1: Autism + Somatization Disorders

Question 1

definition of autism spectrum disorder

Answer 1

complex disorders of brain development - characterized by poor social interaction, verbal and nonverbal communication and repetitive behaviors
-Sx must be present in early development but may not manifest until social demands exceed limited capacities

Question 2

which gender is more likely to be affected by autism?

Answer 2

boys

Question 3

Clinical features of autism

Answer 3

• language delay (expressive and/or receptive)
• impaired social communication and interaction
  
  • lack of reciprocity
  • deficit in joint attention
  • impaired nonverbal communication (gaze especially)
  • impaired social relationships
• restricted, repetitive behaviors
  
  • hand flapping, self injurious behaviors
  • difficulty w/ schedule change
  • restricted interests
  • sensory perception issues
• sometimes intellectual impairment
• motor delays (toe walking, abnormal gait - clumsy)
• “savant” skills

Question 4

timing of Sx in autism

Answer 4

• onset usually noted when 2 y/o
• may be present as early as 6 mo
• may not become apparent until later when social demands exceed capabilities

Question 5

screening instrument for autism

Answer 5

M-CHAT (questionnaire)

Question 6

diagnosis of autism

Answer 6

-Hx: FHx - autism, language delay, MR, tuberous sclerosis, seizure disorders
-PE: growth (ht, wt, head circum, BMI);
skin (Woods lamp eval for hypopigmented macules of
Tuberous sclerosis);
neuro (focal neuro signs may stimulate imaging)
-Test: vision, hearing, lead, language, OT and PT eval if motor delay

Question 7

definition of illness vs. disease

Answer 7

illness: response of individual or family to Sx
disease: pathophysiologic process associated with documentable physical lesion(s)

Question 8

definition of somatization vs. somatoform illness

Answer 8

somatization: tendency to experience and communicate psychological or emotional distress as somatic (physical) sx

somatoform illness: produces significant dysfunction in patient’s life

Question 9

general about somatoform disorders (somatic sx disorder and related)

Answer 9

• characterized by physical sx that cause significant distress and impairment
• NOT caused by direct effects of a substance or by another mental disorder
• if another medical condition is present, the physical sx are far in excess of what should be expected

Question 10

factitious disorder

Answer 10

sx are produced or feigned in order to appear ill, with NO PERCEIVABLE BENEFIT to patient

Question 11

malingering disorder

Answer 11

sx are produced or feigned in response to an EXTERNAL INCENTIVE

Question 12

why do somatic sx disorders have a challenging patient population?

Answer 12

• chronic, difficult to treat

- high utilizers of the medical systems

Question 13

what are risks associated with somatic sx disorders?

Answer 13

• repetitive, unnecessary diagnostic testing
• invasive medical/surgical workups
• medically induced (iatrogenic) illness

Question 14

prevalence of somatic sx disorder: higher in what gender?

Answer 14

females

Question 15

heritability/factors affecting somatic sx disorders?

Answer 15

• genetic and environmental factors
• observed in 10-20% of first degree female relatives of affected patients
• males of these families show an increased risk of antisocial personality disorder and substance abuse disorders (alcohol)

Question 16

associated features of somatic sx disorder

Answer 16

• frequent visits to doctor
• may refuse to acknowledge contribution of psych factors
• co-morbid depressive sx common
• excessive use of analgesics, narcotics
• course tends to be chronic and disabling
• patients on medical disability-vicious cycle

Question 17

management goals of somatic sx disorder

Answer 17

• reduced pain

- increased function!!

Question 18

somatic sx disorder key diagnostic criteria: 3

Answer 18

• one or more somatic sx
• excessive thoughts, feelings, or behaviors
• state of being symptomatic persists usually > 6 mo

Question 19

criteria for illness anxiety disorder (aka hypochondriacs)

Answer 19

• may or may not have medical condition
• heightened bodily sensations
• intense anxiety about the possibility of an undiagnosed illness
• devote excessive time and energy to health concerns
• not easily reassured

Question 20

4 D’s of illness anxiety disorder/ hypochondriasis + key features

Answer 20

• disease fear
• disease preoccupation
• disease conviction
• disability

key: preoccupation, somatic sx not present or only mildly present, care-seeking vs. care-avoidant types

Question 21

prevalence, course and risks for illness anxiety disorder

Answer 21

• equal in women and men
• course varies, may improve with resolution of stressors
• risk for both missed medical diagnoses and iatrogenic complications

Question 22

tx for illness anxiety disorder

Answer 22

• CBT
• relaxation or supportive psychotherapy
• pharmacotherapy:
  
  • underlying depression/anxiety: SSRI’s
  • primary hypochondriasis: high dose SSRI

Question 23

functional neurological sx disorder (FNSD) / conversion disorder criteria

Answer 23

• one or more sx of altered voluntary motor or sensory fxn
• incompatibility b/w the sx and recognized neuro syndromes
• sx are not better explained by another medical or mental disorder
• sx cause distress and impairment

Question 24

sx of FNSD

Answer 24

• motor: weakness/paralysis, tremors, dystonia, pseudoseizures
• sensory: altered/reduced/absent skin sensation, vision, hearing, globus

Question 25

features of sx of FNSD

Answer 25

• distractibility
• sensory sx that split at the midline
• gap b/w tested strength and fxn
• ‘la belle indifference’ - seem too chill about why they’re in

Question 26

which gender is FNSD more common in?

Answer 26

females

Question 27

course of FNSD

Answer 27

• begins in adolescence/early adulthood
• duration of episodes usually short with abrupt resolution (2 wks)
• sx tend to be self limited and do not lead to disability
• rarely, atrophy or contractures can occur from prolonged disease
• recurrence is common and predicts more chronic course

Question 28

better FNSD prognosis is associated with what 5 things?

Answer 28

• acute onset
• identifiable trauma or stressor at onset
• good health before incident
• above average IQ
• absence of other medical or psychiatric disorders

Question 29

tx of FNSD

Answer 29

• treat associated anxiety or depression
• hypnosis
• framing to patient “stress related”

Question 30

examples of psych factors affecting other medical conditions

Answer 30

• chronic job stress + HTN
• anxiety + asthma
• depression + CAD
• alcohol abuse + liver disease
• smoking + COPD
• obesity + diabetes

Question 31

differentiating somatic sx disorder vs. factitious disorder vs. malingering

Answer 31

somatic sx: unintentional sx, cause distress

factitious: intentionally feigned, no perceivable benefit
malingering: intentionally feigned, external incentive

Question 32

describe factitious disorder as imposed on another

Answer 32

• most common in women aged 20-40, often connected to health care
• perpetrated by mothers on children in almost all cases

Question 33

features of malingering

Answer 33

• medico-legal presentation
• discrepancy b/w claimed disability and physical findings
• lack of cooperation or compliance
• association with antisocial personality disorder

Question 34

management of somatic sx and disorders

Answer 34

• establish one physician
• treat co-morbid anxiety and depression
• maintain regular follow up, even when doing well
• use objective evidence of disease to guide medical testing
• gradually shift emphasis from physical complaints to discussing stressors
• watch for drug abuse
• protect from iatrogenic complications

Question 35

pitfalls of somatic sx and disorders

Answer 35

• assuming all physical sx are related to somatization

- physician burnout - too much or too little care