2- Somatoform disorders Flashcards
Do somatic system d/o typically present more often to PCP or psychiatry?
PCP
SSD are typically comorbid w/ what other mental d/o?
Anxiety and depression
What motivates a pt w/ somatic system d/o to seek tx?
Primary gain - unconscious defense against unacceptable internal conflicts
What is the motivation for a pt w/ sx of malingering?
Actions/behaviors for “secondary gain”/external benefit
What are the physical sx of pt w/ SSD?
Multiple complaints w/ multiples organs systems
What are the physical sx of pt w/ Conversion d/o?
Neurological complaints
What are the physical sx of pt w/ Illness anxiety d/o?
Any complaint attributed to serious disease
What are the physical sx of pt w/ body dysmorphic d/o (BDD)?
False perception or exaggeration of physical appearance
What are d/o associated w/ intentionally produced sx?
Malingering (for external goal/gains)
Factitious d/o (“sick role”)
What are disorders associated w/ unintentionally produced sx? (4)
SDD
Conversion d/o
Illness Anxiety d/o
BDD
What is the DSM5 criteria for SDD? (3)
- 1+ somatic sx that are distressing or result in significant daily disruptions
- Excessive thoughts, feeling, behaviors related to somatic sx manifested by 1+ of the following
- disproportionate/persistent thoughts, persistent high level anxiety, excessive time/energy devotion - Present 6+ months
How do pts with SDD typically present their HPI?
- Exaggerated but lack factual info
- See multiple PRs
- Take many meds/hx of lots of procedures/tx
What PCP screening tool is used for SDD (not diagnostic)?
The Somatic Symptom Scale-8
score 0-32
What is the CARE-PA approach to SDD?
Consult w/ psychiatry or CBT Assessment for other illnesses Regular (frequent) visits Empathy (validate) Psychiatric-medical interface Assurance
What is the tx for SDD?
CBT/Mindfulness
+/- Meds (TCA + meds if other psych d/o)
Regular visits
What is the DSM5 criteria for conversion disorder? (4)
- ≥ 1 sx of altered voluntary motor or sensory function
- Clinical findings don’t support dysfunction/sx
- Not better explained by another medical/mental d/o
- Impairment in functioning
Sx in conversion disorder conform to what the pt THINKS, not physiological principles. What are the most common sx in conversion disorder?
Sensory deficits, motor deficits, or pseudo-seizures
*PE will be inconsistent w/ normal neuro exam
Before making a dx of conversion disorder, what must be ruled out?
Must r/o any underlying neurologic etiology
What is the tx for conversion d/o?
Sx spontaneously resolve
Validate pt, be supportive, consult w/ psych
What is the difference b/w SSD and Illness anxiety disorder?
SDD w/ somatic sx
IAD w/ preoccupation of disease/health
What is the DSM5 criteria for IAD? (6)
- Preoccupation w/ having a serious disease
- No/mild somatic sx or excessive preoccupation another medical condition
- High level of anxiety about health
- Excessive health related behaviors or maladaptive avoidance
- ≥ 6 months
- Not better accounts for by another mental d/o
What are the important specifiers for IAD?
Do they seek care
OR
Do they avoid care
IAD is often associated w/ what?
Serious illness in childhood or in a family member
What is the tx for IAD?
Reassurance/regular dr. visits
Avoid unnecessary procedures/meds
Individual/group therapy
What is the DSM5 criteria for BDD? (4)
- Preoccupation w/ imagined defect in appearance not observable or appears slight to others
- Repetitive behaviors or mental acts in response to appearance concerns
- Causes distress/impairment
- Not better accounted for by concerns w/ fat or weight due to an eating disorder
What are the specifiers for BDD? (2)
- W/ or w/o muscle dysmorphia
2. Degree of insight
What is the #1 co-exisiting d/o to BDD?
Depression
also social phobias, substance abuse, OCD
BDD can exist on a continuum with what other disorder?
Delusional disorder
What is the tx for BDD?
