• Develop a realistic perspective on the multi-causality of symptom presentation - usu. too narrow-minded, try to find out pathophysiology for symptom
• Understand the common underpinnings of psychological factors in affecting somatic presentations
• Aware of relevant psychiatric diagnoses used in classifying somatic presentations of psychiatric illnesses: DSM-IV, DSM-TR (update of DMS-IV), ICD

1. Concepts and Terminology
2. Common Psychiatric Diagnostic Categories
3. Clinical Examples
4. Aetiology and Mechanisms

1. Hysteria: Pt too dramatic; Dx of hysterical conversion (eg. Most common during 2 WW's in shoulders - aka combat neurosis, avoidance-avoidance conflict (chance of death in war vs. deserting army + court marshal), cannot decide which should be chosen, therefore develop sickness (eg. Paralysis of arm - can no longer lift arm to pull trigger - therefore removed from avoidance-avoidance conflict)
2. Hypochondriasis
3. Neurosis: no longer used in classification; in touch with reality but afflicted with distress (eg. Anxiety, depression)
4. Nerves
5. Neurasthenia

Note: psychosis: Pt no longer in touch with reality (eg. Auditory hallucination, thought-broadcasting)

1. Psychosomatic: previously psychosomatic illness - now, psychosomatic approach
2. Somatisation: psych (eg. upset about exam results) manifested as physical complaints (eg. Diarrhoea). Common in elderly - eg. Mask depression - c/o weakness/ pain, but these symptoms are part of a depressive disorder. In people who are not in touch with their emotions
3. Abnormal illness behaviour: maladaptive coping

1. Somatoform
2. Medically unexplained symptoms
3. Functional symptoms

1. Psychosomatic approach
2. Functional somatic symptoms
3. Specific psychiatric diagnosis

DSM-IV: "there is much "physical" in "mental" disorders and much "mental "in "physical" disorders"

• F44: Dissociative (conversion) disorders: eg. Asterical field state: lost all memory of personal ID/ background; wander off and start a new life; Hx is a vacuum
• F45: Somatoform disorders: psych illness presenting as physical illnesses
• F48: Other neurotic disorders
• F54: Psychological and behavioural disorders associated with disorders or diseases classified elsewhere: not either/ or; both complicate each other (psych and behaviour complicate physical disorders). Eg. Pt with mastectomy, no recurrence of tumour, Pt subsequently developed intense fear about recurrence , called surgeon twice a day asking for reassurance, developed intense anxiety days before re-consultation with surgeon (start as physical problem and resulted in psych and behaviour problems)
• F68: Other disorders of personality and behaviour

• 300.xx: Somatoform disorder
• 300.xx: Factitious disorders: deliberately fakes his symptoms for specific psychological gain; compensable
• 300.xx: Dissociative disorders
• 316: Other conditions that may be a focus of clinical attention: Psychological factors affecting physical disorders
• V65.2: Malingering: is not a psych disorder; rampant in ML cases; person deliberately feigns symptoms for specific concrete gains (eg. sick leave, disability allowance, compensation money)

1. Somatisation disorder
2. Conversion disorder
3. Pain disorder: organic findings do not account for complaints of pain; severe distress + significant role impairment (eg. Slip and bruise leg, but not cannot walk properly etc, cannot work full-time)
4. Hypochondriacal disorder
5. Body dysmorphic disorder: delusional conviction that parts of body are not aligned/ in balance for one another (eg. Cosmetic surgery underwent willingly to realign jaw, cannot eat for months, then Pt wants to return to original self (convinced that jaw still misaligned), subsequently developed severe depression + suicidal tendencies

1. Heart (cardiac neurosis)
2. GIT (hiccough, dyspepsia, etc)
3. LGIT (psychogenic flatulence, irritable bowel syndrome, diarrhoea gas syndrome)
4. Respiratory (cough, hyperventilation)
5. UG (micturition, dysuria)
6. Other organ systems

1. Neurasthenia
2. Factitious disorder
3. Malingering
4. 4. Elaboration of physical symptoms for psychological reasons (ICD-10)
5. (Disorders of adult personality and disorders)

