1. EMMANUEL GODWIN 5th Year Medical Student College of Medicine University of Nigeria , Enugu Campus Brain fag syndrome , Hypochondriasis and Conversion Disorder

2. OUTLINE Brain Fag Syndrome Introduction Diagnostic Criteria Epidemiology Treatment Hypochondriasis Introduction Epidemiology Diagnostic Criteria Examination Treatment Conversion Disorder Introduction Diagnostic Criteria Common Symptoms Treatment References

3. ---------------------------------- BRAIN FAG SYNDROME

4. INTRODUCTION Introduction Brain fag is defined as ones reaction to the demanding task or situations of school.It is a common term for mental exhuastion The brain fag syndrome(BFS) was defined in the diagnostic and statistical manual of mental disorders as a culture bound syndrome in 1994, just like Koro & others. BFS is a tetrad of somatic complaints; cognitive impairment; sleep related complaints; and other somatic impairments.

5. INTRODUCTION The somatic complaints may consist of pains and burning sensations around the neck; the cognitive impairment consist of inability to grasp written and sometimes spoken words, and inability to concentrate as well as poor retention; sleep related complaints include fatigue and sleepiness inspite of adequate rest; and other somatic complaints such as blurring, eye pain and excessive tearing.

6. Diagnostic criteria The diagnosis of BFS rests not only on the presence of symptoms but also on the association between (a) the unpleasant sensations around the head/neck and (b) study difficulty Raymond H Prince first described this illness among African students in 1960

7. Epidemiology More common sub-saharan Africa. Ola et al (2008) gave the following risk factors for BFS ( confirmed by other studies) Gender(yes/no) Socioeconomic status cultural orientation, neuroticism, cognition

8. Treatment Lorazepam (Anumonye reported) Antidepressants Relaxation excercise

9. -------------------- ------------------ HYPOCHONDRIASIS

10. INTRODUCTION Hypochondriasis is characterized by 6 months or more of a general and non-delusional preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms. This preoccupation causes significant distress and impairment in one's life; it is not accounted for by another psychiatric or medical disorder; and a subset of individuals with hypochondriasis has poor insight about the presence of this disorder. The term hypochondriasis is derived from the old medical term hypochondrium, (below the ribs) and reflects the common abdominal complaints of many patients with the disorder, but they may occur in any part of the body.

11. Epidemiology One recent study reported a 6-month prevalence of hypochondriasis of 4 to 6 percent in a general medical clinic population, but it may be as high as 15 percent. Men and women are equally affected by hypochondriasis. Although the onset of symptoms can occur at any age, the disorder most commonly appears in persons 20 to 30 years of age. Some evidence indicates that the diagnosis is more common among blacks than among whites, but social position, education level, and marital status do not appear to affect the diagnosis. Hypochondriacal complaints reportedly occur in about 3 percent of medical students, usually in the first 2 years, but they are generally transient.

12. Diagnostic Criteria The DSM-IV-TR diagnostic criteria for hypochondriasis require that patients be preoccupied with the false belief that they have a serious disease, based on their misinterpretation of physical signs or sensations. The belief must last at least 6 months, despite the absence of pathological findings on medical and neurological examinations. The diagnostic criteria also stipulate that the belief cannot have the intensity of a delusion (more appropriately diagnosed as delusional disorder) and cannot be restricted to distress about appearance (more appropriately diagnosed as body dysmorphic disorder). The symptoms of hypochondriasis must be sufficiently intense to cause emotional distress or impair the patient's ability to function in important areas of life. Clinicians may specify the presence of poor insight; patients do not consistently recognize that their concerns about disease are excessive.

13. DSM-IV criteria A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms. B. The preoccupation persists despite appropriate medical evaluation and reassurance. C. The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder). D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The duration of the disturbance is at least 6 months. F. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive- compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder. Specify if: With poor insight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable

14. On Examination Detailes Physical examination to rule out somatic causes Mental State Examination(MSE) Appropriate attitude and behavior demonstrates a preoccupation with physical symptoms and complaints. Mood: mildly anxious and depressed No thought disorder ; thoughts are limited to issues around physical symptoms Insight/judgement; insight appears limited in that nonmedical causes of symptoms are not considered. Judgment appears unimpaired.

