History

Fact Explanation
Gender This disorder is relatively more common in women[3].
Persistent, severe, distressing pain for at least 2 years[2][3] Patient will complain of persistent, severe, distressing pain at least for 2 years. Site of the pain( eg; limb pain, back pain, neck pain, headache, abdominal pain, chest pain) will be multiple and variable time to time. However on systemic inquiry patient will not have any systemic symptoms other than pain[1]. Though there is involvement of multiple systems in the presenting complaint they are not connected to each other.
Past medical history[5]" previous visit to the doctor or chronic illness. There may be a history of seeking medical advice from several doctors for the pain symptoms (doctor shopping). Despite of reassurance by the doctors patient has continued seeking treatment. Chronic illness can cause various atypical symptoms due to the psychological impact on the disease.
Drug history[3] As patients will perceive real symptoms in this condition, patient will always ask for treatments. So the patient may have several prescriptions given by doctors during his/her previous visits.
Social history[1][3]: social/ family functioning, educational level, stress and cultural beliefs There may be some degree of impairment in social and family functioning. Due to the recurrent pain patient's daily activities, occupation and other social relationships will be affected. Also doctor shopping may have an impact on economical condition. Identification of the patient's current educational level will help in further management of the patient. Stresses in work, academic difficulties/exams, bullying at school/ working place may also can present with similar symptoms. Cultural beliefs may lead to maintenance of symptoms for a long period.
Psychiatric history[1][3] A past history of somatization, behavioral problems or any other psychiatric illness. This will helpful to diagnose the condition. Personality traits such as maladaptive methods of coping may lead to these symptoms in a situation causing stress. Assess the symptoms of depression[1][4] such as low mood, loss of interest and enjoyment of activities which are normally pleasurable, decreased energy/ easy fatigability.
Family history[6] Family history of anxiety, depression, somatization and other psychiatric illnesses. This will be a predisposing factor.
Evidence of any specific gain from the symptoms Sick role[7] behavior may lead to benefits from society or the family. This will unconsciously leads to persistence of the symptoms.
References
  1. KALLIVAYALIL RA, PUNNOOSE VP. Understanding and managing somatoform disorders: Making sense of non-sense Indian J Psychiatry [online] 2010 Jan, 52(Suppl1):S240-S245 [viewed 11 August 2014] Available from: doi:10.4103/0019-5545.69239
  2. EHLERT U, HEIM C, HELLHAMMER DH. Chronic pelvic pain as a somatoform disorder. Psychother Psychosom [online] 1999 Mar-Apr, 68(2):87-94 [viewed 11 August 2014] Available from: doi:12318
  3. YEUNG A, DEGUANG H. Somatoform disorders West J Med [online] 2002 Sep, 176(4):253-256 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071744
  4. KATON WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry [online] 2003 Aug 1, 54(3):216-26 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12893098
  5. BIRKET-SMITH M. Somatization and chronic pain. Acta Anaesthesiol Scand [online] 2001 Oct, 45(9):1114-20 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11683662
  6. CHANDRASHEKHAR CR, REDDY V, ISAAC MK. LIFE EVENTS AND SOMATOFORM DISORDERS Indian J Psychiatry [online] 1997, 39(2):166-172 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2967103
  7. NICKEL R, HARDT J, KAPPIS B, SCHWAB R, EGLE UT. [Determinants of quality of life in patients with somatoform disorders with pain as main symptom - the case for differentiating subgroups]. Z Psychosom Med Psychother [online] 2010, 56(1):3-22 [viewed 11 August 2014] Available from: doi:10.13109/zptm.2010.56.1.3

Examination

Fact Explanation
Appearance: the patient may look older than chronological age, patient may not have much concern about self care. (eg; maybe unshaven, clothes may not be neat). In addition the patients may appear malnourished. [1,2,3] The patient's general appearance will be a manifestation of his/her difficulty in coping with chronic pain.
Facial appearance: down turned corners of the mouth, flattened expressions, vertical furrowing of the brows. Some may have anxiety features such as horizontal furrowing of the brows, wide eyes, sweating and dilated pupils. [1,2,3] If the patient is depressed , will present with sad mood, down turn corners of mouth, flattened express, vertical furrowing of the brows. If the patient is anxious about the illness/ symptoms , will present with horizontal furrowing of the brows, wide eyes, sweating, dilated pupils
Motor activity; look for any evidence of limited and slow movements or fidgety, restless, frequent movements from one place to other. [1,2,3[ Patients with depression will stay in a one place with limited and slow movements. Anxious patients will exhibit fidgety, restless, frequent movements from one place to another.
Social behavior; look for evidence of poor eye contact, limited conversation, curiosity. [1,2,3] Patients with depression have poor eye contact and limited conversation, while anxious patients are curious and ask several questions.
Speech, no spontaneous speech, rate, amount, volume will be less. [1,2,3] Speech, will not speak spontaneously if depressed and rate, amount, volume will be less.
Mood, level of the mood will be low but other examinations will be normal. [1,2,3] Mood, when subjectively assessed the patient may worrying about the illness. Objectively there is low mood, while range and reactivity is appropriate to the situation.
Thoughts, the patient may repeat the symptoms frequently. [1,23] Thoughts can exhibit preservation the patient may repeat the symptoms frequently and thought blocking, flight of ideas may not be present.
Physical examination will be normal. No abnormality will be detected[1] Pain occurs with out any organic cause. So there will be no physical signs on examination.
References
  1. KALLIVAYALIL RA, PUNNOOSE VP. Understanding and managing somatoform disorders: Making sense of non-sense Indian J Psychiatry [online] 2010 Jan, 52(Suppl1):S240-S245 [viewed 11 August 2014] Available from: doi:10.4103/0019-5545.69239
  2. YEUNG A, DEGUANG H. Somatoform disorders West J Med [online] 2002 Sep, 176(4):253-256 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071744
  3. KATON WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry [online] 2003 Aug 1, 54(3):216-26 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12893098

