Tag Archives: Somatoform Disorders

Comparing PTSD and Somatization Disorder


Comparing PTSD and Somatization Disorder shows that there are some similarities in the symptoms but for the most part they are different.  Somatization Disorder has a lot more physical symptoms while PTSD has more symptoms leaning toward emotional.  The symptoms the two disorders have in common are headaches and stomachaches.  In both cases symptoms can be so severe and last so long that it completely disrupts the person’s life.

Do you have medically unexplained physical, or somatic, symptoms?

Somatization disorder can cause a person towards an emotional reaction such as depression or even suicide because they feel so much pain and can never get a diagnosis for it.  The symptoms often lead to substance abuse.  Thereby leaving them to feel hopeless, as if they will never get the help they need.  Somatization disorder has a wide range of physical symptoms.  A person with this disorder will report many different symptoms over a period of time with no real medical explanation.  These symptoms are often pain throughout the body, but not usually all at the same time.  Pain in the form of headaches, stomach ache, joint or muscle pain.  It could also be internal, such as vomiting, or it could come about as a sexual or menstrual problem.  Neurological symptoms are also common, often occurring as problems with balance or vision and even paralysis.

Generally for a patient to be diagnosed they will have experienced a minimum of eight symptoms.  There will be a minimum number of symptoms from a given category.  An example of this is that a patient will experience four or more symptoms from the pain category, two or more symptoms from the gastrointestinal category, one or more symptoms from the sexual symptoms category, and one or more symptoms from the pseudoneurological symptoms.  When a person is showing signs of these symptoms they will be unexplainable and a medical diagnosis is not usually possible.  Generally the person will explain the pain they are having in a fashion that makes it seem as if they are in more pain than you think they should be in, as if they are over exaggerating the symptoms.

Somatization Disorder lasts for a very long time which is one thing this disorder has in common with PTSD.  PTSD symptoms can last anywhere from months to years.   Most PTSD symptoms are different from Somatization Disorder because they come from more of a psychological background than a physical background.  PTSD symptoms are generally geared more towards an emotional aspect, some examples are worry over dying, acting younger than the chronological age, having an impaired memory or obsessiveness.  It seems that PTSD actually transforms a person’s behavior instead of changing them physically.  This is because when traumatic experiences occur, the feelings they experience, such as shock, nervousness or fear continue on for a length of time and gradually get stronger.  The stronger they get the less of a normal life the person is able to lead.

These increased symptoms can include nightmares or night terrors, hypervigilance, panic attacks, hypersensitivity, low self-esteem and shattered self-confidence or a physical or mental paralysis.  There are three categories often used by clinicians in order to type or group people who are diagnosed with PTSD.  The categories used are re-living, avoiding, and increased arousal.  The people in the re-living group are people who suffer from living through the trauma they have been through over and over again.  This can happen through a flashback or a hallucination or just by being reminded even in small ways.  The people in the avoiding group tend to try to stay away from people, places or things that can remind them of the event.  Unfortunately the person can start to isolate themselves and eventually can turn completely inward from detachment.  The people in the increased arousal group lean towards either having difficulty showing their emotions or on the other end of the spectrum showing overly exaggerated emotions.  This group is also the group who has some physical symptoms such as higher blood pressure, muscle tension and nausea.

In conclusion, it has become very apparent to me that while there are some similarities between PTSD and Somatization Disorder, there are a lot more differences.  It has also become very apparent to me that the people who suffer from these disorders are dealing with a lot of pain, and whether it is physical or emotional, this pain can cause the person suffering from it to shut down and disable them from enjoying the life they were meant to lead.

References

Netherton, S.D., Holmes, D., Walker, C.E. (1999). Child and Adolescent Psychological Disorders.   New York, NY: Oxford University Press.

Blaney, P.H., Millon, T. (2009). Oxford Textbook of Psychopathology.

New York, NY: Oxford University Press.

(2009, February 9). Anxiety & Panic Disorders Guide. WebMD.com. Retrieved October 5, 2009, from http://www.webmd.com/anxiety-panic/guide/post-traumatic-stress-disorder

(Retrieved 2009, October 5). Somatization Disorder. Intelihealth.com.  http://www.intelihealth.com/IH/ihtPrint/W/8271/25759/187986.html?d=dmtHealthAZ&hide=t&k=base

(Retrieved 2009, October 5). Posttraumatic Stress Disorder. American Academy of Child & Adolescent Psychiatry. AACAP.org

http://www.aacap.org/cs/root/facts_for_families/posttraumatic_stress_disorder_ptsd

(Retrieved 2009, October 5). Somatization Disorder. PsychNet-UK.

http://www.psychnet-uk.com/dsm_iv/somatization_disorder.htm

Kinchin, D. (2005). Post Traumatic Stress Disorder The Invisible Injury.

