0.07-0.09 BAC: Slight impairment of balance, speech,
vision, reaction time, and hearing. Euphoria.
Judgment and self-control are reduced, and caution,
reason and memory are impaired, .08 is legally
impaired and it is illegal to drive at this level. You will
probably believe that you are functioning better than
you really are.
0.10-0.125 BAC: Significant impairment of motor
coordination and loss of good judgment. Speech may
be slurred; balance, vision, reaction time and hearing
will be impaired. Euphoria.
0.13-0.15 BAC: Gross motor impairment and lack of
physical control. Blurred vision and major loss of
balance. Euphoria is reduced and dysphoria (anxiety,
restlessness) is beginning to appear. Judgment and
perception are severely impaired.
0.16-0.19 BAC: Dysphoria predominates, nausea may
appear. The drinker has the appearance of a "sloppy
drunk."

Hotchocolate M.D.
0.20 BAC: Felling dazed, confused or otherwise
disoriented. May need help to stand or walk. If you
injure yourself you may not feel the pain. Some
people experience nausea and vomiting at this level.
The gag reflex is impaired and you can choke if you
do vomit. Blackouts are likely at this level so you may
not remember what has happened.
0.25 BAC: All mental, physical and sensory functions
are severely impaired. Increased risk of asphyxiation
from choking on vomit and of seriously injuring
yourself by falls or other accidents.
0.30 BAC: STUPOR. You have little comprehension of
where you are. You may pass out suddenly and be
difficult to awaken.
0.35 BAC: Coma is possible. This is the level of
surgical anesthesia.
0.40 BAC and up: Onset of coma, and possible death
due to respiratory arrest.

DRUG FREE WORKPLACE

Dr. Rene Yat

FACTS
ABOUT 74% OF THE WORKFORCE ARE INTO DRUGS
Most common substance of abuse is alcohol,
methamphetamine, marijuana
It costs employers around $100 billion a year
through lost productivity, increased absenteeism,
and drug-related injuries.
60% of the worlds illegal drug market is in the US
>20 Million Americans use Marijuana
6 Million use cocaine
Half a million use heroin
13 Million Americans are alcoholics
2/3 of drug abusers are employed! are full time
There are more high income drug abusers than low
income abusers
The overall rate of drug abuse in America is 5%.
Current estimates of drug users in these country is
about 5.6 Million
This translate to 600 billion pesos industry
About 8.4 Million people are underemployed
About 6.4 Million out of school are unemployed
Page 6 of 8

D.

E.

Types of Drug Testing

Situational
Pre-employment drug testing
Reasonable cause drug testing
Random Testing
Post accident Testing
Periodic testing
Rehabilitation Testing
A. Pre-employment Drug Testing
This is preventive because it denies employment to
persons who are identified as drug users
It exposes the prospective employers to less liability
involving labor grievances and litigations
Most frequently used type of testing
B. Reasonable cause Testing
Drug testing is used when an employees unsafe or
unacceptable job conduct clearly points to a
problem, which may involve drug use.
This testing is conducted when an employer believes,
based on objective facts, that a particular employee
is unable to perform his/her duties.
E.g. accidents, deviations from safe working practices,
and erratic workplace conduct.
C. Random Testing
One of the most controversial test because it pits the
employers desires against the employees privacy
interest.
Also known as unannounced testing
Also known as No cause testing
These two factors no notice and no cause are
responsible for the unpopularity of this testing
method.

Hotchocolate M.D.
Post-accident Testing
It is an employer-mandated testing of an individual
who is directly involved in a motor vehicle crash or
other accident or near miss accidents.
This testing is based on events that automatically
require testing. Theres no need for indicators of
employees impairment.
Periodic Testing
Is a catch all category that includes drug tests
conducted at designated intervals.
Such tests are usually conducted as an adjunct to
routine check-ups or recertification of occupational
licenses.
The disadvantage of this test, users can simply abstain
from use prior to the scheduled test. And there is a
high preponderance for loss of custody of urine
specimen.

F. Rehabilitation Testing
The frequency and manner of testing employees are
determined by rehabilitation program professionals.
Only the MRO should evaluate positive test results.
The role could be expanded to include rehabilitation
functions.
This is a sort of after care to maximize assurances that
an employee would remain drug free.
Limitations of Drug Test
Unlike blood and alcohol levels, drug test cannot
measure impairment because drug concentrations in
urine or blood do not correlate with the degree of
impairment.
Drug test should be confirmed by GC/MS that is, Gas
Chromatography and Mass Spectrophotometry which
is very expensive test.
5 elements of Drug Free Workplace
1. Formal written policy
2. 2 E.A.P.
3. Training for supervisors
4. Employee Education
5. 5 Drug Testing

Page 7 of 8

Players in the Drug Testing

1. The employer
2. The donor
3. Specimen collection site
4. The laboratory
5. MRO
Substances to Test
Alcohol
Methamphetamine
Marijuana
Cocaine
Benzodiazepines
Barbiturates
Others ( according to the employers SAP )
Direct Cost to your business
Drug abusing employees acquire 300% higher medical
costs and benefits which consequently increases
health insurance rates. [U.S. Chamber of Commerce]
Illicit drug users are five times more likely to file a
workers' compensation claim. [U.S. Dept. of Justice, Drug
Enforcement Administration]

Many illegal drugs are bought by money diverted from

legitimate businesses and could be as much as 100
billion a year. (2.5% of GNP and 8% of discretionary
spending) [U.S. Chamber of Commerce]

Benefits to the employer

Reduce operational cost
Preserve investor or shareholders interest
Protect loyal employee
Improve product and services
Increase profits
Help many people lead a healthier life
Improve services to clients

Hotchocolate M.D.
Employers Right to Implement Testing
Under an employment contract, an employer may
always discharge an employee for a good cause. Good
cause includes dishonesty, immoral conduct,
negligence, incompetence, or disobedience of
reasonable work rules. If a contract for a definite term
does not specifically state that an employer can
terminate an employee for failing to abide by the
employers drug and alcohol policy, the employer may
be faced with a breach of contract claim.
Clearly, an employer can avoid cost of loss of
productivity, and liability of breach of contract claim
arising from the discipline or discharge of an employee
who refuses to take a drug test, or who tests positive,
by specifically including a term addressing drug and
alcohol testing in any employment contract.
Indirect Cost
Credible studies show that a substance abuser will
function at about 67% of his/her capacity! Data
supports the "generalization" that they are NOT
productive workers! [National Institute on Drug Addiction]
Employees using drugs are three times more likely to
be late for work and 2.5 times more likely to have
absences of eight or more days. Collectively, substance
abusers have an absentee rate of 30-35 days per year!
[U.S. Chamber of Commerce]

Drug use in the workplace breeds drug dealers in the

workplace. An Indiana Gallup survey revealed that 32%
of workers knew of drug use by employees on the job;
and 10% had been offered drugs to use on the job while
at work.
Drug users have 3.6 times as many accidents. Up to
40% of industrial fatalities and 47% of industrial injuries
can be linked to alcohol abuse and alcoholism.
[Employee Assistance Society of North America]
Drug users tend to have bad work habits and tend to
reduce morale.
Now, its up to you to make the right choice!
A) DRUG FREE WORKER
B) DRUG CRAZED WORKER
END (,)
Page 8 of 8