15. Treatment modalities Patients with hypochondriasis usually resist psychiatric treatment, although some accept this treatment if it takes place in a medical setting and focuses on stress reduction and education in coping with chronic illness. Group psychotherapy often benefits such patients, in part because it provides the social support and social interaction that seem to reduce their anxiety. Other forms of psychotherapy, such as individual insight-oriented psychotherapy, behavior therapy, cognitive therapy, and hypnosis may be useful. Frequent, regularly scheduled physical examinations help to reassure patients that their physicians are not abandoning them and that their complaints are being taken seriously. Invasive diagnostic and therapeutic procedures should only be undertaken, however, when objective evidence calls for them. When possible, the clinician should refrain from treating equivocal or incidental physical examination findings. Pharmacotherapy alleviates hypochondriacal symptoms only when a patient has an underlying drug-responsive condition, such as an anxiety disorder or major depressive disorder. When hypochondriasis is secondary to another primary mental disorder, that disorder must be treated in its own right. When hypochondriasis is a transient situational reaction, clinicians must help patients cope with the stress without reinforcing their illness behavior and their use of the sick role as a solution to their problems.

16. ------------------------------------- ----- CONVERSION DISORDER

17. Introduction Conversion disorder is an illness of 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 symptoms or deficits of conversion disorder are 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 (

18. Some symptoms of conversion disorder that are not sufficiently severe to warrant the diagnosis may occur in up to one third of the general population sometime during their lives. Reported rates of conversion disorder vary from 11 of 100,000 to 300 of 100,000 in general population samples. The ratio of women to men among adult patients is at least 2 to 1 and as much as 10 to 1; among children, an even higher predominance is seen in girls. Symptoms are more common on the left than on the right side of the body in women. Women who present with conversion symptoms are more likely subsequently to develop somatization disorder than women who have not had conversion symptoms. An association exists between conversion disorder and antisocial personality disorder in men. Men with conversion disorder have often been involved in occupational or military accidents. The onset of conversion disorder is generally from late childhood to early adulthood and is rare before 10 years of age or after 35 years of age, but onset as late as the ninth decade of life has been reported. When symptoms suggest a conversion disorder onset in middle or old age, the probability of an occult neurological or other medical condition is high.

19. Data indicate that conversion disorder is most common among rural populations, persons with little education, those with low intelligence quotients, those in low socioeconomic groups, and military personnel who have been exposed to combat situations. Conversion disorder is commonly associated with comorbid diagnoses of major depressive disorder, anxiety disorders, and schizophrenia and shows an increased frequency in relatives of probands with conversion disorder An increased risk of conversion disorder in monozygotic, but not dizygotic, twin pairs has been reported

20. DIAGNOSTIC CRITERIA DSM-IV-TR Diagnostic Criteria for Conversion Disorder A.One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. B.Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. C.The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). D.The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. E.The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. F.The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder. Specify type of symptom or deficit: With motor symptom or deficit With sensory symptom or deficit With seizures or convulsions With mixed presentation

21. COMMON SYMPTOMS OF CONVERSION DISORDER Motor Symptoms Involuntary movements Tics Blepharospasm Torticollis Opisthotonos Seizures Abnormal gait Falling Astasia-abasia Paralysis Weakness Aphonia Sensory Deficits Anesthesia, especially of extremities Midline anesthesia Blindness Tunnel vision Deafness Visceral Symptoms Psychogenic vomiting Pseudocyesis Globus hystericus Swooning or syncope Urinary retention Diarrhea