1. Mental factors: how Pt makes sense of his symptoms, thinking processes involved
2. Psychological symptoms: anxiety, depression, panic - will affect Pt's presentation? Eg. Mask depression
3. Personality traits or coping style: alexithynic personality: no feeling (anger, frustration, happy) but these emotions translated into physical signs
4. Maladaptive health behaviours
5. Stress related physiological response

1. Adversely influence the course: when Pt not convinced of Dx, go Dr shopping
2. Interfere with the treatment
3. Constitute additional health risks: concurrent Tx
4. Stress-related physiological responses precipitate or exacerbate symptoms of a general medical condition (eg. M tightness (as pain), sweating, palpitations)

• One or more physical complaints (e.g. fatigue, loss of appetite, gastrointestinal or urinary complaints)
• At least 6 months
• No organic aetiology that can account for the severity

• The symptoms are presented as if they were due to a physical disorder of a system or organ that is largely or completely under autonomic innervation or control, ie. the cardiovascular, gastrointestinal, or respiratory system
• 2 types: (1) Complaints based upon objective signs of autonomic arousal (e.g. palpitations, sweating, flushing, tremor) (2) More idiosyncratic, subjective and non-specific symptoms (e.g. sensations of fleeting aches and pains, burns, heaviness, tightness, sensations of being bloated or distended)
• Evidence of psychological stress, or current problems or difficulties that appear to be related to the disorder (but not necessarily so)
• Criteria for diagnosis: (1) Symptoms are persistent and troublesome (2) Additional subjective symptoms referred to a specific organ or system (3) Preoccupation with and distress about possibility of a serious (but often unspecified) disorder of the stated organ or system, which does not respond to repeated explanation and reassurance by doctors

• Preoccupation with fears of having, or the idea that one has, a serious disease based on the persons' misinterpretation of bodily symptoms
• Preoccupation persists despite appropriate medical evaluation and reassurance
• Belief is not of delusional intensity (delusion: unshakeable) whereas hypochondriacs are temporarily comforted by doctor
• The preoccupation causes clinically significant distress or impairment in social, occupational, other important areas of functioning
• Duration of disturbance > 6 months

Functions to

1. Maintain the preoccupation
2. Keep patient's mind on illness-related matters

Examples

1. Reassurance seeking
2. Checking bodily state
3. Constant scanning for changes in body
4. Avoidance of activity: eg. Slight LBP, therefore avoid any activity, worsens back problem (vicious cycle)
5. Effects of rubbing or irritating affected areas (eg. Fear of MI, therefore always check pulse, but anxious therefore pulse increases, vicious cycle)

• Misinterpretation of bodily sensations and signs: eg. Palpitation must mean an impending MI
• Undue focus of attention on bodily responses: eg. If focus on walking, becomes disrupted; the harder to try to sleep, the more alert you become
• Effects of frightening illness-related imagery: eg. Have headache and imagine a BV about to burst
• Attitudes and confirmatory bias: if you are anxious, you look for things that confirm (you ignore non-confirmatory evidence)

• If I get an illness it would be untreatable
• Both sides of the body must be absolutely identical or there is something wrong
• Symptoms always mean something
• if I don't worry about my health, I am more likely to fall ill
• I have a high risk for
• If I have symptoms that I was not aware of before, then it must be something bad

• Autonomic arousal
• Changes in breathing - hyperventilation
• Loss of fitness due to changes in activity patterns
• Caffeine, alcohol, other drugs
• Eg. High Court Judge repeatedly presented to A&E due to MI + breathlessness. Why? Entered chambers and anything happens, it will be 2 hours before anyone finds him. Poured coffee (caffeine + anxiety) caused palpitations -> intense fear -> hyperventilate -> chest pain due to intercostal m contraction. Opened window and hyperventilated more intensely -> felt faint -> rushed out and lay on ground

• Previous experience
• Dysfunctional assumptions
• critical incident/s
• Activation of assumptions
• Negative automatic thoughts/imagery
• Health related anxiety

N.B. Reciprocal nature of the interactions between physiological, behavioural, cognitive, and affective factors in symptom formation

1. Perceived threat
2. Apprehension
3. Body sensations
4. Interpretation of sensations as catastrophic
5. Perceived threat etc

Vicious cycle: crescendo of fear

Difference between Panic Disorder and Hypochondriasis - IMMINENCE

• Panic Disorder = now
• Hypochondriasis = in the future