Didcot, Oxfordshire OX11 9YS, UK.  Retrieved October 5, 2009, from http://www.successunlimited.co.uk/books/ptsympt.htm

 

Examining the Relationships between PTSD, Somatization, and Disassociation


There are clinically significant relationships that can be drawn between PTSD and Somatization Disorder, first and foremost because dissociative symptoms are included in the criteria for both.  The disassociation spectrum of disorders culminates in Dissociative Identity Disorder, where an individual has two or more distinct personalities that serve different functions in a person’s life.  Although pure cases of Dissociative Identity Disorder are extremely rare, the occurrence of dissociative-like symptoms is relatively common (especially in patients that are diagnosed with Somatization Disorder and PTSD).  We can visualize these symptoms as a form of psychological defense mechanism which results in an inability to recall events; a selective memory of sorts.  Reports of “disturbances in time” are not uncommon, for example when someone is unable to remember how they arrived at a certain location.  Disassociation sometimes manifests in depersonalization, or the sensation of “not being in one’s own body.”  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 519)

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Although the DSM-IV-TR has conveniently compartmentalized diagnoses into categorical systems, we should “apply skilled clinical judgment to establish functional relationships among various symptom clusters in any given patient.”  (Van Der Kolk, Pelcovitz, Roth, & Mandel, 1996, expression DISCUSSION)  There is no better forum to explore functional relationships between and among specific diagnosis than the exploration of the interrelationship between PTSD, Somatization Disorder, and Dissociative Disorders.  After all, the disassociations associated with these disorders will frequently present at the same time to the extent that it may be difficult to distinguish where one begins and the other ends.

The DSM-IV-TR diagnostic criteria for 309.81 Posttraumatic Stress Disorder (PTSD) include being exposed to a traumatic event that involved a threat to the physical integrity of self or others.  Secondly, the event must be persistently experienced through recurrent recollections, dreams, flashbacks, illusions, or hallucinations.  Third, the client should demonstrate active and persistent avoidance of stimuli associated with the trauma, and/or a general numbing of general responsiveness.  This frequently manifests in dissociative symptoms, serving as a conscious or unconscious effort to avoid thoughts, feelings, conversations, activities, places, or people.  The resulting disassociation results in feelings of detachment or estrangement, restricted range of affect, or a sense of a foreshortened future.  Finally, the client may present with symptoms of increased arousal including difficulty sleeping, irritability, outbursts of anger, difficulty concentrating, hypervigilance, and/or exaggerated startle response.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 467-468)

In contrast, the DSM-IV-TR diagnostic criterions for 300.81 Somatization Disorder are characterized by a pattern of recurring clinically significant somatic complaints.  The somatic complaints cannot be fully explained by any known general medical condition or the direct effects of a substance.  If they occur in the presence of a general medical condition, the resulting impairment is in excess of what would be expected based on the norm for the general medical condition.  Finally, there are criterions regarding the quantitative and qualitative aspects of the somatic complaints, requiring that individuals present with a relatively wide variance of physical effects.  We could describe this disorder as a form of “somatic dissociation” whereby the client has lost their ability to perceive somatic sensory information, ultimately resulting in a distorted sense of self.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 486)

In a controlled study of Vietnam-era combat veterans, researchers found that combat veterans with PTSD reported and were rated as having a greater number of health problems than combat veterans without PTSD.  They had a greater number of total illnesses across a wider number of medical categories, contributing to the belief that as part of their PTSD, “PTSD patients have difficulty determining the salience of information and that this deficit in information processing may contribute to a patient’s focus on and misinterpretation of somatic sensations.”  (Beckham, Moore, Feldman, & Hertzberg, 1998, expression DISCUSSION)

In another study, researchers attempted to investigate the relationships between exposure to extreme stress, the emergence of PTSD, and the symptoms traditionally associated with “hysteria.”  They found that exposure to extreme stress may result in a variety of combinations of symptoms over time, including symptoms characteristic of somatization disorder and PTSD.  (Van Der Kolk, Pelcovitz, Roth, & Mandel, 1996, expression MODERN TRENDS)

In yet another study that focused primarily on pediatric cancer survivors, researchers found empirical support for the “trauma spectrum model” within which “somatic symptoms may play an instrumental role in the presentation and subsequent detection” of PTSD.  Although we cannot eliminate the possibility that somatic complaints represent true physical symptoms, children with chronic illness typical report higher levels of somatic complaints than healthy peers.  Researchers concluded that “long-term pediatric cancer survivors appear to exhibit somatic symptoms,” as well as PTSD-like symptoms, years after treatment completion.  (Erickson & Steiner, 2000)