22. Other Associated Features Several psychological symptoms have also been associated with conversion disorder. Primary Gain Patients achieve primary gain by keeping internal conflicts outside their awareness. Symptoms have symbolic value; they represent an unconscious psychological conflict. Secondary Gain Patients accrue tangible advantages and benefits as a result of being sick; for example, being excused from obligations and difficult life situations, receiving support and assistance that might not otherwise be forthcoming, and controlling other persons' behavior. La Belle Indifference La belle indifference is a patient's inappropriately cavalier attitude toward serious symptoms; that is, the patient seems to be unconcerned about what appears to be a major impairment. That bland indifference is also seen in some seriously ill medical patients who develop a stoic attitude. The presence or absence of la belle indiffrence is not pathnognomonic of conversion disorder, but it is often associated with the condition. Identification Patients with conversion disorder may unconsciously model their symptoms on those of someone important to them. For example, a parent or a person who has recently died may serve as a model for conversion disorder. During pathological grief reaction, bereaved persons commonly have symptoms of the deceased.

23. Treatment Resolution of the conversion disorder symptom is usually spontaneous, although it is probably facilitated by insight-oriented supportive or behavior therapy. The most important feature of the therapy is a relationship with a caring and confident therapist. With patients who are resistant to the idea of psychotherapy, physicians can suggest that the psychotherapy will focus on issues of stress and coping. Telling such patients that their symptoms are imaginary often makes them worse. Hypnosis, anxiolytics, and behavioral relaxation exercises are effective in some cases. Parenteral amobarbital or lorazepam may be helpful. in obtaining additional historic information, especially when a patient has recently experienced a traumatic event. Psychodynamic approaches include psychoanalysis and insight-oriented psychotherapy, in which patients explore intrapsychic conflicts and the symbolism of the conversion disorder symptoms. Brief and direct forms of short-term psychotherapy have also been used to treat conversion disorder. The longer the duration of these patients' sick role and the more they have regressed, the more difficult the treatment.

24. REFERENCES ^ Jump up to: a b American Psychiatric Association. Task Force on DSM-IV. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. American Psychiatric Pub. ISBN 978-0-89042-025- 6. pp 485 Jump up ^ Oyama, Oliver. "Somatoform Disorders November 1, 2007 American Family Physician." Website American Academy of Family Physicians. Web. 30 Nov. 2011. . ^ Jump up to: a b c d La France, Jr. W. Kurt (2009). "Somatoform disorders". Seminars in Neurology 29 (3): 23446. doi:10.1055/s-0029-1223875 . PMID 19551600. Jump up ^ LaFrance, W. Curt (2009). "Jr., MD., MPH". Somatoform Disorders. 29: 234246. Jump up ^ Curt, LaFrance; Jr, W Curt (1 July 2009). "Somatoform disorders". Seminars in neurology 29 (3): 234. doi:10.1055/s-0029-1223875 . PMID 19551600. Retrieved 29 November 2012. Cite uses deprecated parameters (help) Jump up ^ LaFrance, C.W. "Somatoform Disorders". SEMINARS IN NEUROLOGY, V. 29 (3), 06/2009, pp. 234246. Jump up ^ Oyama O., Paltoo C., Greengold J. (2007). "Somatoform disorders". American Family Physician 76 (9): 13338. Jump up ^ Schacter, D. L., Gilbert, D. T., & Wegner, D.M. (2011). Psychology: Second Edition. New York, NY: Worth Jump up ^ Hales, Robert E; Yudofsky, Stuart C (2004). Essentials of Clinical Psychiatry. ISBN 9781585620333. Jump up ^ Escobar JI, Rubio-Stipec M, Canino G, Karno M (1989). "Somatic symptom index (SSI): a new and abridged somatization construct. Prevalence and epidemiological correlates in two large community samples". J. Nerv. Ment. Dis. 177 (3): 1406. doi:10.1097/00005053-198903000-00003 . PMID 2918297. Jump up ^ Lynch DJ, McGrady A, Nagel R, Zsembik C (1999). "Somatization in Family Practice: Comparing 5 Methods of Classification". Primary care companion to the Journal of clinical psychiatry 1 (3): 8589. doi:10.4088/PCC.v01n0305 . PMC 181067. PMID 15014690.

25. Thank you!