Differential Diagnoses

Fact Explanation
Organic illness [1] Differential diagnosis with organic pathology should be considered according to the patients presentation.
Hypochondriacal disorder[2] These patients suspect that they have a serious, progressive physical illness. They are not much concerned about the treatment. However, they insist the healthcare provider for repeated investigations and the diagnosis.
Dissociative conversion disorder[3] Symptoms are only evident regarding the nervous system. Other symptoms are similar to a reformatory disorder.
Depression[4] Patients with depression also present with several atypical, unrelated symptoms.
Malingering[5] Patients will deliberately produce symptoms. Most of the time there is a clear secondary benefit.
References
  1. YEUNG A, DEGUANG H. Somatoform disorders West J Med [online] 2002 Sep, 176(4):253-256 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071744
  2. SAKAI R, NESTORIUC Y, NOLIDO NV, BARSKY AJ. The prevalence of personality disorders in hypochondriasis. J Clin Psychiatry [online] 2010 Jan, 71(1):41-7 [viewed 11 August 2014] Available from: doi:10.4088/JCP.08m04838blu
  3. AGARWAL AL. Compulsive symptoms in dissociative (conversion) disorder Indian J Psychiatry [online] 2006, 48(3):198-200 [viewed 11 August 2014] Available from: doi:10.4103/0019-5545.31587
  4. KATON WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry [online] 2003 Aug 1, 54(3):216-26 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12893098
  5. MITTENBERG W, PATTON C, CANYOCK EM, CONDIT DC. Base rates of malingering and symptom exaggeration. J Clin Exp Neuropsychol [online] 2002 Dec, 24(8):1094-102 [viewed 11 August 2014] Available from: doi:10.1076/jcen.24.8.1094.8379

Management - General Measures

Fact Explanation
Deciding the treatment setting[1] Majority of patients can be managed in an out patient department and should be referred to a psychiatrist[1]. Patients rarely need in patient care.
Educating the patient[1][2] Patient should educate regarding the, the nature of the disease and the doctor should acknowledge symptoms as real but there is a need to reassure the that there is no organic pathology.
Minimize the harm Patient's may waste time on 'doctor shopping', and spend large amounts of money on expensive investigations. [1]
Changing the agenda[1] First the distressing situations which predispose to the symptoms should be identified. Changing the patient's agenda can help to minimize the frequency of occurrence of symptoms.This should be associated with help the patient with underlying problem.
Minimize sick role[1] Identify the advantages of sick role and reinforcing factors , they should be minimized. This will help the patient to maintain a normal life by improving the level of function.
Continuing care[1] Several sessions of treatment may needed. Number of follow up visits and frequency will be depend on the individual's condition. It is important not to encourage unscheduled visits as some patients may become accustomed to visiting the doctor for reassurance.
References
  1. KALLIVAYALIL RA, PUNNOOSE VP. Understanding and managing somatoform disorders: Making sense of non-sense Indian J Psychiatry [online] 2010 Jan, 52(Suppl1):S240-S245 [viewed 11 August 2014] Available from: doi:10.4103/0019-5545.69239
  2. DOHRENWEND A, SKILLINGS JL. Diagnosis-specific management of somatoform disorders: moving beyond "vague complaints of pain". J Pain [online] 2009 Nov, 10(11):1128-37 [viewed 11 August 2014] Available from: doi:10.1016/j.jpain.2009.04.004

Management - Specific Treatments

Fact Explanation
Pharmacological treatment: Serotonin Selective Re uptake Inhibitors (SSRI) [1] Usually drugs should not be given. However SSRIs are effective (the reason is not known, may be due to the reduction of anxiety) in treating the symptoms. It will more helpful in patients with associated depression.
Placebo drugs: analgesics, vitamins, benzodiazepines Patients will initially improve with placebo but later will not respond as it does not deal with the underlying cause.
Cognitive Behavioural Therapy (CBT) [1][2] 10-12 sessions of CBT will be needed. In this therapy it is suggested that symptoms arise from misinterpretation of bodily symptoms. Thus during treatment, it teaches patients to identify triggering factors, symptoms and illness related thoughts. It also challenges those maladaptive thoughts and seeks to change them.
References
  1. KROENKE K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med [online] 2007 Dec, 69(9):881-8 [viewed 11 August 2014] Available from: doi:10.1097/PSY.0b013e31815b00c4
  2. DOHRENWEND A, SKILLINGS JL. Diagnosis-specific management of somatoform disorders: moving beyond "vague complaints of pain". J Pain [online] 2009 Nov, 10(11):1128-37 [viewed 11 August 2014] Available from: doi:10.1016/j.jpain.2009.04.004