1: Autism + Somatization Disorders Flashcards
definition of autism spectrum disorder
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
which gender is more likely to be affected by autism?
boys
Clinical features of autism
- 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
timing of Sx in autism
- 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
screening instrument for autism
M-CHAT (questionnaire)
diagnosis of autism
-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
definition of illness vs. disease
illness: response of individual or family to Sx
disease: pathophysiologic process associated with documentable physical lesion(s)
definition of somatization vs. somatoform illness
somatization: tendency to experience and communicate psychological or emotional distress as somatic (physical) sx
somatoform illness: produces significant dysfunction in patient’s life
general about somatoform disorders (somatic sx disorder and related)
- 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
factitious disorder
sx are produced or feigned in order to appear ill, with NO PERCEIVABLE BENEFIT to patient
malingering disorder
sx are produced or feigned in response to an EXTERNAL INCENTIVE
why do somatic sx disorders have a challenging patient population?
- chronic, difficult to treat
- high utilizers of the medical systems
what are risks associated with somatic sx disorders?
- repetitive, unnecessary diagnostic testing
- invasive medical/surgical workups
- medically induced (iatrogenic) illness
prevalence of somatic sx disorder: higher in what gender?
females
heritability/factors affecting somatic sx disorders?
- 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)
associated features of somatic sx disorder
- 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
management goals of somatic sx disorder
- reduced pain
- increased function!!
somatic sx disorder key diagnostic criteria: 3
- one or more somatic sx
- excessive thoughts, feelings, or behaviors
- state of being symptomatic persists usually > 6 mo
criteria for illness anxiety disorder (aka hypochondriacs)
- 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
4 D’s of illness anxiety disorder/ hypochondriasis + key features
- disease fear
- disease preoccupation
- disease conviction
- disability
key: preoccupation, somatic sx not present or only mildly present, care-seeking vs. care-avoidant types
prevalence, course and risks for illness anxiety disorder
- equal in women and men
- course varies, may improve with resolution of stressors
- risk for both missed medical diagnoses and iatrogenic complications
tx for illness anxiety disorder
- CBT
- relaxation or supportive psychotherapy
- pharmacotherapy:
- underlying depression/anxiety: SSRI’s
- primary hypochondriasis: high dose SSRI
functional neurological sx disorder (FNSD) / conversion disorder criteria
- 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
sx of FNSD
- motor: weakness/paralysis, tremors, dystonia, pseudoseizures
- sensory: altered/reduced/absent skin sensation, vision, hearing, globus
features of sx of FNSD
- 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
which gender is FNSD more common in?
females
course of FNSD
- 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
better FNSD prognosis is associated with what 5 things?
- acute onset
- identifiable trauma or stressor at onset
- good health before incident
- above average IQ
- absence of other medical or psychiatric disorders
tx of FNSD
- treat associated anxiety or depression
- hypnosis
- framing to patient “stress related”
examples of psych factors affecting other medical conditions
- chronic job stress + HTN
- anxiety + asthma
- depression + CAD
- alcohol abuse + liver disease
- smoking + COPD
- obesity + diabetes
differentiating somatic sx disorder vs. factitious disorder vs. malingering
somatic sx: unintentional sx, cause distress
factitious: intentionally feigned, no perceivable benefit
malingering: intentionally feigned, external incentive
describe factitious disorder as imposed on another
- most common in women aged 20-40, often connected to health care
- perpetrated by mothers on children in almost all cases
features of malingering
- medico-legal presentation
- discrepancy b/w claimed disability and physical findings
- lack of cooperation or compliance
- association with antisocial personality disorder
management of somatic sx and disorders
- 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
pitfalls of somatic sx and disorders
- assuming all physical sx are related to somatization
- physician burnout - too much or too little care