Avoid medical surgeries/procedures
CBT for false belief
Behavior modification/therapy
+/- antidepressants
What is the most effective tx for SSDs?
CBT (sx focused NOT relaxation techniques)
What makes CBT most effective in pts w/ SDDs?
Homework/journalling triggers/thoughts/behavior
Then have therapist provide alternative explanation to the pts interpretations
What is the goal psychoeducation in SDD?
Teach pt to recognize their thoughts, emotions, behavior that lead to somatic preoccupation and provide better coping strategies
What is the DSM5 criteria for factitious disorder imposed on self? (4)
- Falsification of physical sx
- Present to others as ill/injured
- External rewards for behavior are absent
- Not better explained by another mental d/o
What are specifiers for factitious disorder?
Single or recurrent episodes
What is the DSM5 criteria for factitious disorder imposed on another? (4)
*Previously munchausen
- Falsification of physical sx in another, associated w/ deception
- Present another individual (victim) to others as ill
injured - External rewards for behavior are absent
- Not better explained by another mental d/o
* Perpetrator, not the victim receives the dx
What will medical hx show for pt w/ factitious disorder?
Multiple Dr. visits/hospitalizations
- Extensive knowledge of medical terminology
- Eager to undergo test/procedures
What is the tx for factitious d/o?
None
Goal is to recognize d/o early and prevent unnecessary medical tx
Is malingering a psychiatric illness?
NO (it is a behavior)
What is the goal of malingering?
Intentional production of false physical or psychological sx motivated by external incentives (ex: avoid work/military duty, obtain meds/money)
What is a trigger for onset of malingering?
Response to environmental incentive
What is the tx for malingering?
Eliminate external incentive
Confront pt with knowledge of their actions
What is important to do w/ malingering pts?
Careful documentation of encounters as threats may be common
41 y/o M admitted to the hospital after he suddenly went blind. He does not seem overly concerned w/ sudden lack of vision. The only time he gets upset is when discussing his mother’s recent death. His eye and neuro exams are normal and inconsistent w/ sx. A head CT is negative. What is your suspected dx?
Conversion d/o
39 y/o F feels tired, weak, and “just not well”. Her mild sx often keep her from going to work and she is becoming increasingly worried. For the past 4 yrs, she has thought she has hep C which causes fatigue, myalgia, loss of energy and dull abdominal pain. Repeat labs and imaging has revealed no abnormalities but she doesn’t think they are accurate. She is takin vitamins and other natural products to “cure” her sx. What is your suspected dx?
Illness anxiety disorder
34 F presents w/ recurrent abd pain associated w/ bloating, N/V. She has undergone 5 abd surgeries over the past 10 yrs w/ no definitive findings. She has multiple other complaints. She says that no one has found a cause or tx for her sx and she has seen MANY different clinicians. She is extremely agitated and worries that nothing is helping her. She is about to work despite her symptoms but is running out of sick days. What is tour suspected dx?
Somatic symptom d/o
25 y/o F is anxious about the way she looks. She has been obsessed with her face and states something is wrong. She has had 7 plastic surgeries to correct the issues but is still unsatisfied. She isolates herself from other so they can’t see her. What is your suspected dx?
BDD
27 y/o F is evaluated in ER for severely infected arm. She is on several ABX but continues to have infection. Psych consult is ordered after a nurse saw the pt deliberately contaminate her arm. When confronted, the pt wants to leave the hospital. What is your suspected dx?
Factitious disorder imposed on self
29 y/o M complains of severe neck pain following a minor traffic accident. He claims the pain prevents him from working and his lawyer was able to get him a large settlement from his insurance for time lost at work. Pt tells a friend that he exaggerated the pain to get extra money for vacation. What is your dx?
Malingering
Mom reports her 7 y/o often experiences sever abdominal pain. Childs medical record shows many office visits and 3 surgeries. When mom is confronted about falsifying the pt’s sx, she grabs her child and flees the office. What is your suspected dx?
Factitious disorder imposed on another