Without, all three of these studies strengthen the argument for an interrelationship between stress, the presentation of unexplained physical symptoms, and dissociation.  Despite our best effort to compartmentalize disorders in the DSM-IV-TR, it is critical for us as clinicians to recognize and interrelationships between and among these disorders.  Despite an abundance of applicable research, more study is needed to establish the definitive relationship between and among PTSD, somatization disorder, and the spectrum of disassociation disorders.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Beckham, J. C., Moore, S. D., Feldman, M. E., & Hertzberg, M. A. (1998, Nov). Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder.  The American Journal of Psychiatry, 155(11), 1565-1570. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=36011996&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Erickson, S. J., & Steiner, H. (2000, Jul/Aug). Trauma spectrum adaptation: Somatic symptoms in long-term pediatric cancer survivors. Psychosomatics, 41(4), 339-347. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=56303410&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Van Der Kolk, B. A., Pelcovitz, D., Roth, S., & Mandel, F. S. (1996, Jul). Dissociation, somatization, and affect dysregulation. The American Journal of Psychiatry, 153(7), 83-94. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=9840989&sid=3&Fmt=2&clientId=4683&RQT=309&VName=PQD

Somatoform Disorders


 

 

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Somatoform Disorders could be summed up in the following statement… “there are more questions than answers.”  (Blaney & Millon, 2009, p. 499)  As a collection of disorders, it appears as though they don’t belong under the same heading or classification.  Many have more in common with Obsessive-Compulsive Disorder (OCD) than they have with each other.

“The common feature of the somatoform disorders is the presence of physical symptoms that suggest a general medical condition and are not fully explained by a general medical condition, nor by the direct effects of substance, or by another mental disorder.”  (Blaney & Millon, 2009, p. 483)  Somatoform can only be diagnosed by the process of exclusion… which seems odd to me.  It represents a “curve ball” for medical and mental health professionals, because the underlying consensus is that the client “believes they have an ailment, but they don’t.”  I don’t use “very, very” very often, but this has to make it very, very difficult to diagnose.  It might give some explanation to the very low prevalence rates.

I would have expected a greater degree of stress or anxiety in a patient that presents with this disorder, as would be typical of someone who presents with symptoms that can’t be explained.  “Patients with these disorders typically experience little or no anxiety, whereas those with so-called preoccupation disorders are excessively concerned or anxious about the notion that there is something physically wrong with their bodies.”  (Blaney & Millon, 2009, p. 483)  Can we use this lack of anxiety as a “flag” for diagnosis?

The “sick role” seems to be an underlying sociological construct among all the somatoform disorders.  Sick role implies granted privileges (staying home from work) and avoidance of obligations because one has to comply with medical instructions.

I was particularly interested and enthralled with the cultural differences in the presentation of Conversion Disorder (CD).  Not only is it more prevalent among rural residents from low socioeconomic backgrounds, but there is remarkable differences between geographical areas.  The text cited frequent cases of “burning hands” in Asia, which are typically never reported in the Western world.  (Blaney & Millon, 2009, p. 487)

Pain disorder is another anomaly.  What surprised me is that typical clients don’t come to treatment because of the degree or intensity of the perceived pain, but are more likely to come seeking respite from the psychological costs of pain management.  I could anticipate that this would be one of the most debilitating somatoform disorders because of its ability to disconnect clients from family, friends, work, and recreation.  (Blaney & Millon, 2009, p. 487)

I was relatively familiar with the concept of hypochondriasis before reading the text, but I was wholly unaware of the underlying theoretical etiology.  The concept of increased sensitivity to innocuous bodily sensations is new to me.  I was aware that some clients have formed selective attention to illness formation, risk perception, and misinterpretation of benign symptoms.  The suggestion that it is triggered by critical incidents, and is predispositioned by parental attitudes rings true to me.  I was also suitably surprised by the transient nature of the disorder, since it can apparently go into full remission and then appear again when a stressor appears.

Body Dysmorphic Disorder (BDD) is fascinating, quite honestly I have never heard of it.  I think this probably has more to do with societal views of “what is beautiful” than we think.  I was not at all surprised by the suggestion that some believe it to be delusional in nature.  I am a “perfectionist type” myself, but I never in my life would have dreamed this could be one of the results of that predisposition.  The text suggests that it may be compounded by being teased or bullied as a teenager (during puberty), leading to a general lack of social skills and self conscious maladaptive behavior.

Factitious Disorder is when “physical symptoms are produced or feigned intentionally to assume the sick role.”  (Blaney & Millon, 2009, p. 492)  The concept of “hospital hopping” in effort to undergo medical procedures, even surgery, is amazing.  The fact that these patients frequently lie about the nature of their symptoms, and life circumstance in general, probably contribute to the difficulty of diagnosing and treating this disorder.  I mean, how can you believe them?  I would question everything that came out of their mouth, it might be increasingly difficult to sort out “real issues” from “fake ones.”

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.